TASK FORCE ON HEALTH AND FAMILY WELFARE.pdf
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GOV ERNMENT OF KARNATAKA
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TASK FORCE ON HEALTH AND FAMILY WELFARE
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A Commissioned Research Study
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REVIEW OF EXISTING TRAINING PROGRAMMES FOR HEALTH
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PERSONNEL IN KARNATAKA
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By
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Dr. Pankaj Mehta
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Dr. C. Shivaram
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Dr. Ramesh Kanbargi
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The Department of Health and Family Welfare employs more than 60,000 personnel working in
various cadres and in various institutions including the hospitals. The department has health
administrators who look into the policies of the Government to improve service delivery through
Public Health system. There are service providers like Medical Officers, Staff Nurses and
paramedical staff working in the hospital to implement the programmes of the department. In the
selection process, educational qualification is the key factor. However, provision of health
services require many additional skills in addition to technical knowledge and skills like
administrative and management skills. These are not adequately emphasized in basic education
and at the time of entry to the health department, selected individuals greatly lack these skills so
necessary for their effective functioning. It is also an established principle that professionals or
administrators do require a sort of refresher course at periodical intervals in order to update the
professional skills and managerial skills. Limited training programmes are being conducted by the
Department of Health and Family Welfare and these have now widened under the Karnataka
Health Systems Development Project, IPPIX, etc., However, the department does not carry out
routine
nd planned training activities which are important and key factors in human resource
development and management. Therefore, there is a need to review the activities of the training
department and to develop suitable strategies
at all levels for upgrading the knowledge and
skills of the staff of the Department of Health and Family Welfare. This review was undertaken
with the above mandate.
There are two components of this study. The Health Worker (Female)/Auxiliary Nurse Midwives
and Health Assistant/Lady Health Visitor being such an important human resource in health care
delivery it was felt that their training component should be studied and evaluated as a complete
separate entity. SECTION A deals with all categories of health care providers except health
worker (female) and Health Assistant (female) and SECTION B gives details on the health worker
(female) and Health Assistant (female).
-2-
EVALUATION OF TRAINING PROGRAMMES FOR GOVERNMENT HEALTH CARE
PERSONNEL IN KARNATAKA
EXCLUDING HEALTH WORKERS (FEMALE) AND HEALTH ASSISTANT (FEMALE)
-3 -
EXECUTIVE SUMMARY
The Department of Health and Family Welfare employs more than 60,000 personnel working in
various cadres and in various institutions including the hospitals. Limited training programmes are
being conducted by the Department of Health and Family Welfare and have now widened under
the Karnataka Health Systems Development Project, IPPIX, etc.. There is thus a need to look into
this field and to develop suitable strategies to establish a continuous activity at all levels for
upgrading the knowledge and skills of the staff of the Department of Health and Family Welfare.
Hence, this review of "existing training programmes for health personnel in Karnataka" was
initiated under the mandate of the Task Force on Health and Family Welfare.
There are two components of this study. SECTION A deals with all categories of health care
providers except Health Worker (female) and Health Assistant (female) and SECTION B gives
details on the Health Worker (female) and Health Assistant (female).
Section A of the report summarises the present status of training as a component of Human
Resource Development in the Department of Health and Family Welfare and based on the
interviews, opinions, observations and analysis identifies me lacunae and the changes required. It
also gives details of an “ideal” training scenario for the future.
The OBJECTIVES of the study included studying a representative sample of the existing training
systems and training programmes of various types of health personnel in the Department of
Health and Family Welfare, classifying and determining details of various training programmes,
identifying the methods used in training processes, evaluating the staff appropriateness and
fitness of the venue, study of the training manuals and usage of teaching aids.
The METHODOLOGY adopted was
1.
Key Informant Interviews and Discussions.
2.
Primary Data Collection through Self Administered Questionnaire and
Focus
Discussions (Individual and Groups).
3.
Desk Review.
4.
Obtaining a very comprehensive training status and felt needs of the State health
personnel by obtaining information from staff at the 1675 Primary Health Centres and 473
Primary Health Units of the State through a Kannada questionnaire prepared for data
collection.
5.
Review of as many training manuals as possible.
6.
Utilising the valuable data recorded in the investigators logbook.
-4-
OBSERVATIONS
The review of the Training programme for the government health care personnel gave an unique
opportunity and insight to the investigators to understand the existing machinery and mechanics
of the training programmes in the Department of Health. The interaction and discussions with the
implementing staff was not merely a methodology but also a sensitisation and motivation session.
The investigators found themselves with mixed feelings: frustration, indignation, hopelessness in
some areas and rays of hope, happiness and satisfaction where few successful endeavours were
being undertaken even in difficult circumstances. In general, there was a sense of apathy and a
casual approach towards training. The enthusiasm was muted, existing as an exception.
Training was expressed as an activity that “one had to go through”: the unwritten expression
being that training programmes were not always necessary and that a pre-induction training in
administration and medico-legal matters was all that was required. Also, it was felt that factors
outside the immediate purview of the training programme most often determined its successful
outcome.
A visit to the training institutions re-inforced the disappointment.
The once premier training
institute at Ramanagaram was found to be in a derelict and dilapidated condition - a result of
neglect and abandonment of purpose.
The Heads of the Institutions clearly lacked the will and vision to take the issues forward and one
wondered at the rationale of their occupying such an important post. Whether it was because of
past actions of their predecessors or an inadequate support from the State level officials, it
seemed they were “resigned to their fate” and had accepted “reality” and “non-action” as the best
recourse. Obviously if the top level was not concerned, it is not surprising then to find the rest of
the staff lacking any motivation or interest even to undertake their routine training activities let
alone innovation.
During the skills development training courses, due to various reasons, hands on experience was
either insufficient, inappropriate or inadequate. In essence - “going through the motions” was the
general feeling amongst both the investigators and the “trained” personnel. Often, adequate and
appropriate infrastructure was not made available to the trainees after the training course.
Regional requirements for training were not considered and factored while framing the curriculum
or even during its implementation. Standardised syllabus had replaced the earlier freedom to
innovate.
-5-
The Training section has not received its due in the directorate except in the recent past, a
major reason being the lack of realisation of its importance in improving the quality of
health care delivery services.
Another major reason was the lack of a forceful personality in leadership role - an individual who
could demand and obtain the necessary support and finances for carrying out training
programmes on a regular basis successfully. This led to a situation where the training section
had hardly any funds and work to carry out. Even "induction training" - so important for a proper
orientation and grounding of new staff was not being carried out.
With the projects and programmes setting their own training agendas and funding training
programmes, routine training activities of the department took a back seat - leading to a lot of
frustration and a sense of resignation and hopelessness amongst the senior staff of the training
section in the directorate.
The limited time frame projects have demonstrated the need for training and given it the due
importance. Of course, once the project funding is over, training will need to be financed from
routine funding mechanisms of the department. There is therefore a genuine need to streamline
the training section in the department so that it always receives its necessary importance, priority
and support.
At present the department has training institutes (State, Regional and District and ANM training
centres) where all State level training is carried out. In addition, institutes like the National
Tuberculosis Institute also carry out training activities for the state health employees. The State
and District level institutes have only recently been set up (in some districts - are still being set up
under IPPIX).
The training staff in the directorate not having any budget for training purposes and the World
Bank funded projects being able to fund many training activities in these institutes has created a
dichotomy of interests in the department. The training department staff posted in the directorate
feel completely bypassed and frustrated at these developments and their lack of information on
training facilities and activities was indeed surprising but not completely unexpected under the
circumstances.
There is also an absolute lack of coordination of training activities - training being ad hoc and
project driven with no need based appraisals (including geographical distribution) being carried
out. Being project driven, their regular maintenance once the project period is over will be
necessitated from the funds allocated for training. Whether the budget at that stage will be able
to absorb these additional costs needs to be seen specially since in the past the funds allocated
for training activities were so meager and the priority given to training so low.
-6-
It is unlikely that training activities as envisaged and needed can be carried out unless an
estimated Rs.5 crores (only around 1% of the proposed health budget) are annually allocated to
training section (this amount excludes salaries to employees).
With the projects showing the way and giving training activities the necessary fillip and
importance for improving the quality of health services being delivered by the department,
allocating funds for training (to this amount at least) from the health budget should be done
without any compromises in the future.
To streamline training activities of the department - a restructuring of the department staffing and
line of reporting is required.
RECOMMENDATIONS
IDEAL (Desirable) TRAINING SCENARIO for Department of Health, Governments
Karnataka
A] THE STATE INSTITUTE OF HEALTH AND FAMILY WELFARE
1.
The State Institute of Health and Family Welfare becomes the apex trar ’ng institute as
well as an institute of excellence.
2.
The State Institute will be completely autonomous and the funds for its activities and
maintenance are to be allocated from the State Health and Family Welfare Department
Budget directly.
3.
The Institute will have a Director at the helm and this post will be a selection post with all
the perks and privileges that are offered to a person of this level. Its tenure will be for a
period of 5 years. He will report to the Health Secretary directly (Figure 1).
The person
occupying this chair should have a medical degree and should also have training and
experience in medical education and training of trainers. Ideally, the individual should have
spent some years working at various levels in the department in the field.
‘ 4.
A Deputy Director will assist the Director with various administrative and technical matters.
The post of the Deputy Director should be a selection post with requirements similar to the
Director's post and should have a tenure of 5 years.
5.
The institute should have a full complement of training, administrative and supportive staff
with appropriate qualifications.
6.
Considering the importance of social sciences and communication skills, the institute
should have either full time or part time staff for these departments or engage the services
of experts as and when required during training sessions.
7.
The institute should have all necessary training equipment and facilities including teaching
space and identified field training centres.
-7B] THE REGIONAL HEALTH AND FAMILY WELFARE TRAINING CENTRES AND THE
DISTRICT TRAINING CENTRES
The Regional Health and Family Welfare Training Centres (RHFWTC) and the District
1.
Training Centres(DTCs) would administratively be under the State Institute.
2. Their budget will be released by the State Institute.
3.
Their activities to be based on local needs and practices and to be planned and coordinated
by the State institute.
4.
At present there are 2 Regional Institutes in the Northern (West and East) and 2 in the
Southern part of the State (Figure2). There are none in the Central part of the state. This
anomaly needs to be rectified. Also, not all 27 districts have a DTC. Since the activities of a
DTC are different from the RHFWTCs each district needs to have its own DTC or the
RHFWTC should also undertake the activities of the DTCs without compromising on quality in
districts where RHFWTCs exist but where there are no DTCs. However, the State needs to
keep in mind the recurrent expenditure of so many institutes and based on needs appraisal if
it is determined that 2 districts can share one DTC, for practical reasons and long term
effective functioning, recourse to this may need to be taken and the plan of having so many
DTCs reconsidered.
5. With the formation of the D"l Cs, many of the training activities can now be done at this level,
This will require careful coordination and supervision to ensure quantity and quality of
training.
6. The DTCs based on Needs Assessment will identify the training requirements of the district
and forward this to the state institute for necessary plan of action. The DTCs will also directly
oversee the functioning of the ANM training centres in their districts and provide all the
necessary support.
.............
'I necessary facilities and equipment need to be provided to the
7. As in the state Institute, all
RHFWTCs and DTCs at the earliest for their effective functioning. At present, many of them
lack basic teaching aids and educational materials.
8
The effectiveness of these institutes will depend to a large extent on its human resources.
The training institutes should be allotted staff based on qualifications or appropriateness and
not on personal needs, contacts and political influence and the ability to take care of
extraneous criteria (read favours). Merit and appropriateness should be the only criteria.
Abundant precautions should be taken to ensure that these training institutes do not continue
to be the islands of inefficiency they have been for so many years.
9. The Principals
Principals of
of these
these training
training centres
centres should
should be
be selected
selected with
with great
great care and should be
given the right administrative and technical training themselves at the State Institute prior to
their taking up these posts. This is important, as besides having adequate administrative
duties, very often, they will be directly involved in training activities themselves.
-810. Regular upgradation of knowledge and training skills, revision courses, as and when
programmatic changes are introduced should be mandatory for all staff of all training
institutes.
C] PLANNING the TRAINING PROGRAMMES
1. A committee consisting of the Director - State Institute and all Additional Directors of the
Health Department will identify the training needs, prioritise activities and prepare the budget
for training activities.
2. The Director of the State Institute will be the Secretary of this committee and will be assisted
by the Deputy Director in formulating and drawing out the master plan of operations (based
on the needs identified by the committee).
3. Approval for the formulated plans will be put forward during the committee meeting where the
Health Commisioner/ Director General of Health Services are also invited.
4. Approved budgetary funds will be sought from the State and handed over to the State
Institute for implementing the training activities.
5. To carry out the planned training activities funds as required will be made available in
addition to the funds earmarked for training purposes in different programmes (e.g. Malaria,
RCH, Tb. etc.).
6. The training needs of the different funding programmes will be respected and honored.
However, to enhance effectiveness of training, avoid duplication and to cut down on
unnecessary expenditure on travel, DA, etc., wherever feasible multiple training will be
carried out in one training programme.
7. Rigorous district and person wise data of all training undergone will be maintained and
computerised. This is to avoid wastage of resources and to ensure that everybody undergoes
training and not just a favored few (as is the custom very often now - same people going for
different training programmes whereas many others never obtaining a chance to enhance
their knowledge and skills).
8. This Information system on training will be maintained District wise at the District level, the
State Institute and Directorate. When a staff member moves out of one district to another
district, necessary changes will be made and the data base will be continuously and
constantly updated.
9. Since the committee now decides on training, there will not be any need to have a separate
training section in the Directorate - its functions being taken over by the State Institute, its
Director and the Training Committee of the Department. Adequate support from all necessary
sectors in this scenario should be feasible unlike the present situation where funds are never
or meagerly, miserly provided.
10. It will be advantageous to build up the State’s own training resources and training institutes
and depute Health staff for training in such institutes rather than at places outside the state.
At present, because of lack of training facilities many of the State staff are deputed out of the
-9-
state for training purposes. If the training is done within the state we will strengthen and build
up our own systems, strengthen our own resources, and provide training in our environment
using case material which is similar to what the trainees will ultimately see.
11. As far as possible all training should be done within the state or at the most in some training
institutes within the country. There is an unnecessary clamor for foreign training postings.
Today, our country offers almost all training and skills required for the effective training of its
staff or for the provision of quality health services. No carrots in the form of foreign training
sessions are called for. With the money spent on such training a lot more can be achieved
and many more people trained. Very often staff are posted for short term observation
training. When the conditions and environment are so different and where training is "NOT
SKILL BASED ACQUIRING OR HANDS ON", SUCH TRAINING OUTINGS BECOME ONLY
OUTINGS RATHER THEN KNOWLEDGE/SKILLS ENHANCERS. In all fairness, good
training opportunities with full scholarships are offered by international agencies like -WHO,
Commonwealth organization, etc.. It is a shame to see such useful training opportunities
being wasted because of non-recommendation of names on time or processing of papers on
time or staff being released on time. Full use should be made of such opportunities for
professional enrichment.
The State Institute should have information of all such
scholarships/grants availability and should decide on the staff for deputation for such training
courses.
12. A major advantage in having the training programmes within the State is that the training can
be done in Kannada using Kannada speaking patients and families which makes it much
more easier for the participants to understand and absorb. Less financial resources will be
required for such state conducted training and the resources saved could be utilised for
further strengthening of our institutes.
13. Wherever the training is "technical” or the observation invite for technical matters - "technicalpeople (and not non-medical - non-technical administrators) are to be sent/deputed for such
courses. There is merit in this recommendation. Our administrators are made to change
departments quite frequently. Sending them for such sessions then is absolutely non
productive to the department as the technical training in the health sector (presuming that
they are capable of absorbing the technical nuances involved) is not going to be of use to
them in another department like Sericulture or WAKF. However, if the training is for
strengthening administration related skills, the administrative staff should make full use of
such scholarships.
14 There is an immediate identified need of training for about 470 Block Health Educators.
Instead of deputing them in small batches to Gandhigram (and take years to complete the
training for all of them), one of the Regional training institutes could be strengthened and
provided the necessary infrastructure and human resources to carry out this training. All
further induction training for BHEs could subsequently be carried out in this centre. Such
judicious distribution of training activities is very necessary for optimal utilisation of limited
resources.
1
- 10-
15. Distance education methodology is a grossly underutilised training mechanism in our state.
Today, such education facilities from reputed organizations like IGNOU, Jamia Millia,
Manipal, is available in many health areas. They are well planned and so structured that they
are practically useful to the trainees. The government should encourage such training and as
an incentive offer one time payment of a lumpsum amount (one month’s salary?) for every
distance education course of 6 or more months duration completed successfully by the staff
to a maximum of two such courses. In fact, once these universities offer more and more
health related administrative, managerial and technical courses, the Government should
make the successful completion of such a course a mandatory condition for promotion to a
higher grade after a certain level of promotion.
16. If trainers for a particular training area are not available, for effective training to be conducted
it may be necessary to tap the services of an outside expert. This is a must where institute
staff lack the necessary knowledge/skills. It is therefore highly desirable to identify the right
"consultants" and have a resource base of such individuals. Care must be taken to see that
such consultants have the necessary field experience, as very often such "experts" tend to be
very theoretical or out of tune with field based reality. However, having said that, care must
also be taken to ensure that all such expert consultants are not retired staff from the
Department. They do not necessarily make the best experts and the "buddy system" may not
be the best way to utilise the limited resources of *he training section.
17. Strengthening Public Health training is the need of the hour. The well planned and useful
DPH course - post MBBS, had very few takers as it was not advantageous career wise to do
such courses and over a period of time the number of seats available for such training
decreased. That DPH was no longer a necessary criteria for promotion to higher categories
in the Department gave it a final blow. It is only recently that the Government has once
again realised the need for such training for its staff. At present, the medical colleges do
offer a few seats. The Department should plan for the future and provide DPH training at the
State Institute itself. The modalities need to be worked out with Rajeev Gandhi University of
Health Sciences and necessary support for the infrastructure and resources sought so as to
start these courses by 2005 at least. Simultaneously, the colleges providing these courses
should be encouraged, infrastructure made available to them and Government Health staff
deputed.
functioning.
Long term planning is the need of the hour for better and effective future
-11SUGGESTED VISION, GOALS AND OBJECTIVES FOR TRAINING ACTIVITY for the
Department of Health and Family Welfare, Government of Karnataka
VISION
To provide technically competent, socially relevant, appropriate health services to
the fullest satisfaction of the people of Karnataka.
GOALS
By 2002 January, every health care personnel who joins the government health service will
receive induction training.
By 2005, every health care personnel will receive the identified and necessary refresher
training and skills up-gradation.
-
By 2010, systems are in place for the conduct of regular, ongoing, continuous refresher and
induction training with adequate provision of resources.
OBJECTIVES
1.
Preparing the individual’s competence by enhancing communication skills and learning
capabilities that are necessary for managing the day-to-day activities of the health
centre and for delivery of quality health care in accordance with the existing health
programmes and local health situation.
2.
To nurture and enrich the organisation culture which supports and enhances team
effort, harmonious interpersonal relationship, pursuit of excellence, spirit of enquiry and
innovation as a way of work life and to create an organisation environment where each
can share and contribute towards achieving the shared goals.
3.
To create sensitivity to the needs of the society, discharge the multiple roles and
responsibilities and fulfill the obligations as a health care provider.
4.
To help and support each individual to develop their potential to realise their self-goals
while contributing fully to the success of the organisation.
5.
To achieve synchronisation of the goals and aspirations of the individual, organisation
and society.
6.
Enhancing preparedness for willing participation in development activities which have a
bearing on health of the community.
7.
Facilitate building a strong character of integrity, honesty and leadership.
- 12INTRODUCTION
Human Resources development is a serious business. A business, which, requires specific
knowledge and skills to make it run successfully. It is resource and labour intensive. The ultimate
aim is to make a difference - to bring about the desired change amongst the participants and
enhancement of knowledge and skills so as to function more effectively.
Training as a subsystem of the health care system has the objective of optimising the health
resources input to the health care system through strengthening of knowledge, skills and attitudes
of health care personnel. The knowledge, skills and attitude that enable health staff to contribute
to the realisation of the goals of the health care system are usually derived from their basic
education obtained before joining the service and from the experience obtained by working in the
health care system. Proper training therefore plays a very important role in the effective
functioning of the health system.
Changes in health care delivery interventions happen frequently. New technologies are regularly
introduced and call for new skills for their use. The field personnel specially and other personnel
too may become outdated in a short period of time in terms of their knolwedge and skills. This
prevents their optimum utilisation and to their providing outmoded, less effective services. Skills if
not used for a long time get attenuated. Continuous education will assist and motivate staff in
improving their skills. The personnel enjoy the challenge of learning new skills or taking on a new
responsibility or improving their existing skills.
TRAINING AND RETRAINING IS LIKE CHARGING A BATTERY. Training or continuous
education has to be accorded high importance in human resource development and is crucial to
the planning and implementation of any project.
Training as a signal component of HRD is best understood as a learning experience. A training
programme is a learning experience for both the trainer and the trainee. It is also a learning
experience for the system, which commissioned it. A training programme is said to be successful
as long as it is a learning experience. The emphasis on learning and not just on training is
important for it also includes the follow-up of the training as an integral component.
The broader agenda of HRD includes dimensions of undergraduate degree / diploma / certificate
courses; the existing / creating environment in which the training / learning is facilitated; the
media and methods adopted to assess / evaluate; organisation structure and job responsibilities.
Hence to be more appropriate to this line of thinking this report should be titled Human Resources
-13-
Development for Health Care Delivery in the Public Health Sector. However due to the mandate
given in the terms of reference and the time duration, the original title is retained.
This section of the report summarises the present status of training as a component of HRD in
the department of Health and Family Welfare and based on the interviews, opinions, observations
and analysis identifies the lacunae and the changes required. It also gives details of an “ideal
training scenario for the future.
The Objectives of the study were as follows:
1. Studying a representative sample of the existing training systems and training programmes of
various types of health personnel in the department of health and family welfare.
2. Classifying the training programme into pre-induction, in-service, refresher courses, skills
enhancement, additional qualification.
3. Determining details of training programmes like duration, selection process, eligibility,
geographical distribution, their appropriateness and adequacy based on job description of
health personnel.
4. Identifying the methods used in training process.
5.
6.
Evaluating the course content for their appropriateness, adequacy and effectiveness.
Evaluating the staff appropriateness and fitness of the venue for the various training
programmes.
7. Study of the training manuals.
8. Availability, usefulness, appropriateness and frequency of usage of teaching aids in the
training programmes.
METHODOLOGY
The following methodology was adopted for this section:
1.
Desk Review: The existing organization infrastructure, the available past review
reports and related literature were reviewed.
2.
Key Informant Interviews and discussions: The key administrative personnel
responsible for the training programmes for the Government Health Care Personnel at
the level of the Directorate of Health Services, State Institute of Health and Family
Welfare, Regional Health and Family Welfare Training Centres and District Training
Centres were interviewed and their opinions, thoughts, concerns and suggestions were
documented. In addition efforts were made to meet as many senior and retired
Government officials as well as NGO representatives as possible for obtaining their
inputs for the endeavour. Discussions were held with the Chairman and Members of
the Task Force on Health and Family Welfare.
- 143.
Primary Data Collection through
a. Self Administered Questionnaire
i.
Focus Discussions
- Individual
- Groups
b.
Three sets of questionnaires were drafted, field-tested, finalised and used for
data collection. The first set of questionnaire was meant for the Training
Institutions. The second (English) and third (Kannada) sets were used to
collect data from individual health staff - both medical and paramedical.
(Annex!). The interactions with various key individuals commenced from 1“
November 2000.
c.
Field data collection was undertaken during the period 12* November 2000 to
30* December 2000. The Four divisions and the respective Regional Health
and Family Welfare Training Centres including selected District Training
Centres were personally visited. In addition, one district other than the
Divisional Headquarters district was also visited. In these regions as many
Taluka Health Centres, Community Health Centres and Primary Health
Centres as possible were visited during the survey period.
d.
Focus discussions were held with individuals and groups from these Health
Institutions. Contents included: the need for training programmes, need,
duration and contents of the Induction and continued training programmes,
methodology and the location of the training programmes to be undertaken,
staff to be involved, training of trainers and related issues.
e.
All the 1675 Primary Health Centres and 473 Primary Health Units of the State
were posted three copies of the Kannada questionnaire for obtaining a very
comprehensive training status and felt needs of the State health personnel.
f.
The data collected was processed using the MS Office Excel Worksheets and
analysed using the WHO Freeware EPIInfo6 package.
4. As many training modules as possible were collected and reviewed.
5.
The investigators logbook formed an important and valuable source of data for analysis
and report preparation.
6. The names of Institutions and Individuals who participated in the study are given in
Annex 2.
OBSERVATIONS
The following paragraphs document the findings of the researchers of the training endeavour and
activities in the Department of Health and Family Welfare. The presentation includes three parts:
1.
Summary tables of the information given by the Health Care Personnel in the structured
format.
- 152.
3.
The information obtained during the focus discussions with the Health Care Personnel by the
investigators.
The information processed from personal discussions and as a result of the documents made
available.
[1] SUMMARY TABLES OF THE INFORMATION GIVEN
BY THE HEALTH
CARE
PERSONNEL IN THE STRUCTURED FORMAT (English)
The average age (in years) of the study population
Table 1:
Mean
Range
Number studied
Category
52
25 to 58
87
_____ Medial
47
28
to
58
93
Paramedical
48
25
to
57
43
Non Medical
47
28
to
55
7
Not mentioned
Median
51
50
50
50
Mode
52
52
50
29
Since the Department does not have similar data on all its employees, the representativeness of
this group could not be ascertained. However, all groups had persons with wide age ranges.
Table 2:_____ Sex distribution of the study population
Male
Category ______ Number studied
55
(63%)
087
_____ Medial
31
(33%)
093
Paramedical
36
(84%)
043
Non Medical
06
(86%)
007
Not mentioned
128
(56%)
230
Total
Female
29 (33%)
62 (67%)
07 (16%)
01 (14%)
99 (43%)
Not mentioned
03 (04%)
00 (00%)
00 (00%)
00 (00%)
03 (1%)
The lower female representation is partly because of their being studied in details separately, the
findings of which are presented in the second part of this study.
Table 3:_____ Average period of service (in years) of the study population
Median
Mean
Range (years)
Number studied
Category
20
19
1 month to 36
87
_____ Medial
27
25
1
month
to
37
93
Paramedical
25
22
1
month
to
36
43
Non Medical
16
17
1
month
to
33
7
Not mentioned
Mode
2
30
27
Again, a wide range helped give greater opportunity for representation of staff having had varying
induction and in-service training opportunities.
Qualification of the medical personnel
Number (%)
Qualification
25 (29%)
MBBS
______________________ ______
24 (28%)
Post graduate Diploma___________ _________
33 (38%)
Post Graduate Degree
________
01 (01%)
postdoctoral_________ ___________________
04 (04%)
Not mentioned______________ ________
Note: The specialist areas are given in Annex 3
Table 4:
- 16Desire
of
the
study
population
for administrative knowledge
Table 5:
Not stated
Para Medical Non Medical
Required _____ Medical
04 (57%)
11 (27%)
25 (27%)
52 (61%)
_____ Yes
01 (14%)
04 (09%)
15(16%)
15(17%)
No
02 (29%)
28
(64%)
53
(57%)
20 (22%)
Not mentioned
»
Total
92 (40%)
35 (15%)
102 (45%)
The Medical staff are responsible for administrative supervision unlike the paramedical staff. The
finding that 61% of them desired greater administrative knowledge is indicative of their interest,
inadequacies in the basic training content and is a very positive sign to improve their
administrative functioning.
Desire of the study population for Technical knowledge
Table 6:
Not stated
Non Medical
Para
Medical
Required
Medical
04 (57%)
07 (16%)
29 (31%)
37 (43%)
Yes
01 (14%)
09 (21%)
10(11%)
29 (34%)
No
02 (29%)
27
(63%)
54
(53%)
21
(23%)
Not mentioned
Total
77 (34%)
49 (21%)
103 (45%)
Only 31% paramedical and 43% medical staff desired greater technical knowledge. These low
percentages need to be further investigated, specially for the paramedical staff who do not have .
too many training opportunities.
Desire of the study population for evaluation and supervision knowledge
Table 7:
Total
Not stated
Para Medical Non Medical
Medical
Required
74
(32%)
03
(43
/o)
03 (7%)
32(34%)
36 (42%)
______ Yes
51
(22%)
01 (14%)
13 (30%)
07(8%)
30 (35%)
______ No
104
(46%)
03 (43%)
27 (63%)
54 (52%)
21 (19%)
Not mentioned
Supervision and evaluation activities are important activities of health care personnel specially of
the medical category. Greater focus needs to be given to enhancing these knowledge and skills.
Desire of the study population for administrative skills
Table 8:
Not stated
Para Medical Non Medical
Medical
Required
01 (14%)
08 (19%)
22 (24%)
32 (37%)
Yes
03 (43%)
08
(19%)
18(19%)
35
(41%)
______ No
03 (43%)
27
(63%)
53
(57%)
20
(22%)
Not mentioned
Desire of the study population for technical skills
Table 9:
Para Medical Non Medical
Medical
Required
Total
63 (28%)
64 (28%)
102 (46%)
Not stated
Total
03 (43%)
01 (14%)
03 (43%)
54 (24%)
69 (30%)
106 (46%)
Desire of the study population for evaluation and supervision
skil s_________
Not stated
Para Medical Non Medical
Medical
Required
03 (43%)
03
(7%)
29(31%)
23 (27%)
Yes______
01 (14%)
13 (30%)
10(11%)
42 (49%)
No_______
03 (43%)
27 (63%)
54 (58%)
22 (25%)
Not mentioned
Total
58 (25%)
66 (29%)
105 (46%)
Yes
No
Not mentioned
20 (23%)
45 (52%)
22 (25%)
26(28%)
12 (13%)
55 (59%)
05 (12%)
11 (26%)
27 (63%)
Table 10:
The large number of non-responses in skills enhancement section was rather unfortunate and
prevents coming to any definite conclusions about them.
-17-
Table 11:
Category
Number of training programmes attended
Training
Number
programmes
studied
Induction
documented
10 (4%)
280
87
____ Medial
6 (5%)
155
93
Paramedical
1 (2%)
65
43
Non Medical
17 (3%)
500
223
_____ Total_______________________
Note: The List of training programmes is given in Annex 4
Course type
In service
266 (95%)
98 (63%)
45 (69%)
409 (82%)
Not
mentioned
04(1%)
51 (32%)
19 (29%)
74(15%)
Duration of training programmes evaluated
Table 12:
Duration (in days)
Training
Number of
Category
programmes
personnel
Median
Mean
Range
documented
studied
1 to 90~
10
19
280
87___
Medial
14
49
2
to
365
155
93
___
Paramedical
21
37
3
to
90
65
43
Non Medical
Table 13:
Type of training programmes
Medical
Nature of the Programme
(n= 280)
231 (83%)
Lecture demonstration
91 (33%)
Workshop__________
160 (57%)
Participatory________
67 (24%)
Role play___________
64 (23%)
Hands on Training
52 (19%)
Modular
Paramedical
(n = 155)
83 (54%)
31 (20%)
78 (50%)
60 (39%)
32 (21%)
21 (14%)
Non Medical
(n= 65)
36 (56%)
07 (11%)
17 (26%)
10(15%)
08 (13%)
04 (06%)
Mode
03
30
90
Total
(n=500)
350 (70%)
129 (26%)
255 (51%)
137 (27%)
104 (21%)
077 (15%)
In this group, there were only 23% amongst the medical group and 21% amongst paramedical
who received hands on training.
Trainees comments on the training programmes
Non Medical
Paramedical
Medical
Training Programme
(n= 65)
(n = 155)
(n= 280)
42
(65%)
97 (63%)
217 (78%)
Highly useful_______
29 (45%)
82 (53%)
212 (76%)
Adequate__________
31 (48%)
76
(49%)
197
(70%)
Content adequate
35 (54%)
83
(54%)
211
(65%)
Content relevant
40 (62%)
83
(54%)
212
(76%)
Helped acquire
Total
(n=500)___
356 (71%)
323 (65%)
304 (61%)
329 (66%)
335 (67%)
knowledge_________
Helped acquire skills
312 (62%)
Table 14a:
195 (70%)
82 (53%)
35 (54%)
Trainees comments on the training programmes
Non Medical
Paramedical
Medical
Training Programme
(n= 65)
(n
=
155)
(n= 280)
ADDITIONAL KNOWLEDGE
32 (49%)
84 (54%)
206 (74%)
Useful in every day
activity_________________
06 (9%)
11 (7%)
Used once in way________ 32 (11%)
05 (8%)
02 (1%)
Occasionally____________ 18 (6%)
0 (0%)
0 (0%)
Not applicable___________ 11 (4%)
Table 14b:
Total
(n=500)
322 (64%)
49 (10%)
25 (5%)
11 (2%)
-18ADDITIONAL SKILLS
Useful in every day
activity___________
Used once in way
Occasionally_______
Not applicable_____
191 (69%)
82 (53%)
29 (45%)
302 (61%)
31 (11%)
23 (8%)
14 (5%)
12 (8%)
03 (2%)
0 (0%)
10(15%)
04 (6%)
0 (0%)
53(11%)
30 (6%)
14 (3 %)
The above table clearly depicts the benefits of training programmes to this group.
Reasons for non-application of the knowledge and skills
Non Medical
Paramedical
Medical
Reason
(n= 65)
(n = 155)
(n= 280)
KNOWLEDGE_______
6 (9%)
7 (5%)
20 (7%)
No opportunity______
0 (0%)
0 (0%)
0 (0%)
No interest__________
0 (3%)
2 (1%)
6 (2%)
No freedom to act
2 (3%)
4 (3%)
35 (13%)
Lack of technical
support____________
0 (0%)
3 (2%)
Inadequate equipment
29 (10%)
4 (6%)
14(5%)
No encouragement
1 (1%)
Table 15:
SKILLS_____________
No opportunity_______
f .o interest__________
No freedom to act
Lack of technical
support_____________
In adequate equipment
No encouragement
Total
(n=500)
4(1%)
0 (0%)
14 (3%)
41 (8%)
32 (6%)
19 (4%)
15 (5%)
0 (0%)
5 (2%)
19 (7%)
5 (3%)
0 (0%)
2 (1%)
4 (3%)
5 (8%)
0 (0%)
0 (0%)
2 (3%)
25 (5%)
0 (0%)
7(1%)
25 (5%)
27 (10%)
6 (2%)
3 (2%)
1 (1%)
0 (0%)
4 (6%)
30 (6%)
11 (2%)
About a quarter of the participants were not able to utilise the knowledge and skills given in the
training programmes - the major reasons being inadequate equipment and lack of technical
support.
Trainers ability as perceived by the trainee
Paramedical
Medical
Particular
(n = 155)
(n= 280)
Impart knowledge 94 (65%)
223 (80%)
good____________
91 (59%)
204 (73%)
Impart skills - good
Communication 85 (55%)
204 (73%)
good
Table 16:
Non Medical
(n= 65)
Total
(n=500)
34 (52%)
351 (70%)
24(38%)
319 (64%)
24 (38%)
313 (63%)
The training ability of paramedical and non-medical trainers obtained quite low ratings. Since
they are a very important component of health care delivery services, the trainers’ abilities for
these groups needs to be enhanced.
[2]
INFORMATION OBTAINED DURING FOCUS DISCUSSIONS WITH THE HEALTH
CARE PERSONNEL BY THE INVESTIGATORS
The following issues were raised during the open ended discussions:
- 19a)
(Health Personnel) Learnt PHC administration mostly through self-learning and
through the guidance from non-medical and para-medical staff, perusal of records
and scrutiny of the government circulars.
b) Many difficulties faced while managing the financial aspects, in the initial stages.
c)
INDUCTION TRAINING
•
Induction Training should be a must.
•
Lack of induction training resulted in lack of self-confidence and competence
to manage the administration of the PHC at the initial posting.
•
Induction Training should be conducted before the selected candidates are
posted to the respective PHCs.
•
The duration should preferably be three (15 days to six months) months.
•
Of these one month should be in theoretical aspects of administration and
finance. In the remaining two months the selected candidates should be
exposed to practical training including training at sub-centre and PHC levels
rather than being trained only at the divisional level.
•
The Training pattern should be 1/3 field-work, 1/3 discussion, 1/3 lectures.
•
Induction training should commence from sub-centre level.
•
Current Induction Training emphasized more on clinical aspects rather than
office procedures.
•
An opinion was also expressed that the newly recruited staff should be
posted first to PHC for one or two months and then drawn for induction
training. By doing so, they would be more focussed on their training
requirements.
d)
Topics suggested for inclusion in the Induction training for Medical Officers were:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Administration
Supervision
Management (Finance, Vehicle, Materials, Stress and Personnel)
Human relations
Inter-sectoral co-ordination
Job responsibilities
Office procedures
Medico-legal aspects including Law and Medicine
Inter-personal relationship with staff and general public
Human Resources Development
How to deal with Non Governmental Organisations?
Counselling for adjustment to rural areas.
Use of computers
Disciplinary powers
Pfreventive ) & S(ocial) M(edicine)
MTP
Tubectomy
-20•
e)
Leadership qualities
PARA-MEDICAL TRAINING:
•
Need for induction training for the Nursing staff.
•
Pre-induction training for Para-medical staff to be between 2 to 3 weeks.
•
Pre-induction Training for Lab technicians is a must. The present LT training is of
poor standards.
•
ANM training should be under DHO and not under District surgeon. Since they
would be working under the supervision of the Programme Officers and the DHO.
•
ANM Training to be 24 months rather than 18 months. Of these 6 months should
be “internship" training in association with experienced ANMs.
•
Minimum qualifications for ANM training should be PUCII year pass / graduation.
•
The trainers should possess Diploma in Public Health Nursing.
•
The ANM training centres to be l der the supervision of the District Training
Centre Principal and the staff of these institutions to be associated with ANM
training.
f)
IN-SERVICE TRAINING
• In-service Training should be need based rather than based on
hierarchy. The training and postings at present are not need based.
•
The training programmes are many a times repititous.
•
The TAJ DA payment is delayed and inadequate.
•
Ideal duration of the training programme should not be too long or too
short. The best period is 3-5 days.
•
Training schedules should not hamper regular and routine service
delivery (problem of single medical officer).
• Need for better accommodation facilities and incentives for the
trainees was mentioned by many.
• Many Medical Officers of Health are not attending TOT. There is
confusion in deputation to training programmes. Late intimation
precludes from attending the training programmes. Training not being
mandatory / compulsory is a common reasons for poor attendance.
There was divided opinion regarding private practice being a reason
for poor attendance during the training sessions.
-21 -
•
In-service training of ANMs being promoted to LHV cadre for 6
months duration is insufficient.
g)
TRAINING PROGRAMME
•
Training groups to be Homogenous as heterogenous groups will
result in loss of interest in training, the training being multilevel and
more time-consuming.
Training and other resource materials should reach the trainees well
•
in time.
•
Training in AIDS and Tuberculosis at Foreign institutes (I! sic).
• No incentive should be given for undergoing the training programme.
•
Training should be on the lines of IAS / KAS.
•
There are lacunae in training but certificates are issued.
• Equal importance should be given for training in all National Health
Programmes.
• It was surprising to hear one of the trainee mentioning that Training in
Communicable diseases is practically nil.
• ATI training for administrative Officers is a must from middle level
onwards.
• Administrative re-inforcement training should be conducted once in
three to five years.
• Health management training should be given at all levels.
•
There should be periodical short course training in supervisory skills.
•
Contract Doctors are not Administrative heads; so management
training to them is a waste.
• Learning should be participatory rather than lecture based; skill based
rather than theoretical; the theory practical ratio to be 10 to 20 to 40:
60 to 80 to 90; unlike at present - 60% theory and 40% practical (just
the reverse).
•
Practical sessions to have discussions, demonstrations and problem
solving exercises and not just reading and by-hearting of notes.
• Hands-on training and workshops are better.
h) POST TRAINING SCENARIO
•
Following training the Medical Officers do not practice what they
have learnt.
•
The required infrastructure is not available or provided.
-22•
The
trainees
do not have
confidence
following
(especially
laproscopy) training.
•
Feed back from the trainees is a must. Monitoring and follow up
evaluation should also be undertaken. The present system of pre
test and post-test assessment needs a change.
•
The trainees must be accountable to the official superior and to the
general public. The responsibility for each trainee after the training
should be decided prior to training.
•
There should be periodical feed back from every cadre regarding the
training undergone. This also should include their ability to apply the
learning from the training in their day-to-day work.
•
Inspectorate team should be formed to monitor and supervise
training activities on the spot. Independent evaluation of training
process by external agency should be provided for.
i)
CME should be introduced for all categories of health personnel. For Medical Officers
CME / refresher courses should be held at the district level and at Divisional level
once in 6 months to three years. There should be re-inforcement training for taluka
level and CHC level doctors for 7 working days and 2 weeks for DHO level. Training
should include updates on National Health Programmes.
j)
PROMOTIONAL TRAINING:
Promotion should be need-based.
•
Promotional training is very much required particularly in the areas of
administration, finance and supervision at all levels.
•
The topics should include administration, rules and regulations,
finance, planning, supervision and personnel management.
•
However a few expressed that promotional training was not required
since the topics would have been covered during the induction
training.
k)
There should be more and more interaction between faculty of teaching institutions
and health personnel.
I)
Exposure to General or Family Practice during internship (is desirable).
m) All Circulars from the Directorate should be marked to the Principals of the Training
Centres also.
n) Upgrade the post of the Principal, RHFWTC to the DJD level
o) Faculty at the training center require TOT re-orientation once in two to three years or
whenever new programmes are introduced. A major training need identified was
-23training in advanced and recent communication technology. Faculty at RFWTC
should be screened for teaching competency before appointment.
p)
Changes in health and programme interventions are fast and frequent - so planning
is not possible. (- in response to the preparation of the Annual Training Plan). There
must be political will for allocating resources for undertaking training.
q)
It is preferable to have Karnataka Health Administrative Services, KHAS like KAS.
3]
INFORMATION PROCESSED FROM THE DOCUMENTS
(A)
The following paragraphs summarise the information collected from the
training institutions:
State Institute of Health and Family Welfare, I5* Cross, Magadi Road, Bangalo - 23
This institute has been set up right next to the RHFWTC, Bangalore. The Total filled up Positions
is 68% (28 / 42). TEN Deputy Director Posts are sanctioned apart from those of office staff. A
total of 06 are reported to be vacant including that of 02 Deputy Director posts. A Deputy Director
and an Accounts officer are working part-time.
The facilities cover an area of 4200 Sq ft with 12 rooms for faculty, 9 rooms for other staff, 5
classrooms and 1 Seminar room.
The functional equipment are 1 OHP, 1 Slide projector, 1 Computer with Printer, 1 photocopying
machine, 1 binder, 3 Audio cassette players, 3 VCPs, 4 TV monitors.
The two Transport vehicles (Jeep and an Ambassador car) are on road.
The Library with 563 books occupies an area of 400 Sq FT and there is No separate staff. There
are plans for subscribing to Journals.
The Hostel has 16 rooms for trainees, 1 staff room, 1 dining hall, a kitchen and a recreation hall
with a TV.
The sanctioned budget was released on time and was adequate. Seventy seven percent of the
amount was utilised and Rs. 10,04,123 was surrendered, (reasons being non filling up of staff
and non conduction of some training courses)
The training conducted at this center was RCH orientation training for faculty of ANMTC/LHVTC
under the Government of India.
The Centre has NO PUBLICATIONS to its credit.
The Instructional materials available are 20 Modules / Manuals, 02 models, one set of 36 slides
and 10 video films.
Regional Health & Family Welfare Training Center, Magadi Road, Bangalore- 23
Filled up posts 83 % (12 Teaching faculty, that include 03 Doctors) Vacancies of Health
Education Instructor 01, Management Instructor 01, Artist cum photographer 01 and 02 Group lD’
staff.
-24An Urban Family Welfare Centre is also attached to the center with an additional staff of 05 out of
the sanctioned 06. All the above staff are employed on a full time basis.
The facilities cover a floor area of 4000 SqR for faculty and other staff including 01 classroom, 01
Seminar room, Audio Video room and a Library.
The equipment available consists of an overhead projector 01, Slide projectors 04, Audio
cassette players 02, video cassette players 02, still camera 01 and TV monitors 02. Of these 03
Slide projectors and 01 Audio cassette player are Non-operable but can be repaired.
Transport consists of 01 Tempo, which is on road while the Mahindra Jeep 01, Mini Bus 01 are
under repair. An Ambassador car is to be condemned. 25% Vehicles are on road:
There is no library staff. The library, contains 1095 Text Books including reference books and 04
subscriptions for periodicals.
The Hostel comprises of 02 buildings (old and new) with a total of 19. Each has its own dining hall
and kitchen. Neither of the buildings have recreation facilities.
The Budget release for 1999 - 2000 was delayed. The center incurred an excess expenditure of
Rs.4, 55,453/-
02 Training programmes were conducted:
Generation Awareness T-iining Course (Composite group 2) in 1999-2000
and a Course on Management for Medical Officers of Health in the current year.
The Teaching staff’s time during Non-training was spent as below:
60 % in preparing instructional materials,
10 % in staff interaction,
20 % in professional enrichment, and
10 % in Translation work and attending work assigned by DH&FWS and State Institute.
The 704 instructional materials include 300 Slides, 85 video films, 250 models and manuals.
Remaining (69 - 9.8%) consist of charts, models, flip charts/books, flash cards, information kits,
pamphlets, folders and posters.
Teaching materials prepared by the institute and used for training include the following:
1. Sukhee Kutumba (folder by the Faculty, HFWTC, Bangalore)
2. WHO day- April 7,2000 (folder) {translated by the center into Kannada }
3. CHETANA.... Training modules for
• Block Health Educators.
• Senior Health Assistants (M&F)
• Junior Health Assistants (M&F)
The last two are English training modules translated into Kannada.
The other two publications to the credit of this institution are:
2. Nimma Arogya Kapadikolli by the Faculty, HFWTC, Bangalore
3. Surakshita Laingikate, by the Faculty, HFWTC, Bangalore
Regional Health & Family Welfare Training Centre, Metagally, Mysore 16
Positions filled up 87% (7 of 8). The faculty includes 02 Doctors. The one vacancy is
that of Health Education Instructor.
-25The center has a building with 14 rooms (13 for the faculty and 1 for the other staff). In
addition there are 02 classrooms and one each of the following, Seminar room.
Demonstration room and a Recreation hall. The total floor space covered is
approximately 350 SqMts.
The equipment available at the center consists of 02 OHP's one each of s,^e projector.
Audio cassette player and 16mm projector. Two each of Video Cassette player and T
Monitors. Of this equipment one Video Cassette Player is in need of repair while the
TranspoteTon0 islnthe form of two vehicles - One a Swaraj Mazda Canter which is in
service while the other is a Standard -20 which needs to be condemned.
The Library has 57.7 SqMts of floor area and has 927 books. However, no Journals or
Periodicals are being subscribed to. A lending facility as well as a photocopier and
computer are in the library. Working hours are 10 AM to 5 PM.
A hostel is also provided and it consists of 10 rooms for students and 15 for the staff and
a dining hall, kitchen, and a recreation hall with a TV .
The Budget for the previous financial year was sanctioned and released on time. The
amount utilised was Rs. 26,14,331. The amount released Rs. 27,55,860 was found to be
adequate.
The training undertaken last year was an In-service training for Medical Officers and
another for Zilla Parishadh members, BEO, NGO’s CDPO and Taluka Panchayat
members.
No publications have been made from this center.
The teaching staff’s Non-training time usage was as follows:
10% in course planning,
15% in lesson planning,
20% in preparing instructional materials,
10% in field follow up
20% in staff interaction
25% in professional enrichment
The Instructional materials available at the center for teaching include 36 Charts, 160
Modules and Manuals, 3 Models, 120 Slides and 18 Video films.
No teaching materials have been prepared by the center.
Regional Health and Family Welfare Training Centre, KIMS Campus, Hubli 580 022.
Positions filled up: 76% (41 / 54) The 13 vacancies are for Office Supdt (01), Driver (01),
Typist (01), Class D (02), Sanitation officer (01), Skilled Mechanics (05).
The faculty at the centre include apart from the Principal and 02 (Doctors) Chief
Assistant Medical, Social Science, Health Education, Public Health Nurse Instructors,
-26Management Instructors, Health Supervisors, Communication Officers, Assistants,
Office staff and Motor vehicle related positions.
The center covers a total floor space of approx 520 sq mts and includes 07 rooms for
faculty, 02 for staff and one for the Projectionist apart from 04 classrooms as
instructional areas. There are no Seminar Room, Demonstration room or Lab Facilities.
The Hostel facilities comprise of 16 rooms for the trainees, a dining hall and kitchen.
There is no recreational room but a few games, TV and radio are made available at t e
hostel.
The offices of Sample Survey and Assessment unit, the Taluka Health Office and Urban
FW center are accommodated in the 118 sq mts area of the centre.
Functional equipment at the center include 1 Over head projector, 4 slide projectors, 3
video cassette players, 1 TV monitor, 1 each 16mm and 8mm slide projector and 1
Microscope.
The OHP (1), slide projector (1), audio cassette player (1), TV Monitor (1), and the PA
System need to be repaired. Both the 8mm and 16mm projectors are to be condemned.
Of the 5 vehicles for Transport facilities the two mini vans are to be condemned. Three
vehicles are on road, including a Jeep.
The Library with a floor area of 44.2 SqMts has 1323 Text Books and Reference books
with a subscription to 11 Journals and Periodicals. There is photocopying facilities, but
NO LIBRARIAN has been sanctioned.
A budget of Rs. 66,68,440 was sanctioned on time and was found to be adequate. An
amount of Rs. 8,35,095 (12.5%) was surrendered for various reasons.
The training courses conducted were:
In-Service training for Medical Officers in STD surveillance
- STD surveillance for Sr. Health Assts / Staff Nurses (13 batches)
Awareness generation training under RCH for Medical Officers with NGOs (06
batches)
- RCH workshop for District Programme Officers (1 batch)
- Community Health Training for one batch of Ayurvedic Students.
RCH training for two batches of SOSVA Personnel.
Community Health for one batch of Staff Nurse students.
Population Education training for four batches of ITI students.
- RCH training for NGO’s.
- MLEC programme for In-service personnel.
The studies undertaken from the center are:
- a report on the evaluation of trained personnel under IPP IX.
- A report on the evaluation of Pulse-Polio Immunization coverage in Hubli-Dharward.
KAP study report on Diarrhoea at Yaraguppi village.
- A Sample study on Birth-Death Report at Sulla and Kiresur villages.
- Knowledge study on ANC care and Breast feeding at Yellapur town.
J
-27The Teaching staff spend their time during the Non-training period as follows:
05% in lesson planning,
05% in preparing instructional materials,
05% in measuring learning,
20% in field follow-up,
05% in record keeping,
10% in staff interaction,
10% in professional enrichment.
The other 40% is taken up by other activities like Talk shows on AIR, School Health,
etc.,.
The center has Charts (on health & FW programmes), 2 Modules and manuals, 1 Model
Skeleton 1 FW programme Model, 82 video films and 16 strip films as Instructiona
material
]
The following Teaching materials has been prepared by the institute:
1) Kannada version of the Chetna training module for BHE’s
2) Video-cassette for Ayurvedic practioners and FW in the field.
were developed for IEC
3) Folk literature , including songs, drama and Harikatha were
Bangalore.
Regional Health & Family Welfare Training Centre, Old Hospital Premises,
Gulbarga.
The filled up positions is 84% (16/19) with 7 Part Time faculty. Many of the faculty of the centre
have a Diploma degree in Health Education.
In the
In
the floor
floor area
area of about 3470 Sq ft, there are 7 rooms for the faculty, 04 for the staff, 2
classrooms, 1 Seminar room, 1 Dark room and an AV room. There is no Laboratory or
Demonstration room.
The functional equipment include 1 OHP, 1 Audio cassette player, 1 Video ^mera^ 3 TV
monitors and 1 Video cassette player. The Still Camera is to be condemned and the 02 OHPs, 1
Side projector, 1 VCP and the Photocopying machine are in need of repair.
A total of two vehicles - a mini bus and a matador are on road. A Jeep is to be condemned.
The Library with an area of 300 Sq ft has 701 books. No Periodicals or Journals are being
subscribed. There is no computer or photocopying facility.
The Hostel with a floor area of 1800 sq ft has 15 rooms including a room for the warden, a Dining
hall, kitchen and a recreation hall.
Of the Budget released for the previous financial year 32% was utilised. Rs.2,48,082 was
surrendered since no deputation was made for the RCH awareness programme resulting in non
conduct of these courses.
The Training programmes conducted were as follows:
In-service RCH awareness programme for Medical Officers.
- SOSVA Field workers training under RCH.
District level workshop on RCH.
No separate publications have been made from this center.
The Teaching Staff‘s Non-training time activities were as follows:
L
-2821.4% in course planning,
21.4% in lesson planning,
10.7% in preparing instructional materials,
14.28% in Field training,
28.6% in record keeping, and,
03.6% in Professional enrichment.
The instructional materials available at the center are 6 Charts, 4 Modules / Manuals, 2 Models,
23 Slides and 32 videocassettes.
The teaching materials prepared at the center are:
- Module for BHE category “ Chetana Module “
CME training teaching lessons.
(B)
ASSISTED/ FUNDED PROJECTS AND TRAINING PROGRAMMES
International and Multilateral and Multinational Agencies
The international and multi lateral and multinational agencies including the World Bank have been
assisting the Government of Karnataka and the Department of Health and Family Welfare directly
or indirectly through Government of India. The assistance has been in terms of both soft credits
and grants to undertake the health and disease related endeavours and training is an important
component in these projects.
This has even got a historical context. The first public sector Family Planning clinic was started in
Ramanagaram with assistance from the Rockfeller Foundation. The Induction training
programmes was started in this centre during the pre-independence days.
The India Population Projects I and III though specifically concentrated on the development of
infrastructure also undertook training endeavours. Programme specific training got a major boost
both in terms of both methodology and content
(MODULAR training programmes) with the
Universal Immunisation Programme.
The Child Survival and Safe Motherhood Programme implemented in phases since 1992 by the
Government of India with assistance from the World Bank attempted at "rationalising the
(fragmented) services with a package". The well thought out situation analysis as a methodology
of training which was a major component in the CSSM training programmes did not seem to be
implemented with the spirit which it was intended to.
The current ongoing projects are India Population Project VIII (for Urban slums in Banglore
Cities and recently extended to eleven other cities in the State), India Population Project IX (for
upgrading the Primary Health care Infrastructure in select districts of the state with a major
component of training - establishing the State Institute of Health and Family Welfare and the
District Training Centres) and Karnataka Secondary Health Systems Development Project
(for upgrading the network of Referral services at the secondary level care). The Reproductive
L
-29and Child Health Programme though a World Bank funded programme is being implemented
through the Government of India. The World Bank is assisting the Government of India in the
National AIDS Control endeavours by supporting the formation and sustenance of the Karnataka
Sate AIDS Prevention Society (a major component is training in HIV / AIDS including
management of Sexually Transmitted diseases). Two other programmes on similar lines are the
District Blindness Control Programme and the Revised National Tuberculosis Control
Programme. A comprehensive Health, Nutrition, Population Project is in the offing and is
slated for the middle of 2002.
The following paragraphs highlight both the general and the programme specific review of training
programmes in these projects.
1.
Unfortunately, the Disease specific or programme related training programme was
promoted at the cost of generic training programme. This lead to many health staff not
receiving this very necessary and important entry level enabling capacity for
appropriate functioning. It may be noted that the current very senior level functionaries
who are about to retire are the only ones who have received the generic or induction
training programmes exception being the new recruits over tne last two years.
However, the General Law and Accounts exam, which the health care personnel have
to pass to obtain their increments was the only saving grace in this situation.
2.
Overall training needs assessment of the system gave way to programme requirement
training. The pros and the cons of such an approach cannot be dismissed as academic
discussions. We have in the system today, people who have not been trained for their
keeping in mind their job responsibilities and have learnt the trick of the trade of
managing by trial and error (see vide supra - Focus discussion). This unfortunately is a
highly undesirable method of learning.
3.
A major positve feature of the Externally funded projects have been the
systematic independent Mid Term Reviews that have been undertaken. The strict
monitoring of the progress of the planned activities has indeed resulted in the
desirable mid course corrections.
4.
Efforts are now on to integrate the systems and sub-systems more so with regards to
training - creation of the State Institute of Health and Family Welfare and the District
Training Centres through India Population Project IX and the re-introduction of the
Induction Training through the Karnataka Health Systems Development Project being
examples.
-305.
A question still remains unanswered. Do the time bound (5 years) project mode of
these endeavours end up in merely 'having new buildings' without adequate,
appropriate skilled human resources? This needs to be seen beyond the rhetorical
question for there is a distinct possibility that there would be the double burden of new
buildings with inadequate trained staff and inappropriately trained health care
providers. Unless this question is addressed as an immediate priority, there will be
precious little to even think let alone talk about the Public Health and Primary Health
Care for the future generations of the residents of the State.
The review of the IPP VIII, IPP IX and the KHSDP training programmes revealed the recent
conduct of independent in-depth studies (Mid Term Reviews). One of the MTRs (for KHSDP
Skills training evaluation) is being concluded. It is too very early to expect to asses the impact of
the changes being brought in. There have been certain process shortfalls indicated in these
MTRs. Given below is our finding on the progress made subsequent to the MTR based on our
discussion with the concerned officials. Pending the submission of the final report of the Skills
evaluation review for KHSDP, the gist of the informal personal interaction with the evaluator is
documented below.
It was evident that training was now getting a relatively higher priority than earlier. The IPPVIII
(Bangalore City component) is far ahead in terms of the training for its health care personnel in
particular the new category of LINK WORKERS. The IPP IX demonstrated that despite the
shortfall in the targets that were to be achieved both in terms of infrastructure and training
programmes, there has been considerable progress documented. The KHSDP has re-introduced
the Induction Training programme for the new recruits and also initiated the Clinical Skills
upgradation programme. The HIV/AIDS training programme has introduced the participatory
learning methods in the training sessions. The new training programme for RCH has taken the
integration forward with administrative training, communication skills and supervision skills.
(c)
TRAINING MANUALS
Multiple training manuals are being used for training purposes by various training institutions.
Quite a few of these are manuals used in other states for training purposes or manuals
recommended by Central Government (NIHFW, Manuals used in Andhra Pradesh, CHETNA
manuals, etc.,.) Some of the above manuals have been translated into Kannada for the training of
para-medical staff. A review of these manuals indicate a need for updating of information. Many
of these were prepared for training purposes for earlier programmes and changes have
happened since (for example - CSSM and the current RCH programme). By far and large, the
manuals do not present knowledge in a training format. They read more like textbooks or guide
-31 books. Training exercises, presentation of knowledge in a format which would be easy for the
trainees to absorb, newer methods of training methodology, lack of learning objectives as well as
essential knowledge, non-interactive format were some of the flaws noted (exceptions being the
NIHFW manuals which are being used under IPPIX at DTCs, and a few others like the RCH,
etc.,.). The contents in these manuals seemed to be more theoretical and lacked the focus and
emphasis on the field situation and ground realities. A change in focus of the concerned
programme very often necessitates the training institute to commission a new training manual.
Change is inevitable and programmes are constantly evolving. However, the change sometimes
is rapid and frequent often leading to repeated trainings with very few new learning additions.
Because it is a new programme the manuals also get redone with slight modifications.
(D)
OTHER SPECIFIC ISSUES INCLUDE
1. All the heads of the Training institutions at the State and Regional level do not have the
requisite experience and capability required for the posts. This necessarily has a bearing
on the various endeavours of the institutes. Where the top is shaky, non-confident, not
capable how much can one expect from the team.
2.
The antecedents of the post of the Medical Lecturer Cum Demonstrator (MLCD) could
not be ascertained.
3.
Only Sixty percent of the personnel interviewed were able to understand the questions
asked and give appropriate response.
4.
Those who had cleared the Accounts Higher and General Law Part-1 mentioned that it
gave them greater confidence and competency to handle
day-to-day PHC
administration.
5.
POL issue: POL was earmarked as per trainee per day. When the number of trainees
was 30 this amount would be sufficient. But when the number of trainees was less which
was usually the case the amount would be inadequate. This was more so, when the
number of trainees were 10 or 15.
6.
A finding which was disturbing was the "fees” paid to the staff of the training institutes for
taking training sessions. Often about half the fees of an expert external consultant, the
need to pay these "internal" department/training institute staff is hard to justify/explain
considering that they have been employed to do training(’) and conducting/giving training
is their job! So if they are required to be paid additionally for conducting training sessions
of the various projects in their state or regional institutes then what is their salary being
paid to them for? This matter obviously calls for some justification.
-32DISCUSSION AND CONCLUSION
a) The review of the Training programme for the government health care personnel gave an
unique opportunity and insight to the investigators to understand the existing machinery and
mechanics of the training programmes in the Department of Health. The interaction and
discussions with the implementing staff was not merely a methodology but also a
sensitisation and motivation session.
b)
The
investigators
found
themselves
with
mixed
feelings:
frustration,
indignation,
hopelessness in some areas and rays of hope, happiness and satisfaction where few
successful endeavours were being undertaken even in difficult circumstances. In general,
there was a sense of apathy and a casual approach towards training. The enthusiasm was
muted, existing as an exception. Training was expressed as an activity that “one had to go
through”: the unwritten expression being that training programmes were not always
necessary and that a pre-induction training in administration and medico-legal matters would
suffice. This outlook decreased the effectiveness of the training programmes. Participants
often looked at training as an “opportunity for change”, “to go out” - rather than a learning
and growing session. These naturally lead to enormous wastage of resources.
c)
Factors outside the immediate purview of the Training programme most often determined its
successful outcome - timely intimation, deputation and relieving of the personnel; the
payment of adequate TA/DA on time; the training facility (infrastructure / staff / equipment
including vehicle) available. A very critical determinant of success was the feeling of the
usefulness of the training programme by the trainee. In the absence of strict monitoring and
evaluation in general administration and with a relaxed disciplinary effort, training
programmes depended on the individuals perception rather than systems requirement. In this
regard, the Tubectomy and MTP training programmes were the main casualty.
d)
Most of the trainees were at the fag end of their careers or they would be unable to put their
training into practice.
e) A visit to the training institutions re-inforced the disappointment; the once premier training
institute at Ramanagaram was found to be in a derelict and dilapidated condition - a result of
neglect and abandonment of purpose. The available infrastructure at some of the regional
Institutes was also found to be inadequate and this could be one reason for their gross
underutilisation. The number of training days never exceeded 30 days in the previous
calendar year in all the training centers visited. Amazingly, the Heads of the Institutions
-33-
clearly lacked the will and vision to take the issues forward and one wondered at the rationale
of their occupying such an important post. Whether it was because of past actions of their
predecessors or an inadequate support from the State level officials, it seemed they were
“resigned to their fate” and had accepted “reality” and “non-action” as the best recourse.
Obviously if the top level was not concerned, it is not surprising then to find the rest of the
staff lacking any motivation or interest even to undertake their routine training activities let
alone innovation.
f)
Often, Adequate and appropriate infrastructure was not made available after training. During
the skill development due to various reasons, hands on experience was either insufficient,
inappropriate or inadequate. In essence - “fooling ourselves" was the general feeling
amongst both the investigators and the “trained” personnel.
g)
Regional requirements for training were not considered and factored while framing the
curriculum or even during its implementation. Standardised syllabus had replaced the earlier
freedom to innovate.
h) The Training section has not received its due in the directorate except in the recent past, a
major reason being the lack of realisation of its importance in improving the quality of health
care delivery services.
Another major reason was the lack of a forceful personality in
leadership role - an individual who could demand and obtain the necessary support and
finances for carrying out training programmes on a regular basis successfully. This led to a
situation where the training section had hardly any funds and work to carry out. Even
"induction training" - so important for a proper orientation and grounding of new staff was not
being carried out.
0
With the World Bank financed projects setting its own training agendas and funding training
programmes, routine training activities of the department took a back seat - leading to a lot of
frustration and a sense of resignation and hopelessness amongst the senior staff of the
training section in the directorate.
i)
The limited time frame projects have demonstrated the need for training and given it the due
importance. Of course, once the project funding is over, training will need to be financed
from routine funding mechanisms of the department. There is therefore a genuine need to
streamline the training section in the department so that it always receives its necessary
importance, priority and support.
-34k)
At present the department has training institutes (State, Regional and District and ANM
training centres) where all State level training is carried out. In addition, institutes like the
National Tuberculosis Institute also carry out training activities for the state health employees.
The State and District level institutes have only recently been set up (in some districts - are
still being set up). The funding for this came from IPP IX / KHSDP. The training staff in the
directorate not having any budget for training purposes and the World Bank funded projects
being able to fund many training activities in these institutes has created a dichotomy of
interests in the department.
The training department staff posted in the directorate feel
completely bypassed and frustrated at these developments and their lack of information on
training facilities and activities was indeed surprising but not completely unexpected under
the circumstances.
I)
There is also an absolute lack of coordination of training activities - training being ad hoc and
project driven with no need based appraisals (including geographical distribution) being
carried out.
Und^r these circumstances - the setting up of new District training centres adds
an altogether new dimension in training funding and activities.
Being project driven, their
regular maintenance once the project period is over will be necessitated from the funds
allocated for training. Whether the budget at that stage will be able to absorb these additional
costs needs to be seen specially since in the past the funds allocated for training activities
were so meager and the priority given to training so low.
m) It is unlikely that training activities as envisaged and needed can be carried out unless an
estimated Rs.5 crores (only around 1% of the proposed health budget) are annually allocated
to training section (this amount excludes salaries to employees). With the projects showing
the way and giving training activities the necessary fillip and importance for improving the
quality of health services being delivered by the department, allocating funds for training (to
this amount at least) from the health budget should be done without any compromises in the
future.
n) To streamline training activities of the department - a restructuring of the department staffing
and line of reporting is required.
INFERENCES AND CONCLUSIONS
-351.0
TRAINING POLICY / FINANCING / PLANNING / ADMINISTRATION
1.1
There has been an absolute neglect of the training component in the department.
The approach of the directorate has been casual and not systematic.
1.2
There is an absolute paucity of "routine funds" with the training section in the
Directorate. This has lead to a lack of interest, hopelessness and frustration
amongst the training staff of the department specially in the Directorate
1.3
The externally funded projects have been able to give training a much needed
focus and importance. They have assisted in setting up of new training
institutions and provided the older ones with work and some "training funds".
1.4
The Training activity in the Department of Health and Family Welfare is "project
driven". At the stage of the development of the different Project Proposals there
has been noted a coherence of thoughts and activities for the Human Resource
Development for the Government Health Care Sector.
1.5
Transforming of the thinking into action has been delayed or has not been
achieved.
1.6
There exists no mechanism for centralised planning of training nor any needs
based inputs from the field.
1.7
There is no database of the training undergone by the government health staff.
1.8
The different programmes and projects independently conduct some degree of
needs assessment and plan the training activities. This leads to considerable
wastage of resources. (Same individual obtaining a repeat training in the same or
very similar area).
1.9
There has been noted an indifference with regards to proper administration of the
training institutions. The Posting of the heads of these institutions seems to have
been undertaken without regard to the requirements of the training centre. It is
very unfortunate that these institutions for excellence have been considered as
“accomodative posting centres” or “rehabilitation centres”.
2.0
TRAINING INSTITUTIONS / ORGANISATION / EQUIPMENT
2.1
There exists a network of training organisations right down to district level with a
great potential.
2.2
There exists human resources in the health sector who with adequate motivation
and training could convert these institutions into centers of excellence. What is
urgently needed is to match the needs with requirements and putting the right
person in the right position.
2.3
The postings at the training institutions are sought more for convenience and
selections are based more on “personal needs, ability to influence, etc.," than on
-36ability to train. For many others, training institution postings meant "loss of
practice" and therefore was undesirable.
2.4
The training institutions are grossly underutilised. The SIHFW and the DTC are
new institutions and are yet to become totally functional. The RHFWTC continue
to be neglected.
2.5
The attention given to maintenance of the institutions is highly inadequate /
insufficient.
2.6
3.0
Key vacancies remain unfilled / gets filled with wrong personnel.
TRAINING NEEDS ASSESSMENT
3.1
There is no systematic comprehensive Training needs assessment undertaken at
any point of time and no training database exists.
3.2
The TNA when undertaken has not been correlated to the performance /
achievement of the individual health care personnel (even as evidenced by the
confidential reports of the department)
3.3
There is a need to delineate, specify and inform the personnel about the job
responsibilites.
3.4
TNA should also incorporate the infrastructure that would be necessary for the
trained personnel to effectively undertake specified endeavours.
4.0
FACULTY/TRAINERS
4.1
The Faculty in the training institution are demotivated and consider themselves
unfit either because they are not adequately qualified or prepared for the post
they are occupying or their training potential remains unutilised / grossly under
utilised.
4.2
A great felt need is the approapriate Training of Trainers in all the training
institutes. The JIPMER Model used for RCH ToT is an example of success.
5.0
TRAINING MANUALS
5.1
Multiple training manuals are being used for training purposes by various training
institutions.
5.2
These manuals need updating of information. By far and large, the manuals do
not present knowledge in a training format. Some of the flaws noted include lack
of training exercises, underutilization of newer methods of training methodology,
lack of learning objectives and non-interactive format.
5.3
There is a dire need to have a very thorough and detailed analysis of the various
manuals that are presently being used for training purposes. They need to be
made more user-friendly, have a greater self-learning component and more
-37practical and field based exercises. The NIHFW has recently come out with the
updated versions of many of their training manuals incorporating the latest
programmatic changes. The training institutes have already been provided with
copies.
5.4
The contents in these manuals seemed to be more theoretical and lack focus
and emphasis on the field situation and ground realities.
5.5
With a change in focus of the concerned programme the training institutes
commissioned new training manuals. With programmes constantly evolving,
frequent changes lead to repeated trainings with very few new learning additions.
However, the manuals get redone with slight modifications for almost all new
training courses.
6.0
TRAINEES
6.1
There is a demand for Induction Training and Promotional Training by most
health care personnel - both medical and paramedical.
6.2
There is also an expressed desire for regular periodic Continuing Education
programmes.
6.3
There is a need for improving the facilities given to the trainees including TA/DA,
Resource materials, quality of hostel accommodation, food, etc.,
7.0
FEEDBACK / FOLLOW UP / MONITORING
7.1
The existing system of monitoring and feedback is limited to Post-Test
assessment related to the subject matter. No long-term or application of skills
monitoring is carried out at present.
7.2
There exists no monitoring of the Training programmes and activities of the
training department save for the budget spent.
-38-
RECOMMENDATIONS
The RECOMMENDATIONS have been made based on the following:
a) Observations made by the investigators during their personal visits
b)
Discussions with the concerned health care personnel.
c)
Information from the analysis of the Self-Administered Questionnaire.
d)
Records and documents that were shared by the concerned officials with the investigators.
IDEAL (Desirable) TRAINING SCENARIO for Department of Health, GovernmenLof
Karnataka
A] THE STATE INSTITUTE OF HEALTH AND FAMILY WELFARE
1. The State Institute of Health and Family Welfare becomes the apex training institute as well
as an institute of excellence.
2. It is completely autonomous and the funds for its activities and maintenance are to be
allocated from the Health and Family Welfare Department Budget directly.
3. The Institute will have a Director at the helm and this post will be a selection post with all
the perks and privileges that are offered to a person of this level. Its tenure will be for a
period of 5 years. He will report to the Health Secretary directly. The person occupying
this chair should have a medical degree and should also have training and experience in
medical education and training of trainers. Ideally, the individual should have spent some
years working at various levels in the department in the field.
4. A Deputy Director will assist the Director with various administrative and technical matters.
The post of the Deputy Director should be a selection post with requirements similar to the
Director's post and should have a tenure of 5 years.
5. The institute should have a full complement of training, administrative and supportive staff
with appropriate qualifications.
6. Considering the importance of social sciences and communication skills, the institute
should have either full time or part time staff for these departments or engage the services
of experts as and when required during training sessions.
7. The institute should have all necessary training equipment and facilities including teaching
space and identified field training centres.
B] THE REGIONAL HEALTH AND FAMILY WELFARE TRAINING CENTRES AND THE
DISTRICT TRAINING CENTRES
1.
The Regional Health and Family Welfare Training Centres and the District Training
Centres would administratively be under the State Institute.
2.
Their budget will be released by the State Institute.
I
-39-
3. Their activities to be based on local needs and practices and to be planned and
coordinated by the State institute.
4. At present there are 2 Regional Institutes in the Northern (West and East) and 2 in the
Southern part of the State.
There are none in the Central part of the state.
This
anomaly needs to be rectified. Also, not all 27 districts have a DTC. Since the activities
of a DTC are different from the RHFWTCs each district needs to have its own DTC or the
RHFWTC should also undertake the activities of the DTCs without compromising on
quality in districts where RHFWTCs exist but where there are no DTCs. However, the
State needs to keep in mind the recurrent expenditure of so many institutes and based on
neeeds appraisal if it is determined that 2 districts can share one DTC, for practical
reasons and long term effective functioning, recourse to this may need to be taken and
the plan of having so many DTCs reconsidered.
5.
The DTCs based on Needs Assessment will identify the training requirements of the
district and forward this to the state institute for necessary plan of action. The DTCs will
also directly oversee the functioning of the ANM training centres in their districts and
provide all the necessary support.
6.
As in the state Institute, all necessary facilities and equipment need to be provided to
these institutes at the earliest for their effective functioning. At oresent, many of them
lack basic teaching aids and educational materials.
The effectiveness of these institutes will depend to a large extent on its human resources.
The training institutes should be allotted staff based on qualifications or appropriateness
and not on personal needs, contacts and political influence and the ability to take care of
extraneous criteria (read favours). Merit and appropriateness should be the only criteria.
Abundant precautions to be taken to ensure that these training institutes will not become
the islands of inefficiency they have been for so many years.
8. With the formation of the DTCs, many of the training activities can now be done at this
level. This will require careful coordination and supervision to ensure quality of training.
9. The Principals of these training centres should be selected with great care and should be
given the right administrative and technical training themselves at the State Institute prior
to their taking up these posts. This is important as very often they will be directly involved
in training activities besides having adequate administrative duties.
10. Regular upgradation of knowledge and training skills, revision courses, as and when
programmatic changes are introduced should be mandatory for all staff of all training
institutes.
C] PLANNING THE TRAINING PROGRAMMES
1.
1
A committee consisting of the Director - State Institute and all Additional Directors of the
Health Department will identify the training needs, prioritise activities and prepare the
budget for training activities.
-40-
2.
The Director of the State Institute will be the Secretary of this committee and will be
assisted by the Deputy Director in formulating and drawing out the master plan of
operations (based on the needs identified by the committee).
3.
Approval for the formulated plans will be put forward during the committee meeting where
the Health Commisioner/ Director General of Health Services are also invited.
4.
Approved budgetary funds will be sought from the State and handed over to the State
Institute for implementing the training activities.
5.
To carry out the planned training activities funds as required will be made available in
addition to the funds earmarked for training purposes in different programmes (e.g.
Malaria, RCH, Tb. etc.).
6.
The training needs of the different funding programmes will be respected and honored.
However, to enhance effectiveness of training, avoid duplication and to cut down on
unnecessary expenditure on travel, DA, etc., wherever feasible multiple training will be
carried out in one training programme.
7.
Rigorous district and person wise data of all training undergone will be maintained and
computerised. This is to avoid wastage of resources and to ensure that everybody
undergoes training and not just a favoured few (as is the custom very often now - same
people going for different training programmes whereas many others never obtain a
chance to enhance their skills).
8.
This Information system on training will be maintained District wise at the District level
and at the State Institute and Directorate. When a staff member moves out of the district
to another district, necessary changes will be made and constantly updated.
9.
The committee now decides on training, This therefore means that there is no need to
have a separate training section in the Directorate - its functions being taken over by the
State Institute, its Director and the Training Committee of the Department. Adequate
support from all necessary sectors in this scenario should be feasible. Unlike the present
situation where funds are never or meagerly, miserly provided.
10. It will be advantageous to build up our training resources and institutes and depute staff
for training in such places. At present, because of lack of training facilities many of our
staff are deputed out of the state for training purposes. If the training is done within the
state we will strengthen and build up our own systems, strengthen our resources, and
provide training in our environment using case material which is similar to what they will
ultimately see.
11. As far as possible all training should be done within the state or at the most in some
training institutes within the country. There is an unnecessary clamor for foreign training
postings. Today, our country offers almost all training and skills required for the effective
training of its staff or for the provision of quality health services. No carrots in the form of
foreign training sessions are called for. With the money spent on such training a lot more
can be achieved and many more people trained. Very often staff are posted for short
-41 -
term observation training. When the conditions and environment are so different and
where training is "NOT SKILL BASED ACQUIRING OR HANDS ON", SUCH TRAINING
OUTINGS
BECOME
ONLY
OUTINGS
RATHER
THEN
KNOWLEDGE/SKILLS
In all fairness, good training opportunities with full scholarships are
offered by international agencies like -WHO, Commonwealth organization, etc.. It is a
shame to see such useful training opportunities being wasted because of non
ENHANCERS.
recommendation of names on time or processing of papers on time or staff being
released on time. Full use should be made of such opportunities for professional
enrichment.
The State institute should have information of all such scholarships
availability and should decide the staff for deputation for such training courses.
12. A major advantage in having the training programmes within the State is that the training
can be done in Kannada using Kannada speaking patients and families which makes it
much more easier for the participants to understand and absorb.
Less financial
resources will be required for such state conducted training and the resources saved
could be utilised for further strengthening of our institutes.
13. Wherever the training is "technical" or the observation invite for technical matters "technical" people (and not non-medical — non-technical administrators) are to be
sent/deputed for such courses.
There is merit in this recommendation.
Our
administrators are made to change departments quite frequently. Sending them for such
sessions then is absolutely non-productive to the department as the technical training in
the health sector (presuming that they are capable of absorbing the technical nuances
involved) is not going to be of use to them in another department like sericulture or
WAKF. However, if the training is for strengthening administrative related skills the
administrative staff should make full use of such scholarships.
14. There is an immediate identified need of training for about 470 Block Health Educators.
Instead of deputing them in small batches to Gandhigram (and take years to complete
the training for all of them), one of the Regional training institute could be strengthened
and provided the necessary infrastructure and human resources to carry out this training.
All further induction training for BHEs could subsequently be carried out in this centre.
Such judicious distribution of training activities is very necessary for optimal utilisation of
limited resources.
15. Distance education methodology is a grossly underutilised training facility in our state.
Today such education facilities from reputed organizations like IGNOU, Jamia Millia,
Manipal, is available in many health areas. They are well planned and so structured that
they are practically useful to the trainees. The government should encourage such
training and as an incentive offer one time payment of a lumpsum amount (one month’s
salary?) for every distance education course of 6 or more months duration completed
successfully by the staff to a maximum of two such courses. In fact, once these
universities offer more and more health related administrative, managerial and technical
courses, the Government should make this a mandatory condition for promotion to a
higher grade after a certain level of promotion.
sjo}Ods Guijuaujaiduj! aidmnuj se naM se saiiiAijoe Guiuibji
pue Buipun/ AjeiuauiBej/ /o asneoaq ajnioruis juasajd aqi japun suaddeq ueyo Aie*
se siuioduaiA aAiwadujoo/iuafijaAip }ou pue juajaqoo e eAeq oj si paaoons oi Buiuibji jo/
Ajesseoau Ajqa os/e si ieqM ing anj± sjauien o; ya/ isaq si Guiuibji juaiupedea
saiuujejBojd duiuiejj aqi oj ssauaAipejja pue Aimqeuieisns ‘iusujiiujuioo uuaj Buo/ ajoui
e epiAOjd oi se os papuatuujooaj Buiaq si oueuaos juasajd aqj uiojj. luajayip ajinb pue
/eoipej qBnoqi lesodojd aAoqe aq± Buiuaieajqi pue snoppou/ ‘aAppadiuoo ssa/ ‘aApoapa
ajoui aq pjnoqs Apnjadoq siq± qaBpnq pajinbaj aqi saAOJdde pue sapiApoe Buiuibji
uo ainipsu/ aieis JoioajiQ aqi sasiApe aapiujujoo siq± aiejoioajia aqi ui paseq aje
oqM sjoioas pe/o saApeiuasajdaj qiiM patujoj si aauicuuioo Buiuieji aqi ‘aiejoioajia aqi
ui paseq peis Buiuibji /o uopeiuasajdaj ou si ajaqi qBnoqi uaAj lesodojd aAoqe aqi ui
paBesiAua auou aje ajaqi sepeis Buiuibji aiejoioajicj woj} aouejpuiq ou aAeq piM aBjeqo
luapuadapui ajoiu io/ e qpM ainpisuj eieis - Joioajpj aq± sapiApoe Buiuibji ui paA/OAUi aie
peis sit Pue sainipsui Buiuibji aqi - AouaBe auo Ajuo mou se uopopi ssa/ aq him ajaqi lnq
pajinbaj aq pels ssa/ piM Ajuo ion 'suopsaBBns aAoqe aqi oi saBeiueApe Aueiu aje ajaq±
isee| ie goO3
sesjnoo
esaqi jjejs oj sb os ji|6nos seojnosej puB ajnpnjjsBJiui aqj joj poddns Ajbss9oqu
pus AjJSJOAiun iqpuBQ Aeafey qiiM ino pa^OM aq oi paau saijj|Bpoiu aqi amiijsui ajBis
aqj jb Buiuibji siqj apiAOjd puB ajnjn/ aqi jo/ UB|d pjnoqs luawpBdaa aqi sibbs Maj
b jajjo op sa6a||oo iBoipaiu aqi luasejd iv
jjeis sji joj Buiuibji qons joj paau aqi pasi|Baj
uibBb aouo ssq luaiuujaAOO aqi isqi Auueoaj A|uo si u
MO|q |buij b 11 babB seuofiaiBO
jaqBiq oi uoiioiuojd joj Buajuo Ajbssooou b joBuoi ou sbm HdO
pasBOJoap Buiuibji
qons joj B|qB|iBAB sjbqs jo jeqiunu aqi aiuii jo pouad b jbao pub sasjnoo qons op oi
esiM jeejBO snoaBaiuBApB iou sbm 11 sb sja>|Bi moj Ajba paq ‘saai/M isod - esjnoo HdO
injasn pua pauuBjd ||0M aqi inoq aqi jo paau aqi si Buiuibji queen oilQnd BuiueqiBuaJis
l\
uoiioes Buiuibji aqi jo saojnosaj paiiiuii aqi asijiin
oi Abm isaq aqi eq iou Abiu ..tueisAs Appnq,, aqi pua spadxa isaq aqi 8>|buj AjuBSsaoeu
iou op Aeqi lueiupBdaa aqi luojj jjbis pejiiej iou ojb siUBijnsuoo pedxa qons ||B taqi
ejnsua oi ue>|Bi aq os|B isniu eJBO ‘isqi pies SuiABq ‘jbabmoh AjiiBej pasaq pjeij qiiM
auni jo jno jo leoiiajoeqi Ajoa eq oj puej ..spedxe,, qons uajjo Ajoa sb ‘eouauedxa piaij
AjBSseoeu aqi eABq sjUBiinsuoo qons jaqj aes oi ue)jej aq isnw ajBQ sjanpiAipui qons
jo asaq aojnosaj B aABq pua ..siuBijnsuoo,, iqfiu eqj Ajijuapi oj eiqBJisep AjqBiq ejojajoqi
si l| s||p|s/aBpa|MOiD| AjBSseoeu aqi >|0B| jjbis ajniiisui ajeqM isniu b si siqi yedxa
apisino ub jo saoiAjas aqi dai oi Ajesseoau aq Aeiu 11 auop aq oi Buiuibji aAiioejja joj ‘91
-It’
-431. TRAINING POLICY / PLANNING / FINANCING / ADMINISTRATION
a. The Department of Health and the Directorate of Health and Family Welfare need
to spell out their Vision, Policy, Goal and Objectives for a comprehensive Human
Resource Development particularly for training its personnel.
b.
The Department of Health and Family Welfare needs to set up a functional, co
ordinated, central mechansim to assess the systems training requirements and
its monitoring.
c. There is a need to set up mechanisms to undertake both internal and external
evaluation of its training programmes.
d.
There is a need to streamline the administration and functioning of the training
activities sub-centre upwards.
e.
For achieving the planned training activities, an exclusive financial support to the
extent of 0.5 to 1% of the total budget of the health department should be made
available.
2. TRAINING INSTITUTIONS / ORGANISATION / EQUIPMENT
a. The SIHFW should be mad
functional as an apex, nodal centre and an
institution of excellence. All the existing Training Institutions to be administratively
and functionally linked up to perform as an effective organization under the
leadership of SIHFW.
b.
The existing RHFWTCs should be strengthened and steps taken to ensure their
adequate utilization.
c. The existing DTCs need to be made functional at the earliest.
d.
Prioritisation of allocation of limited resources would very much be required so as
to achieve its efficient and effective utilization, specially since the number of
training institutions have now increased.
e.
There is an urgent need to address the release of funds for repairs and
maintenance of the institutions including non-functional but repairable equipment
in the existing centres.
f.
A uniform standard of personnel and equipment need to be specified for the
training institutions across the State.
3. TRAINING NEEDS ASSESSMENT
a.
The TNA should be taken up systematically for all levels and should be co
ordinated with the Individual Performance assessment of the health care
personnel.
-44-
b.
Health Management Information Systems HMIS) need to be put in place on a
priority basis for the training needs and training undergone of all health care
personnel. This has to be generated from the district level upwards and the
information base and accession should also be made available district level
upwards.
4.
FACULTY/TRAINERS
a. Only individuals with relevant and appropriate qualifications and experience
should be posted to these centres.
b.
All the faculty including the heads of the institutions should undergo a pre-posting
training in Educational Technology before taking charge of their posts.
c.
The Trainers should be given a periodic refresher course to upgrade their
knowledge and skills.
d.
More models like the JIPMER model need to be immediately formulated and
implemented. This is all the more necessary considering the spurt of training
activities planned for in the coming months and recruitment of staff for the newly
established DTCs.
e.
Consultants should be empanelled for key support areas of training like
Communication, Social Sciences, Statistics, etc., at each training institute. These
consultants are to be chosen on their merits and experience in training. They
need not necessarily be selected from retired or functioning government officials.
f.
The Training activities of all trainers including consultants should be evaluated for
each session not only by the trainees but also by institute staff and feed back for
making the necessary changes provided.
5.
TRAINING MANUALS
a.
There is a dire need to have a thorough and detailed analysis of the various
manuals that are presently being used for training purposes. They need to be
made user-friendly with a greater emphasis on self-learning and more practical
and field based exercises. The manuals need to present knowledge in a training
format and not as textbooks or guide books. Training exercises, presentation of
knowledge in a format which would be easy for the trainees to absorb, newer
methods of training methodology, stating of learning objectives and essential
knowledge and use of interactive format are required.
b. A set of essential training manuals should be provided to all training and health
care institutions including PHCs. Appropriate mechanisms for their storage and
safety at these institutions need to be worked out.
c.
A process needs to be evolved that would make it feasible to update the manuals
with the additional inputs / changes rather than completely redoing them with
-45changes happening in the programmes. This would result in saving of precious
resources.
d.
6.
Whereever feasible, the training manuals instead of being freshly written should
be adopted / adapted from existing manuals on the same or similar subjects.
TRAINEES
a. Trainees should be released on time, and they should report at the beginning of
the training course. Very often the introductory sessions are the most important
sessions in the training programmes and missing these sessions greatly
weakens the effectiveness of the rest of the training programme. Also the
trainees should be present through out the training course. Mechanisms to make
this feasible should be developed and instituted (for example linking the monthly
emoluments to the successful completion of the course as per defined
parameters).
b.
Induction Training and Promotional Training to be made mandatory for all
categories of Health Care Personnel.
c. Follow-up mechanisms should be instituted to assess the post-training
performance of the individual trainees periodically.
7.
FEEDBACK / FOLLOW UP / MONITORING
a. A system of immediate Post-training assessment regarding the training
programme needs to be carried out. This should look into subject matter,
methodology of the training and effectiveness of the faculty. A system needs to
be instituted for the reporting of feedback to the concerned faculty and action
taken on the post-test assessment.
b. A periodic (once in three years) review / evaluation of all the existing training
programmes for the health care personnel should
be undertaken. Evaluation
also needs to be carried out whenever any new component is added to the on
going training programmes.
c.
The performance appraisal (Confidential Reports, etc.,) of the individual staff
should include the training undergone and identify further training needs.
An effort has been made to define the vision, goats and objectives
for the department. This needs to be adopted with appropriate
modifications by the department so as to increase the commitment
towards training. Also given below is the outline of a proposed
pilot endeavour for training activity in one division.
-46VISION, GOALS AND OBJECTIVES FOR TRAINING ACTIVITY FOR THE
Department of Health and Family Welfare, Government of Karnataka
VISION
To provide technically competent, socially relevant, appropriate health services to the
fullest satisfaction of the people of Karnataka.
GOALS
By 2002, January every health care personnel who joins the government health service will
receive induction training.
By 2005, every health care personnel will receive the identified and necessary refresher
training and skills up-gradation.
By 2010, systems are in place for the conduct of regular, ongoing, continuous refresher and
induction training with adequate provision of resources.
OBJECTIVES
1.
Preparing the individual’s competence by enhancing communication skills and learning
capabilities that are necessary for managing the day-to-day LJtivities of the health centre
and for delivery of quality health care in accordance with the existing health programmes
and local health situation.
2.
To nurture and enrich the organisation culture which supports and enhances team effort,
harmonious interpersonal relationship, pursuit of excellence, spirit of enquiry and
innovation as a way of work life and to create an organisation environment where each
can share and contribute towards achieving the shared goals.
3.
To create sensitivity to the needs of the society, discharge the multiple roles and
responsibilities and fulfill the obligations as a health care provider.
4.
To help and support each individual to develop their potential to realise their self-goals
while contributing fully to the success of the organisation.
5.
To achieve synchronisation of the goals and aspirations of the individual, organisation
and society.
6.
Enhancing preparedness for willing participation in development activities which have a
bearing on health of the community.
7.
Facilitate building a strong character of integrity, honesty and leadership.
PILOT ACTIVITY
It is absolute necessary that any radical surgery is attempted a pilot endeavour be
planned in a smaller sub system which provides for opportunity and facilitates for an
adequate and in-depth learning of the crisis management in the system. Additionally,
-47this approach accomplishes the much-needed involvement of a larger select group of
the system who, are the stakeholders for change.
The following needs have been considered while formulating the Pilot Activity of the Team of
Excellence in Training (TOEIT).
a)
There is a need for co-ordinated decentralised planning for the endeavours
towards Training. This includes Training Needs Assessement, framing of the curricula
and identifying the resources at each level of training before implementing the activity.
b)
The State Institute of Health Family Welfare to be recognized as the apex and
premier Institution for training in the state. The RHFWTC and the DTCs to be identified as
the regional and peripheral wings of the apex institute.
c)
The existing organisation structure of the Training “wing” of the department
needs to be restructured. There should be a similar staffing pattern at the three levels District, Division / Region and State. There should be a well laid out and comprehensible
hierarchy with specified responsibilities. The lines of authority with their attendant network
linkages to be identified..
d)
The system also needs to factor the future training requirements of the state with
regards to the health sector.
The following points delineate the components of the proposed Pilot endeavour for Training
activity. The final Plan of Action may be arrived at after further consultations.
1. Gulbarga division to be the focus of the endeavour.
2. The Divisional Joint Director, Gulbarga to be the team leader for the activities. Twenty
to twenty five members selected from amongst the existing staff / faculty / officials in
the Division would constitute the TOEIT.
3. Necessary support could be drawn from the District Training Centres, the Regional
Health and Family Welfare Training Centre and the State Institute of Health and
Family Welfare.
4. The current research team would be the key facilitators for the endeavour.
5. The Task Force on Health and Family Welfare and the team involved in the preparation
of HNP Policy for the Department of Health and Family Welfare to facilitate and also
provide the required technical inputs.
6. The TOEIT would undertake a systematic training needs assessment in the division
keeping in mind the existing realities of service delivery, the proposed activities of the
department and the future requirement of the system.
7. The TOEIT would then involve themselves in the preparation of the curriculum,
methodology (including identification of resource persons, resource materials and
training environment) and schedule for the training for the next three years. They
would also prepare the required annual and total budget for the endeavour.
8. The Pilot Activity would be monitored on a regular and pre-identified intevals and will
be based on suitable indicators (both qualitative and quantitative).
-48-
i'.’S
EVALUATION OF TRAINING PROGRAMMES FOR GOVERNMENT HEALTH CARE
PERSONNEL IN KARNATAKA
HEALTH WORKERS (FEMALE) AND HEALTH ASSISTANT (FEMALE)
-49-
INTRODUCTION
Health status of people in India has shown remarkable improvements during the last two
decades. The Crude Death Rate (CDR), Infant Mortality Rate (IMR) and Crude Birth Rate (CBR)
have shown sharp fall and key health indicator 'Life Expectation at Birth’ which was about 42 in
early Fifties has crossed 60 years in the early Nineties. Wide differentials across states in India,
however, have persisted throughout suggesting the need to take corrective measures to bring in
much desired equity in health to reach the goal 'Health For All by 2000’ India has committed at
Alma-Ata in 1978 (See Table 1 for differentials).
The data presented in Table 1 clearly brings out the fact that Southern States - Kerala, Tamil
Nadu, Karnataka and Andhra Pradesh have shown relatively better performance as compared to
Hindi speaking BIMARU States - Bihar, Madhya Pradesh, Rajasthan, Uttar Pradesh and Orissa.
Wide differentials within state by rural-urban residence, gender and social class exist across the
Districts. The Human Development Report 1999 - Karnataka provides CDR, CBR and Life
expectancy at Birth for all the districts that reveal the differentials. IMR another sensitive health
indicator shows that Dakshina Kannada reported the lowest IMR (27) in the state while Gulbarga,
Bijapur, Bellary had IMR about 3 times higher than Dakshina Kannada district. There is other
strong evidence to support the IMR estimates - institutional deliveries in Dakshina Kannada
accounted for 77 percent while in Gulbarga it was only about 27.9 percent suggesting the strong
negative association between IMR and institutional deliveries - safer deliveries.
TABLE 1 : HEALTH SITUATION IN INDIA AND SELECTED STATES
State
Maternal
mortality
ratio 1986
C DR 1996
IMR 1996
Sex
Ratio
1991
CBR
1996
R
U
T
R
U
T
India
77
46
72
9.7
6.5
9.0
580
| 927
| 27.5
AP_______
73
63
13
60
88
90
102
73
99
38
25
16
39
67
60
61
54
65
65
53
14
53
85
85
97
71
96
9.2
8.6
6.3
8.7
10.7
9.6
11.8
10.6
11.2
5.9
5.4
6.0
6.6
8.2
7.1
7.6
6.9
7.5
8.4
7.6
6.2
8.0
10.3
9.1
11.1
10.2
10.8
394
439
247
372
920
627
507
813
844
972
960
1036
974
879
910
931
911
971
22.8
23.0
18.0
19.5
34.0
32.4
32.3
32.1
27.0
934
934
23.4
25.7
Karnataka
Kerala____
Tamil Nadu
Uttar Pradesh
Rajasthan
MP________
Bihar_______
Orissa
439
7.4
5.4
8.7
48
31
58
Maharashtra
373
6.2
8.3
61 _____7.6
46
__ ________ ' 68
Gujarat
Source: 1) Family Welfare Programme in India, 1996-97, Government of India.
2) Mari Bhat P.N., 1995.
The latest data-set (1998-1999) collected in National Family Health Survey and Reproductive
and Child Health Survey (NFHS II and RCH) provide valuable insights for effective policy
-50interventions to reduce the disparities across districts by rural-urban residence, social class and
gender.
Findings from both the surveys suggest that the out reach services of maternal and
child health hold the key to bridge the differentials and these services are to be delivered by
Female Health Workers popularly known as Auxiliary Nurse Midwives (ANMs) and Lady Health
Visitors (LHVs).
The Present Study
The present study is> an attempt to examine the role of these grass root level female health
workers and adequacy of their training to discharge their responsibilities satisfactorily that can
help to reduce considerably the disparities observed across districts.
Objectives
Taking into consideration the major midwifery responsibilities assigned to the ANMs and LHVs
after a rigorous foundation training of 18 months the study proposes to achieve the following
objectives.
•
To examine the knowledge of ANMs regarding the Ante-Natal care service and its
delivery to pregnant woman.
•
To assess their knowledge of identifying the high-risk pregnancies and ensuring safe
delivery that will help to reduce maternal mortality.
•
To examine the knowledge of supplementary nutrition to be advised and supplied to all
pregnant women to reduce malnutrition.
•
To examine their knowledge of identifying high risk infants and measures to be taken to
ensure their survival to reduce IMR further.
•
To identify inadequacies in the training of ANMs/LHVs if any, and suggest corrective
measures.
The Sample
The study was conducted in three districts of Karnataka that differ widely in indicators relevant to
reduce IMR and MMR. These indicators were drawn from the RCH Survey (First Phase -
Kanbargi et.al., 1998). They are :
•
Percent women who received full Ante-natal care package (At least 3 ANC visits + 2TT
injections and 100 I FA Tablets)
•
Percent institutional deliveries.
•
Percent children in 12-23 months age who did not receive any immunization.
•
Percent women who had knowledge of all modern contraceptive method.
Based on these criteria following three districts were selected.
-51 TABLE 2 : SELECTION OF THE SAMPLE DISTRICTS
Institutional
District /
Full ANC
State
(percent)
deliveries
(percent)
1
2
3
76.6
78.9
Udupi (DK)
48.4
Tumkur
68.7
27.9
Gulbarga
21.2
52.4
52.2
State______________________________
Children not
immunised
(percent)
0.5
0.5
31.1
8.3
Family
Planning
knowledge
of all
modem methods
Percent____________
70.7 _______________
40.8 _______________
27.2_______________
46.1
Source: Rapid Household Survey RCH, 1998, Kanbargi el Al.
The three Districts selected differed maximally in several other variables also. For example the
percent girls marrying before 18 years - legally approved age was highest in Gulbarga about 59
percent, 29 percent in Tumkur and only 5 per cent in Udupi (which was part of Dakshina
Kannada then. We selected Udupi District based on the data of Dakshina Kannada district as
data for Udupi are yet to be made available. The observed early marriage and its impact on
CBR is clearly reflected in these districts (Gulbarga 32, Tumkur 24.7 and 21.4 in Udupi).
The three selected districts - one highly advanced - Udupi, one with medium progress - Tumkur
and one backward - Gulbarga in terms of demography and health would be able to provide
insights sought in the functioning of the ANMs and LHVs in the state.
For data collection 8
Taluks 22 PHCs and 87 sub-centres were selected randomly. The following table provides these
details.
TABLE 3 : THE STUDY AREA
Taluks
District
Udupi
Tumkur
Gulbarga
Total
Udupi
Kundapur
i) Gubbi
ii) Madhugiri
iii) Kunigal
i) Afzalpur
ii) Gulbarga
iii) Chitapur
8 Taluks
PHCs
SC (ANMs)
8
26
6
41
8
20
22 PHCs
87 ANMs
Methodology
The relevant data was collected from all ANMs available in the selected PHC/Sub-Centres by
employing survey methodology. A standardised questionnaire was constructed for administering
to each ANM/LHV in the selected PHC/Sub-centre. The administering of the questionnaire was
preceded by a brief introduction about the survey and assurance that the information collected
will be kept confidential and used only for research purpose. In PHC we met the medical officer
(MO) and other staff present and briefed them about the study. We assured all that they will not
be harassed by Health Department or any authorities for sharing their honest views on the
functioning of the Health Care Services.
-52There were focus group discussions to get insights in the functioning of the Institutions that
provided valuable information. This information is exploited to supplement the hard data
collected in the survey.
Each questionnaire administered to ANMs/LHVs took over an hour. The interviews were
abrupted often when many ANMs broke down who were to be consoled to start the interview
again. The respondents reported that it is first time in their entire service someone is enquiring
about their problems and welfare. When they were asked whether they would be happy if their
daughter (those having one) was offered ANMs job, it was revealing that most of them reported
that they do not mind if their daughter goes for agricultural labour but they don’t want them to
become an ANM like their mother. It indicated harsh working environment they are situated in,
their frustration and helplessness.
Data and Analysis
The brief profile presented in Table 4 suggest that most of the Female Health Workers are
currently married, have at least 10 years of schooling and in their middle ages with long
experience. As there are limited opportunities of advancement in the career they feel dejected
struck with the same work for years. Those who were on the verge of retirement were eagerly
looking forward for the day to free themselves and lead a relaxed life.
TABLE 4: FEMALE HEALTH WORKERS IN THE STUDY AREA :
A PROFILE (87 ANMs and LHVs)
1
_______ Variable
Age (years)
Below 40
41
49
50
58
2
Per cent
31
33
23
35.6
37.9
26.4
04
77
06
4.6
88.5
6.9
11
17
41
14
13.3
20.5
49.4
16.9
Marital Status
Single
Currently Married
Widowed/Divorced
3
Frequency
No.of living children
0
1
2
3+
-53TABLE 4: FEMALE HEALTH WORKERS IN THE STUDY AREA :
A PROFILE (87 ANMs and LHVs) (continued)
4
Below SSLC
SSLC Pass
PUC
PUC +
5
Frequency
_______ Variable
Education
18
54
Per cent
20.7
62.1
11
12.6
04
4.6
Less than 5
9
- 14
- 29
22
39
10.3
25.3
44.8
30 +
17
19.5
Length of Service
(in years)
One of the major problems faced by the respondents was shortage of housing - only 40 percent
of them had housing facility provided by the Government, whereas 23 per cent of ANMs were
residing in rented houses in the sub-centre villages. Another 23 percent were in a rented house
in the sub-centre village and the rest 37 percent were commuting to their place of work that
required about an hour. Udupi had an excellent net work of public transport with very good road
that was found to be a very important factor to improve accessibility to health care services
whereas Gulbarga had bad roads or no roads and poor public transport that badly affected easy
accessibility. Tumkur can be placed in between these two districts with some area with good
roads - Kunigal section whereas Madhugiri was having serious problem of roads and public
transport. It would be of interest to mention here that during our visit to observe an ANC camp at
a sub-centre village in Gulbarga we had to leave our car at a point and hire a Land Rover jeep to
reach the Sub-Centre as the road was full of boulders and ditches which only jeep could
negotiate with great difficulty. To cover a distance of 15 kilometers it took an hour at high cost.
Lady Health Visitors have to supervise the work of ANMs. In the study area we could get only 10
LHVs who had to cover on an average 40 villages in addition to their administrative work of
compiling service statistics from each ANM on maternity, immunisation, etc. The fact as reported
by both LHVs and ANMs is that supervision/work monitoring in the villages has almost ceased to
exist. Many senior ANMs recalled that when they joined service they had to cover larger areas population but they used to enjoy the work. There was a team spirit, co-operation and guidance
from M.O and DHO. Work was taken very seriously. The Medical Officers provided home visits
to sterilised cases for follow-up services. Deliveries were supervised and post natal care then
was good. Now hardly anybody bothers about supervision and monitoring. ANMs feel lonely
and helpless in the job as there is neither any help nor guidance and no supervision but if
anything goes wrong they will be held responsible. The information collected from ANMs show
that exceptionally large number of villages 11 to 18 villages were to be covered by 13 ANMs in
Tumkur. Whereas in Udupi and Gulbarga despite vacancies that add burden to ANMs work they
were found to be covering about 3-4 villages as size of population is large. As over half of the
-54-
ANMs were natives of the same district they were quite familiar with sociology and culture of the
area. While more villages add only to travelling time, size of the population, average number of
couples to be served in RCH seem to
t. be well within manageable limits of ANMs with very few
exceptions.
The Foundation Course
The female health workers have to complete the foundation course specially designed for them
to be eligible for consideration for the job. But some had 2 years training while over 80 percent
had completed 18 months course at different District Head Quarters. Surprisingly it was found
that there was a long time gap before they got the job. About 20 percent had joined after 3-4
years of their completion of the course and they took considerable time to refresh their training
skills they had almost forgotten.
Indeed, 6 ANMs had joined service after 5 years gap.
In
addition to the foundation course LHVs have to undergo another 6 months training to become
LHV.
They were asked to assess the quality of their foundation training course in terms of (a)
Curriculum (b) Duration (c) Regularity of Faculty (d) Quality of training (e) Practical training in
hospital and (f) Practical training in the field. Their response was classified in 3 categories. The
distribution of r ^ponses are reported below.
TABLE 5 : ASSESSMENT OF THE FOUNDATION TRAINING BY
THE TRAINEES (PERCENT)
_________ _________
Poor
Fair
Good
x
X
3^
±
X
6
Curriculum________
Duration__________
Regularity of Faculty
Quality of training
Practicals in hospital
Practical in field
78.2
34.5
70.0
24.1
19.5
25.3
15.0
63.2
25.3
644
57.5
59.8
2.3
2.3
8.0
19.5
11.5
Can’t say
4.5
2.3
2.3
3.4
3.4
3.4
It is to be noted that 18 months duration is divided as 12 months theory and 6 months practicals
in hospital and field. The majority of ANMs (63.2 percent) considered that duration was too short
as they had to complete 10 theory papers. It is also reflected in the assessment of practicals in
hospital as 57.5 percent reported that on job training was too short to master the art of good
midwifery. Almost 60 percent felt that the field training that forms the most important component
of their job was inadequate.
Majority of the ANMs opined that the curriculum is good but heavily biased towards theory
whereas most important for their job is field work where they have to manage themselves with
midwifery that put heavy responsibility. Communication skills which they need most in their field
work was found to be lacking. It seems there is an assumption, that all ANMs have that skill.
During discussion with ANMs we asked how confident they were when they conducted the first
delivery of their career. Majority response was they were very shaky. Few were fortunate to
-55have a LHV who was good to instill confidence in them giving guidance in the conduct of delivery
that went a long way in building their confidence. But many were not that fortunate but could
manage the situation without any serious problem.
How the training received several years back is relevant now? Several respondents mentioned
that except midwifery hardly anything is relevant. AIDS, RCH, Target free approach are all new
and are relevant now. More skills are required for day to day work and to recorded them
properly in the registers provided.
SECTION I
In this section we have tried to review the training programmes that respondents have completed
and how they perceived their utility in their day to day work. The major programme in this regard
was the Child Survival and Safe Motherhood training followed by several other short term skill
knowledge enhancing programmes.
Child Survival and Safe Motherhood (CSSM) Training
Reduction in maternal and child mortality was highlighted in the National Health Policy 1983.
The sustained high levels of immunisation programme that increased contacts of female health
workers with women and children demonstrated that about 2million children were saved durin^
1984-92 (the difference in child mortality rates of 1984-92 which was monitored). It was followed
by Universal Immunisation Programme that envisaged that every child would be protected by all
the preventable killer diseases of children.
In order to accelerate the declining trends observed in child mortality Child Survival and Safe
Motherhood’ programme was launched in August 1992. It was fine tuning of the earlier
programme with emphasis on quality and outreach. It is very relevant for this study to consider
the objectives of CSSM programme and examine the ANM/LHV training impact on their
performance.
The CSSM had set the following goals:
1. By 1995
a)
Eliminate neonatal tetanus.
b)
Reduction in Measles by 90 percent, deaths by 95 percent.
2. By 2000
a)
Elimination of Poliomyelitis.
b)
Reduction in diarrhoea deaths by 70 percent.
c)
Reduction in ARI deaths by 40 percent.
d)
Reduction in maternal mortality to 2 per 1000 deliveries.
e)
Reduction in IMR to 60 or less per 1000 live births.
f)
Reduction in under 5 mortality to 10 per 1000 children under 5 years of age.
g)
Reduction of perinatal mortality to 35 per 1000 births.
-56In order to equip the Female Health Workers for the huge programme massive training
programmes were launched in the states began. An earlier study conducted in Karnataka that
covered Channapatna and Hoskote Taluks (all PHCs and Sub centres) found that CSSM training
given to ANMs/LHVs had significantly improved their midwifery skills and improved immunisation
in the area resulting in reduction in IMR (Kanbargi, 1997).
In the study area only 60 percent of the respondents had undergone CSSM training.
The
duration of training varied between 3 days to 21 days at different locations where the training
was imparted. It was not possible for us to verify the wide ranging duration and the reasons for
it.
However, most of the respondents expressed their appreciation for providing training that
refreshed their memory. There is hardly any continuing education programme for them.
An
important fact that came out during the study was how CSSM changed some age old practices
that were routinely followed. For instance, babies were given bath soon after birth that often led
to complications. The CSSM training has changed it. Now baby is kept warm for a day before
giving bath.
This practice may reduce considerably the incidence of diseases peculiar to
childhood. The training also, as reported by all those trained, enhanced their knowledge on
ANC, PNC and midwifery skills many of whom had learnt 20-25 years back. The five cleans or
Pancha Shuchitwa was very much valuable learning. Some of the respondents expressed their
happiness that CSSM training not only improved their skills but was accompanied by a booklet
and a Disposable Dai Kit (DDK). The booklet which should be given to every ANM/LHV as they
reported it has proved invaluable for them for all time. (Unfortunately the Research Team could
not see the booklet).
The respondents were asked about other skill based short term special training programmes that
are imparted. There does not seem to be any systematic approach in organising these training
programmes nor there seem to be any compulsion that say those who have put in 20 years of
service should have some minimum number of training programmes. As one ANM (very senior)
told us that often they do not know that their colleague from other sub-centre had gone for a
training programme about which MO had not even informed others. It was only after her return
they learnt.
We had listed 10 important programmes to check how many of them were attended by the
respondents. They were training programme pertaining to Malaria, Cataract, Tuberculosis,
Family Planning Target Free Approach, RCH, Leprosy, AIDS, IUD, MPW, MTP and an open
ended 'others’. The response and ratings recorded are presented below:
TABLE 6 : TRAINING PROGRAMMES AND THEIR ASSESSMENT
Rating
Percent
No.of ANMs
Training
Some what
Very good
trained
useful
60.0_______
26.6
17.2
15
Malaria
Cataract
TB______
Target free
RCH
Leprosy
60
23
59
37
67
69.0
26.5
67.8
42.5
77.0
25.0
17.4
16.9
32.4
19.4
41.7_______
65.2 _______
59.3 _______
54.1_______
55.2
Not
useful
13.3
33.3
17.4
23.8
13.5
25.4
-57TABLE 6 : TRAINING PROGRAMMES AND THEIR ASSESSMENT (continued)
41,0
AIDS
39
44.8
35.9
IUD
18
33.3
20.7
61.0
MPW
45.0
23.0
50.0
20
04
MTP
4.6
100.0
46.7
48.9
45
Others
51.0
23.1
5.6
5.0
4.4
The rating and percent trained for different health programmes reveal some interesting facets.
Even during our discussion the findings in the table were repeated. Short term programmes
particularly one-day training was disliked by most of the respondents. It was reported in all sub
centres that the faculty would arrive, generally, late and by the time the programme starts it is
time for lunch and post lunch session - after heavy lunch is not very conducive for learning. The
administration might have to confront with several problems in encouraging training courses
lasting for at least a week. Given the large number of vacancies in the sub-centres, withdrawing
ANMs for training for a week will certainly disrupt the skeletal services that reach the community.
Arranging right resource person for the programme, communicating with the trainees etc. do
pose hurdles in efficient organisation. However, given the rating of the trainees and assessment
of the utility of these programmes it may be more productive to enhance the duration and enforce
discipline of the resource persons.
There is also the problem of the size of the trainees. An elderly ANM reported that she was one
of the 30 trainees in a programme and was sitting in the back row, hardly could hear what was
lectured and instrument to be used was only one which she could not see at all. By the end of
the day she thought she would not have missed anything by not attending it.
A shocking observation which the earlier study (Kanbargi 1996) had found was substantiated
here that only one in five ANMs knows how to insert an IUD. It is widely acknowledged now that
Indian Family Planning Programme is synonym with massive female sterlisation as they account
for 80 - 90 percent of all acceptors. The programme managers argue that if women prefer only
sterilisation what can be done? This argument is hollow as the eligible women who need
contracepting method are not even fully aware of the choice they have. The district level
information provided in Table 2 makes it very clear. It is only female sterilisation which is
universally known in rural areas. Spacing methods ignored in the family welfare programme
need urgent redressal.
SECTION II
Review of Training Impact: Insights from the Field
This section has tried to review the impact of training programmes on day-to-day practice of the
respondents. It is classified as (I) Antenatal care, (ii) Identification of high risk pregnancies (during Ante-natal care), (iii) Midwifery services and (iv) child care. These are all part of safe
motherhood and child survival programme which is being implemented in the state for few years
now. As it was revealed that only 60 percent of respondents have undergone CSSM training but
interaction among trained and not trained possibly will improve overall performance of all
respondents.
-58Antenatal Care
The antenatal period is of great importance in determining future course of events for an
expectant mother. During pregnancy traditional practices are followed despite some modern
knowledge. It surely influences the health care seeking behaviour of women and their health
status that will have a great bearing on outcome of the pregnancy. One of the most important
fact that affect pregnant women’s health is the suggested strict diet regime - severe restrictions
on food - what to eat and what not to eat. The strong dietary taboos can further adversely affect
the nutritional status of women most of whom are already malnourished. But there are also
traditional norms that put restriction on activities that may have some beneficial impact.
The knowledge about conception is widely known to all - pregnancy is recognised by the
absence of periods or nausea. If the ANMs are regular in their beat and meet all the potential
women they are likely to know that a particular woman has missed her period and if she had a
fairly regular cycle guess that she is pregnant. The care should start from registering such
women.
The recently completed RCH survey (Kanbargi et.al. 1998) considered at least 3 ANC visits to
each pregnant woman during her pregnancy, 2 anti tetanus injection and supplementing nutrition
by providing folic-acid tablets for 100 days as minimum package to be ensured to each pregnant
woman. The survey found wide variations across districts ranging between 78 percent in
Dakshina Kannada - Coorg districts to only 21 percent in Gulbarga. There could be a variety of
reasons to be explored. Many researchers have questioned the efficacy of this approach in
reducing maternal mortality in the states e.g. a study conducted in Kanakpura rural areas found
“ante natal care provided by the government was only “contact service” and are often routine that
leaves much to be desired. Weight of most of the women was not recorded, not haemoglobin
estimated nor urine test done.
practioners.
This is in marked contrast to services provided by private
Apart from providing tetanus toxoid and iron folic acid very little is done in
government health care” (Jayashree Ramakrishnan et.al., 1999).
The findings from the present study fully agree with the above observations. The questionnaire
had a check list of 14 items like (I) Registering a pregnant woman which should be the beginning
of the service and when is it done? When a woman informs about pregnancy or during 3 - 5
months of pregnancy? It was assumed that ANM is supposed to visit the households routinely
and during her visit a woman may report that her periods are post-poned or missed. However,
the respondents could not distinguish the nuance and the objective behind splitting the question
in two parts and it was of not much use in over 50 percent of respondents, (ii) When they start
supplying IFA Tablets, (iii) When the Tetanus Toxide injections are given, (iv) When is the blood
pressure measured, (v) When urine test is done, (vi) when is the blood test done, (vii) when is
the taken, (viii) when is the abdominal examination done, (xi) when is the vaginal examination is
done, (x) Whether diet advise is given (xi) Whether advice on breast feeding given (xi) Whether
the woman is informed about possible complications in pregnancy (xii) Whether contraceptive
advice is given to either post-pone next pregnancy or avoid it and lastly whether need for post
natal check-up is explained? The following chart provides the responses of ANMs/LHVs to these
questions.
-59TABLE 7 : ANTENATAL CARE KNOWLEDGE : PERCENT
Check list
SI
No
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Registration__________________
I FA tablets___________________
TT injection___________________
BP__________________________
Urine test___________ _____ _
Blood test_______________
Weight test___________________
Weight taken ________________
Abdominal check______________
Diet advised
_______________
Breast feeding advise___________
Pregnancy complications explained
Contraception advised__________
Post-natal check advised
Frequency
No
Yes
0~
100.0'
0
100.0
98.5 ________ L5_
92.0 2______ 8.0
96.6 _______ 3J_
93.1 2________ 6.9
3.5
96.5 __
100.0 _________ 0
74.7 ________ 25.3
100.0 _________ 0
100.0 __________0
83.9 ________ 16.1
94.3 _________ 5.7
14.0
86.0
Most of the ANMs were aware of what is ANC and its importance. But they had problems with
discharging these responsibilities because of lack of instruments required like BP instruments
and stethoscope, chemicals needed for testing urine etc. In addition many ANMs were not sure
what is high BP that need attention? Weighing machines were provided to only 10 percent of
ANMs. Only one ANM in a sub-centre (Gulbarga) showed me two weighing machines - one for
just born babies and other for adults. She had another weighing machine for babies who can be
placed in the panel weighing. But this was an exception, checking haemoglobin content and RH
- ve was not possible even in Community Health Centres and PHCs.
It was clear that the knowledge of ANMs is not fully exploited in providing quality care during
pregnancy. To explore further we visited two ANC camps in Gulbarga district —one held in a
sub-centre and another at a CHC. The Registers maintained revealed that in CHC about 20
percent of women were examined for blood pressure and taken their weight. It was reported that
large crowd about 100- 150 women makes it impossible to provide the text book - prescribed
services to all pregnant women.
The sub-centre clinic was held in a school - an opology for the absence of quality service. There
was one table and a chair courtesy the school and the room was partitioned by a thin dirty bed
sheet for examining women. Hardly there was any privacy. There was a crowd of 50 - 60
women at noon still waiting for their turn to be examined. The Lady Medical Officer was tired but
committed to do her best to the pregnant women who had walked long distances to come here.
They had very little choice as the ANM staying in the sub-centre village was hardly equipped with
her needs. She had hired a room at the back of the school, she had to collect water from a well
and go to field for her natural calls. Her husband was staying in Gulbarga.
We observed that because ANMs have not been provided with required facilities they request the
pregnant women to come to a ANC camp held once in a week or once in two weeks. The Sub
Centre we observed held ANC camps every week and serves about 10 near by village women.
The camp naturally gets crowded making it difficult to do all required tests for each one. A
seasoned medical practioner will take the blood pressure if she has reason to doubt otherwise in
-60-
such situation no. Maintaining record of blood pressure, weight gain chart that immensely help in
identifying high risk pregnancies/babies and planning safe deliveries is not possible. If the ANMs
who are trained for ANC and used only for distributing I FA tablets and abdominal check-up it is
gross under utilisation of their talents and putting more pressure on limited resources at the Sub
Centre causing great inconvenience to women clients.
The ANC section has two very important questions that are generally ignored. One was whether
the expecting mother knows when she is expecting a baby - probable date of delivery. The
ANM should be able to suggest the same. We observed 82 out of 87 were aware how to
estimate the date of delivery. Another crucial factor is where it will take place? It is crucial
because during ANC period there will be clear indication regarding the type of delivery - whether
it will be normal or complicated. Depending on the need ANM can suggest the place. If it is
going to be a normal delivery certainly can take place at home. If not, the family has to arrange
for a hospital delivery including the resources. But surprisingly only two in three ANMs reported
that they often suggest to women where they should go for the delivery. But the rest said it is to
be decided by the family based on their economic situation. Our broad impression was, as
mentioned early, the ANC means 3 visits to pregnant woman, 2TT injections and IFA supply of 3
months. Though it may be considered as minimum needed, much more has to be done to do
justice to CSSM programme and improve the situation of women and children.
Identification of High Risk Pregnancies
Identification of high-risk pregnancies is the first and single most important step to be followed by
going to a referral hospital fully equipped to provide efficient services to ensure safe delivary.
The responsibilities of the ANMs and LHVs listed in the Training Manual prepared by State
Department of Health and Family Welfare under India Population Project (IPP IX) include urine
test and blood test of all pregnant women for albumin, sugar and hemoglobin contents during
their home visits. It also mentions that at least 50 percent of the deliveries are to be conducted
by ANMs and the rest conducted by Trained Dais are to be monitored or supervised by ANMs.
The questionnaire has prepared an exhaustive list of symptoms that indicate high- risk
pregnancies. Each ANM was asked whether they know what constitute risk to pregnant woman.
The list prepared included risks related to last pregnancy termination, history of systemic illness,
reported complaints during pregnancy in addition to the generally known factors like first birth or
higher order births, height of the woman, status of blood pressure, etc.
The knowledge reported in the following tables is based on combined responses - some
spontaneous and others received after a little probing. The responses are presented in two
formats for the convenience and understanding of the reader.
-61TABLE 8 : IDENTIFICATION OF HIGH RISK PREGANCIES
Symptoms
SI
No
1_
3
4_
5
6
7
8
9
10
Not
aware
percent
11.5
25.3
37.9
18.4
47.1
Aware
(percent)
Age less than 18 and over 35 years_____________________
1st or 4th and higher order births_______________________
Current pregnancy within two years of previous __________
Height less than 4’. 10”______________ __ ______________
Abnormal wieght gain - over 10 kg. Weight gained during
pregnancy___________________
______________
Sustained high blood pressure over 140/90________________
Poor weight gain 5 - 6 kg only_________________________
Mai presentation of foetus
____________________
Weak or no movement of foetus____________ ___ ________
Convulsions in pregnancy____________________________
88.5
74.7
62.1
81.6
52.9
49.4
50.6
48.3
78.0
54.0
70.0
51.7
22.0
46.0
30.0
It may be mentioned here that many ANMs in Tumkur District reported that for this interview they
had spent two sleepless nights to go through their notes/books of training period to refresh their
memory like they used to prepare for their theory examination. However, the information
provided in Table 8 and 9 is disappointing picture. It was the respondents in 50+ age who had
more problems in responding as they frequently said “we have forgotten many things taught long
back”. There were two respondents who were deaf and posed problems for communicating
effectively.
It may be noted here that most of the respondents knew that short women constitute high risk
during their pregnancy but they could not define what is short? Similarly they knew that
sustained high blood pressure during pregnancy carry high risks but did not know exactly what is
high blood pressure. As mentioned earlier most ANMs do not possess the instrument and those
few who had it, was not in working condition.
TABLE 9 : IDENTIFICATION OF HIGH RISK PREGNANCIES
History of last pregnancy
"sF
No.
i) Last pregnancy terminated as
1
Abortion
Still birth
Premature birth
ii) In complicated delivery with
prolonged labour ended with
2
Retained placenta
Sepsis
In neonatal death
Systemic illness
Heart disease
(ii) Diabetics
(iii) TB
(iv) Hypertension
Aware
Percent
Not Aware
Percent
64.4
57.5
55.1
35.6
42.5
44.9
55.1
60.9
16.1
44.9
39.1
71.3
71.3
77.0
57.0
28.7
23.0
43.0
17.0
83.0
J
-62E
9
:
IDENTIFICATION
OF
HIGH
RISK
PREGNANCIES (continued)
TABL
Woman complains of
3
Breathlessness
Excessive tiredness
Palpation
Puffiness of face
Tightening of ring/bangles/chappals
Vaginal bleeding
Pain in abdomen
Fevers
32.2
44.8
48.3
35.6
62.1
52.9
36.8
18.4
67.8
55.2
51.7
64.4
37.9
46.9
63.2
81.6
The responses presented in tables 8 and 9 reveal inadequate knowledge about identification of
high risk pregnancies among the ANMs. The focus group discussion clearly brought out the
problem of ensuring safe delivaries even in cases of identified high risk pregnancies as the
required facilities were not available even at Community Health Centres supposed to be first
referral centres.
An example of a maternal death reported in one PHC area would explain the situation on ground
level.
The woman who delivered a baby with the help of a trained Dai and developed
complications on third day. She was bleeding. The PHC kept her for a day with medication.
The bleeding did not stop and she was advised to go to District hospital in the night. The amily
could not arrange transport and resources. Instead they took her home and she died next day.
Some enquiry was conducted and the case was hushed up.
The data collected on ANC services and ability to identify high-risk pregnancies reveal that there
is a long way to go to achieve effective reduction in maternal mortality and infant mortality. As
noted earlier ANC means three visits to pregnant woman, 2TT injections and 100 IFA tablets.
Even this minimum package of services have made considerable impact in bringing down IMR in
the state, further decline depends upon improving the services of ANMs, infrastructures of PHCs
and CHCs to reach the goal of IMR 30 mentioned in the policy statement of 2000.
Institutional Births
Institutional deliveries are meant to provide safe motherhood and the resultant significant
reduction in maternal deaths. Wide variations were observed in them in the selected districts from about 79 percent in Dakshina Kannada to only 21 percent in Gulbarga. ANMs in Udupi
reported that many of them have not conducted a single delivery during last five years because
women prefer to go to maternity homes or Government hospitals at District level. The private
sector health services in Udupi - particularly the Manipal Hospital have expanded their maternity
services to rural areas that has almost ensured safe delivery to any woman - poor or rich. Our
visit to a remote place in Udupi where we had to cross a river to reach the village revealed that
just a telephone call to the Manipal Hospitals maternity home situated at a distance of 14
kilometers will provide them not only free delivery but also free ambulance service to transport
the pregnant woman to the hospital. The public-private co-operation observed in the district is
really remarkable to try in other poor districts like Gulbarga or Bellary that can improve
accessibility to good care and go a long way in ameliorating the sufferings of poor women.
-63-
As a contrast to Udupi ANMs who have not conducted a single home delivery during last five
years, committed ANM in Gulbarga where there is hardly any choice for most rural women
reported that she conducted 120 deliveries this year of which 20 were high risk whom she
referred to CHC and ensured safe births. Another ANM reported to have conducted 94 out of 99
births in her areas this year - 5 being conducted by a trained dai. These two ANMs stay in the
sub-centre quarter and a visit there will convince that they were model sub-centres. The two
ANMs were residents there, available any time for service, had BP instrument, weighing
machines for babies and adults, providing good ANC by testing urine, keeping records of weight
to know the gain, recording BP of all women and ensuring the pregnant woman at least one
check-up by a lady medical officer to confirm that every thing is OK with all her clients. The sub
centre that as conceptualised at the starting of out reach programme, perhaps was like this. The
outreach programme might have conceptualised such sub-centres as modesl. But they are
exceptions now as ANMs having no housing facilities stay in a place where she can get a house
on rent and naturally night deliveries can not be attended by her.
Identification Of High Risk Babies (Who weighed less than 2500 gms at the time of Birth)
The data collected in Reproductive and child Health (RCH Phase 1) survey in the selected three
districts revealed that only about 7 percent of babies born in rural areas in Gulbarga district were
weighed after birth and 58.3 percent of them were under weight (less than 2500 gms). On the
other hand in Udupi (Dakshina Kannada) 62 percent babies born were weighed and only 13
percent of them were under weight and in Tumkur about 28 percent of babies weight was
recorded and 20 percent of them were reported weighing less than 2500 gms. These findings
present a grim picture for Gulbarga and also to some extent Tumkur that certainly fare better
than Gulbarga for underweight babies who carry high risk of death. Though one of the simple
measure to reduce this incidence of low weight babies is to improve the nutritional level of the
mother by supplementing her diet and providing IFA tablets. The ANMs have knowledge of the
under nourished mother and the need to supply IFA tablets to them in their area
The RCH survey reports that in Gulbarga where the proportion of low birth weight babies is
highest in the study area only 48 percent of pregnant women had received IFA tablets, it was 87
percent in Tumkur and 92.3 percent in Udupi (Dakshina Kannada). It is difficult to understand
why this simple low cost remedy available is not taken seriously in Gulbarga where it is
absolutely essential.
It would be interesting to note here our observations and the community perceptions about how
these essential services are delivered by ANMs.
Our interaction with community leaders and women in particular provided surprising data. We
met a Lady Panchayat Chairman in Gulbarga who was in her late forties, literate and was having
concern for women’s issues including their health. She said that the ANM stays in the village
(only village she is to serve as it is quite large with 3500+ population), has a telephone at home
and also keep some essential drugs for emergency. She conducts most of the deliveries in the
village by charging anywhere between Rs.300 - 1000 depending upon the economic status of
the family. But she never visits any home for providing services. People have to call her on
phone or meet her personally if they require any service - of course at a price. The Lady
I
-64Panchayat Chairperson did not know that ANM is supposed to visit all families in her jurisdiction
to enquire the welfare of women, their pregnancies, children health etc. Even her husband and
many others who gathered there during our focus group discussion reported ignorance and said
the panchayat will issue a letter to the Medical Officer in this regard soon to ensure her services
to all homes in the village. It would not be surprising in such situation that poor and scheduled
caste women may not be able to avail her services free.
This was not an exceptional example in Gulbarga. In three more sub-centre areas we observed
similar things. Absence of good roads and transport facility may be important hurdles to ANMs in
addition to inadequate housing facilities. But administration both in the health department and at
Zilla Parishad should try to improve the situation to ensure accessibility to health care for all.
Rarely, except in ones we could see a chart showing ANMs travel programme for the week
usually displayed in all PHCs. It was also surprising that many ANMs/LHVs in Gulbarga were
not found earing uniform white saree during working hours. But in Tumkur and Udupi we did not
see any ANM/LHV not in the uniforms.
However an effort was made to know respondents abilities to identify high risk new born babies
(who weigh less than 2500 gms) if check listing some symptoms.
TABLE 10: ID ENTIFYING HIGH RISK NEW BORN BABIES (WEIGHING <2500 gms)
Aware (percent)
_________ Symptoms
78.2
___________
___
Refusal of feed____
56.3 ______________
Increased drowsiness
75.0__________ ___
Difficult breathing
55.0______________
Cold to touch_______
62.0
___________
Yellow staining of skin
26.4 ____________
Convulsions________
14.9
Others____________
The data presented in Table 10 reveal that there is much to be desired. However, some ANMs
were aware that if the baby is cold, they would keep it under 200 watt electric bulb to improve the
body temperature of the baby.
Acute Respiratory Infection (ARI)
Only about half (52 percent) of the ANMs were aware about Acute Respiratory disease and 85
percent of them had knowledge of at least one symptom of ARI and also were aware that it is an
important reason for high I MR.
Pneumonia
Most of the ANMs, (91 percent) were aware about pneumonia and more than half of them knew
one or more symptoms of pneumonia like excessive drowsiness, respiratory grunting, convulsion
and inability to drink.
Diarrhoea and Dysentry
Diarrhoea, a major killer of infants and its symptoms like passage of watery stools 3-4 times a
day was known to 92 percent of ANMs. However, there was confusion among many in
distinguishing diarrhoea from dysentry which has symptoms like blood in faces, abdominal
11
-65cramps, fever and weight loss. Only one in five respondents were aware that diarrhoea/dysentry
is a major killer of infants. All respondents were aware (100 pr cent) of dehydration that follows
dysentry/diarrhoea and could mention all the symptoms like restlessness, decreased skin tugor,
dry mouth-tongue, sunken eyes and lethargic appearance of the baby. Management of
dehydration through measures such as giving ORS or home made syrup of sugar and salt,
plenty of gluids, and continue to breast feeching was known to all respondents.
The strong emphasis given to the child immunisation was reflected in every respondent knowing
what immunisation is to be given when. Liquid I FA. however, to be given to malnourished babies
was known to only one in four perhaps it is not supplied in the state. It was reported that children
are given small I FA tablets.
Knowledge about Cold Chain
While immunisation coverage has shown remarkable improvement over time, quality of
immunisation has remained a question to be answered. Is cold chain maintained to ensure the
required vaccine potency? We wanted to test whether personnel who play a key role in
immunising children know about cold chain?
It was revealing experience for the research team which visited a Primary Health Centre in
Gulbarga district. It seems a diary is to be maintained and the temperature shown on the
thermometer of the new type refrigerator in the PHC where vaccine is stored is to be recorde by
the Medical Officer. We were surprised the recording in the diary was up to date with recorded
temperature, date and signature of the Medical officer but the thermometer that indicates
temperature was not working for several days and not repaired. It was also clear from the
observation of the diary that all the entries for the month were made the previous day. Neither
the staff nor the clients who receive were aware of the importance of maintaining cold chain to
ensure effective immunisation.
Compare this with what was reported by almost all respondents in Udupi. They said that the
immunisation day for them will become a nightmare if power in the area was shutdown even for
half an hour as mothers would object for immunising their children as there was power shut down
yesterday as such what guarantee is there of the vaccine potency? With all the explanation by
the ANMs about the advantages of new freezers that they have, some mothers would still prefer
to go to private practitioners for immunisation. These observations, though accidental, reveal the
casual approach adopted by qualified responsible authority whom the illiterate and ignorant
community trusts and it deserves serious consideration in the department to ensure that there is
responsible approach how immunisation under the circumstances it was not surprising that about
40 percent of respondents expressed their ignorance about the required temperature to maintain
the vaccine potency.
Infant Feeding
There was a question to check the respondents’ knowledge on exclusive breast-feeding. What
does it mean? How long a baby should be exclusively breast-fed? Response of all the
respondents was that babies should be breast-fed for 3 months. They also knew the advantages
that exclusive breast-feeding provides more nutrition (90 percent), protects against infections (87
d
-66-
percent) but only 46 percent knew about its contraceptive effect. The RCH survey 1998 found
that in Gulbarga babies being breast fed within two hours of birth accounted for only 9.5 percent
while it was 36 percent in Tumkur and 47 percent in Dakshina Kannada District. Continuously
repeated advantages of cholestrum milk that provides effective immunisation to babies is almost
denied in Gulbarga. The general opinion of ANMs was their advice during ANC and delivery
does not make much sense against the strong traditional beliefs that still govern the community
behaviour.
Weaning
We also enquired whether the respondents are aware about weaning? And when to start it?
Each ANM reported that breast milk will be inadequate to babies growth after three months and
babies will have to be introduced to some other semi solid foods like 'Ragi Sari’, Rice Ganji’,
'Bele kattu or liqufied pulses’ etc. which can be prepared at home with locally available food.
Few of them reported that they also suggest to mothers to go for baby food available in the
market. More than 70 per cetn of ANMs in Udupi reported that weaning food also can be
purchased from market.
While the latest WHO recommendation is that exclusive breast milk should continue for 6 months
and only afterwards weaning foods be introduced, all available evidence in Karnataka show that
there is need to improve the understanding of mothers in rural areas about the advantages of
cholostrum milk and exclusive breast feeding. Surveys have reported wide spread practice of
squeezing cholostrum milk and feeding just born babies with variety of liquids like sugar and
syrup castoroil with enormus, health hazards. The respondents reported that during mothers
club meetings as well as during ANC they explain all the advantages of breast-feeding including
cholestrum milk however the outcomes are poor. In this regard there is need to consider for
vigorous campaign and improved I EC programme. Several babies we saw in ANC camps in
Gulbarga and Tumkur convinced about the poor health status of surviving children. They were
looking thin with sunken eyes. It is possible that under-nourished mothers even though supplied
I FA tablets were not regularly consuming them to derive the benefits.
General Knowledge
We perceived ANMs/LHVs as backbone of rural health delivery system. They are the link
between the vast rural illiterate women and modern health care providing PHCs. They are
expected to visit every household in their area and are familiar with each of the household that
make them not only a health worker but a friend, philosopher and guide to those women. During
their visit they may conduct mothers meeting to provide them important information on their own
or have to answer some questions raised by their clients. Therefore their knowledge and advice
carries great impact as such this study attempted to assess how familiar they are with the
population problem - particularly whether they knew that India’s population has crossed 100
crore mark. We asked what is India’s population and gave three hints - 50 crore, 150 crore and
100 crore. Only 46 percent of them could say it is 100 crore.
It was noted earlier about the low age at marriage of females and its consequences on I MR,
MMR and also fertility levels. Marriages before a girl attains 18 years of age are legally
-67prohibited. But its impact is negligible on the marriage age. Only 79 percent of respondents
were aware of legally approved age at marriage of boys and girls. One in five respondents were
not aware themselves and they may not have discussed about it is the meetings of mothers. If
female age at marriage continues to rise as slowly as is observed despite all efforts than what
are the options left to policy makers to reduce its consequences? Or should this area be left as
nothing can be done as it is parents of the bride and groom who decide the marriage who and
are not bothered about the age? Marriage is certainly a complex social and economic issue.
Good harvests see more marriages in any village and droughts few or no marriage and difficult to
bring interventions to drastically change the pattern.
In this situation female health workers can play a very important role of motivating the young
married couples to postpone the first birth by a couple of years or till the young woman attains 20
years. The focus group discussion revealed that talk about contraception will begin only after the
couple has one or two children and intensive efforts begin only after 2 children. It is obvious that
if sterilisation is considered as the only suitable method for the couple by the ANM, there is no
alternative. But can they not advise them to use condoms or safe period or even least harmful
orals that are available in the market? They are not trained to motivate couples for adopting
spacing methods.
The focus group discussions also brought out some interesting problems ANMs face in the field.
It was reporteu that the distribution of IFA tablets to pregnant woman generally starts in fifth
month of pregnancy. If given soon after registration of pregnancy of the woman and the
pregnancy is terminated in abortion women hold the ANM responsible for it. Because it is she
who supplied IFA tablets saying that her health will improve and on the contrary she had
abortion. Such news spread very fast in villages the whole village may turn out hostile and ask
her not to give those tablets to any pregnant woman in their village. Similarly motivating for
contraception is confronted with the problem of child survival. If the only son among the two the
couple has dies. ANM will not be forgiven for motivating them to accept sterilisation. So to play
safe they said it is better a couple should have two sons and a daughter before undergoing
tubectomy. It is not surprising that NFHS II found 90 percent of sterilised women had not
adopted any other contraceptive method before. Distribution of Bill and condom through public
sector, therefore, constitute insignificant proportion in rural Karnataka.
This background is aptly reflected in the responses of ANMs/LHVs as 18 percent of them could
not say what is safe period and explain it correctly. But 95 percent could explain what tubectomy
is and how it is performed because they reported that they explain it to all potential acceptors.
Medical Termination of Pregnancy
Abortions were legalised in India in early 1970s and the number of legal abortions have
increased significantly over the time as also approved places for conducting abortions. But rural
women are deprived of this facility as most of the PHCs in the study area do not have the
equipment or person / approved by the government to provide abortion facility to women. None
of the ANMs are trained to conduct MTP and when we asked them when will they recommend
MTP to women? It was disappointing that none of them had suggested any woman to go for an
abortion. Looking at the clandestine abortions reported and observed by the hospital records
-68showing sepsis/infections caused by quacks while aborting and admitted to hospitals in serious
conditions, there is need to examine what ANMs can do in rural areas. While ANMs took a moral
stand and their response was very firm in reporting that they neither perform nor recommend
MTP to any woman that does not reflect reality.
The job responsibilities listed by the Department of Health and Family Welfare 1999 clearly has
mentioned that ANMs should identify women in need of MTP and inform them the nearest
approved place for MTP to obtain an MTP. We think there is an urgent need debate on the issue
of providing this facility to rural needy women.
The Eligible Couple Register
Eligible Couple Register the Female Health Workers are supposed to maintain and keep it up to
date with all relevant information. It is a valuable document that guides in her work. It has all
information she needs - how many currently married women are there by contracepting status
and number of children, helps in identifying children is need of immunisation, and women in need
of advice on nutrition, etc. A general complaint emerged in all our meetings was the shortage of
EC Registers - some places not supplied for 7 - 8 years and ANMs have to purchase a Note pad
and record the information to the best of their abilities. Non-supply or irregular supply certainly
creates serious problem in compiling service statistics from Sub-Centre.
We wanted to learn from ANMs whether still they feel EC Register serves an important purpose
and help them. There was a unanimous response that it is important and they should be
supplied EC Register so that they will be able to improve their performance.
Mothers Meeting
The respondents also informed that they routinely conduct mothers’ meetings and discuss
different health issues and about nutrition. They think that these meetings will become more
effective if the ANMs are provided with educational materials for use during the meeting to make
the meetings more productive.
Advise to Adolescents
The needs of the adolescent girls that were ignored for long is getting attention now. There are
special programmes designed for their benefit. To improve their knowledge about personal
hygiene and health. There were few reports of providing Tetanus Toxide injection to these
adolescent girls. What was interesting to learn from many ANMs was that often in mothers
meeting some adolescent girls also participate and when the topic of contraception / pregnancy
is to be discussed they are asked to go out as they need not learn about contraception because
educating these unmarried girls in Family Planning methods because of the fear of using them
before marriage. Given the sea change that is being realised through recent research on
changing sexuality in the society and the AIDS threat becoming more and more serious there is
need to think about what should be the policy for these girls. Most of whom are illiterate and
ignorant of many vital issues concerned with their own person.
contraception will that enchance its use after they get married?
The Working Environment
If they are educated about
u
-69We examined the training programmes that the ANMs/LHVs have undergone so far and the
extent they are utilising the skills - knowledge that they were able to retain from them. The focus
of the study however was confined to issues concerned with the health and survival of women
and children who still constitute a major component in the crude-death rate.
It was mentioned that the grass root female health workers are considered as backbone of our
rural health delivery system in Karnataka and with several drawbacks in the system considerable
progress has been made during the last two decades. The widely differing indicators of
achievements among different districts and by gender and social class within each district is a
cause for concern and further improvements will be faster if backward districts, deprived sections
within backward districts get relatively more attention. As it is, there is uniform policy and
strategies in the state.
We did not come across any special efforts to improve health care
delivery services in Gulbarga or Tumkur.
The three districts selected for this brief intensive study present three unique settings. Udupi
has very high female literacy, high age at marriage, wider knowledge of contraceptive methods
Box 1
PHThe Researc^Team reached here by 10 AM. There was only an Attender and no responsible staff
member The Attender - the only person in the PHC was not aware of our visit nor about reasons for
the absence of the l/c MO and other staff. The PHC had conducted Tubectomy Camp two days earlier
and there were six women (who had come from different village). One of them had developed
complications and was advised to go to Gulbarga for consultations by Head Quarters ANM. Who had
undergone Tubectomy operation.
The Head Quarter ANM who is supposed to provide care to the sterilised women had gone on
leave as her husband seriously took ill and she admitted him in a hospital in Sholapur. Thes MO had
not come to the PHC for a week without any reason nor informed any authority - ike Taluk Medical
Officer and resides at Gulbarga situated at a distance of about 45 kms. Journey takes about 2 hours
because of bad road conditions.
We contacted the DHO and reported the situation who in turn telephoned taluk Medical Officer who
rushed to our place. He reported his helplessness as he had warned the MO a couple of
We
also learnt that the local MLA also had warned him to be punctual but of no consequence. In-charge
an
MO was not able to improve his functioning. The Taluk Medical Officer who
honest also expressed his helplessness regarding the verification of drugs in the PHU as the
pharamacist never met him nor showed the tock during his last three visits.
while it is a contrast in Gulbarga - a district perhaps politically very influential as 6 ministers hail
from that district in the contemporary political scene with two of them may be considered as very
heavy weight politicians in every sense. Things could have been better with their interventions in
the district. But unfortunately health, sector, perhaps, does not command much attention. To
make things worse any disciplinary action against an erring official in health sector-from an ANM
to Medical officer is extremely difficult as there will be instructions from top that he or she is our
person and nothing should be done to him/her and there ends the matter. This benevolent
attitude of powerful personalities of the district has almost demoralised the health department in
the district. The crucial services are casually taken. The Box 1, 2 and 3 present the contrasting
picture to high light the issues in three different settings.
The three senarios presented depict differing consequences on the people of the area.
Gulbarga Pulic Health Care service is a single most important provider of services to the people
H
Box 2
A PHC in Udipi District
Contrast:
t this PHC, without prior intimation, at 9.30 A.M. We were surprised that ‘he PHC was busy
We arrived at
MO, Lab Technician and other staff were attending the patients. On an average there are 50
functioning -1
patients a day. The young MO here is appointed on a contract basis but is very regular to his work and fully
,
committed.
sx™ sstss
“ ""h'xus
.
~
concerned authorities whose addresses were mentioned in bold letters.
The MO reported that the drugs supplied to him are of very good quality and adequate. The drugs that, Pnva*e
sector hospitals provide to their patients is certainly not of better quality than that of PHCs. Therefore the
visitors to the PHC are happy that the centre works not only very efficiently but also supplies quality drugs He
had only one complaint - that the patients who visit his PHC have simple ailments while he was interested in
attending to chronic/serious cases also and improve his abilities. For this he goes to a Private Hospital in the
night - not for earning more money but to improve his understanding.
with negligible presence of private sector even in the District Town. If the Public Health Services
are inaccessible to people, will have serious health consequences.
Udupi on the other hand strong presence of private sector which has social commitment as seen
by the free delivery services with free transport just with a Telephone Call. The Public health
Box 3
We reached this PHC in Tumkur by 9.30 am. All the staff including ANMs/LHVs were waiting for us. The
Medical Officer was a young man with 8 years of experience in PHC. He was in a neatly pressed white
coat and any visitor would recognise him as a Doctor.
The PHC was crowded with patients. But lacked many facilities. There was no running water. Toilets
were there but not clean. The PHC did not have a compound wall and in the evening cattle, drunkerds
squatted in the compound creating scare among inmates (Delivery cases).
All the feamle health workers complained that they are not supplied registers to record for several years,
cholirination of wells, DDT spraying has been stopped since three years. The ointment, paracetemol
supplied to them is inadequate - does not last even for 4 months but people.
It was surprising with all the problems the PHC was still serviving people as seen by the large crowd of
outpatients. There are 70 - 80 patients on an average visiting the PHC for consultation and treatment.
We contacted the DHO and reported the situation who in turn telephoned taluk Medical Officer who rushed
to our place. He reported his helplessness as he had warned the MO a couple of times. We also learnt
that the local MLA also had warned him to be punctual but of no consequence. In-charge MO was not
able to improve his functioning. The Taluk Medical Officer who looked committed and honest also
expressed his helplessness regarding the verification of drugs in the PHU as the pharamacist never met
him nor showed the stock during his last three visits.
care services are equally efficient and competant but suffers from inadequate infrastructure and
equipment. The end result is that the educated population can make a reasonable choice and
there is choice for the rich and also for the poor. Poor are assured of good health care at Public
Health Institutions. PHCs function efficiently - maintain working hours, ensure presence of
Doctor and supply of drugs of as good as quality that of private sector quality. It is not surprising
that health indicators, health seeking behaviour indicators are most impressive. Tumkur district
on the other hand is certainly better than Gulbarga in several ways. The PHCs work regularly
though there were complaints of shortage of drugs, quality of drugs etc. General public, though
heavily depend on Public health Institutions, there are large number of quacks having presence
in every village having a population of 4 - 5000. Shivashakti Clinic, Unani Davakhana and a hot
of other clinic try to provide some relief to needy poor. We did not come across any untoward
u
-71 incident occuring because of quacks as we were informed that if the 'Quack' realise that he can
not handle the case, he will advise them to go to Tumkur District hospital and will not take any
risk.
In this background it may be noted that increasing number of Institutional deliveries affect work
burden of female health workers as it has happened in Udupi. Our information collected from
ANMs report that only 6 percent of deliveries are conducted by them and the rest occurred at the
Institutions. In Gulbarga about 40 kilometers away a PHC reported that during April 2000 December 2000 had 627 births about 200 at PHC and the rest 427 by 8 ANMs in the PHC.
There were 7 still births. 27 infant deaths reported.
Not a single birth had taken place in private nursing homes. The Medical Officer of the PHC
stays in the quarter and is always accessible to the needy. His wife is a lady Medical Officer
whose services are also easily availed any time. As they stay in PHC they have full control over
other staff who also show concern and commitment to the health concerns of the public. But
such PHCs are exception in the District. The general rule in Gulbarga is that either Medical
Officer’s post is vacant, if it is filled the person is erratic in discharging his responsibilities as the
authorities are hesitant to discipline them because of political interference. While the situation is
continuing like this the social costs are too high even to measure or community suffers
enormously. The case of Kunchoor illustrates this. Kunchoor or Kunchavaram is a village
situated at the border of Karnataka -Andhra Pradesh in Gulbarga. The village has a PHC and
for last five months there is no medical officer (vacant). Lady Medical Officer’s post is filled but
she never turns up. The Chairman of the Taluk Panchayat died three days ago (when we were
enquiring) without any medical assistance, 2 children died during the week and causes for these
deaths are not known. The member of the Zilla Parishat, a resident of this village has tried his
best to get a 'couple' husband-wife’ team to this PHC but without any success.
In such a
situation expecting ANMs/LHVs to be committed in discharging their responsibilities in futile. The
Kunchoor PHC area is dominated by a Scheduled Tribe-Lambadies.
SUMMARY AND CONCLUSIONS
The short term intensive study was carried out in three districts of Karnataka State that widely
differ in health and demographic indicators. The main objective of the study was to assess the
various training programmes the grass root level female health workers (ANMs/LHVs) have
undergone, extent of their utilisation by them in their day to day work. The study went beyond
the stated main objectives to examine whether providing training per se will improve health care
services as its effective exploitation is related with a host of other factors like infrastructure,
equipment and team spirit at PHC level from where these services are organised, supervised
and monitored.
The focus of the study was confined to those training programmes that were designed to improve
the health status of women and children - more specifically in reducing further IMR and MMR.
For this intensive study 3 districts - Udupi, Tumkur and Gulbarga were selected. From these
d
-72-
three districts 8 Taluks and 22 Primary Health Centres were selected.
All Female Health
Workers (ANMs/LHVs) at these centres were administered a standard questionnaire that was
specially constructed to check their skills required in their work.
The 87 respondents were
covering a population of 2, 61,155.
All respondents had successfully completed the foundation course - 18 months and few had 2
years training programme. The gap between the completion of course and joining the service for
many was as large as 4 - 5 years in few exceptional cases.
The general impression of the respondents regarding their training that some had completed 30
years back was that there was inadequate attention to practical hospital training and training in
field work. An indication of this was the reported 'shaking of hands’ during the first delivery
conducted by most of them. There were one-or-two exception to this general observation. An
ANM in Gulbarga mentioned she had the best opportunity of conducting 24 deliveries during her
training period under the able supervision and guidance of a gynecologist. It was suggested that
training programmes should be need-based and practical in real life situation and not just
lecturing with lot of information.
There was long gap between Foundation course and the next most important training
programme related to maternal and child health viz. CSSM training. The findings show that still
40 percent of ANMs have to undergo this programme that has great relevance to reduce further
IMR and MMR.
It was shocking to find that most of the ANMs are not trained to insert IUD. Policy studies have
repeatedly highlighted the urgent need to enhance use of spacing methods particularly among
rural women as it will have directly impact on the health of women and children. This needs
serious attention.
Similarly ANMs/LHVs need to be more sympathetic to women’s need for Abortion. Whether they
can be trained to perform medical termination of pregnancies is a technical question to be
decided by experts, we strongly recommend that at least MTP service be made available at PHC
level and ANMs/LHVs should be trained in the legal aspect of MTP and when they can
recommend it to needy women.
In addition to CSSM, a host of training programmes have been conducted for the respondents.
A general observation is that the short term training programmes of one or two days have been
rated as not very satisfactory by the respondents.
There was a strong suggestion of all
respondents in Tumkur and Gulbarga that Continuing Education programme for a week should
be a regular feature to update their skills and knowledge of maternity and child health. This
-73-
programme should be holistic and may cover other relevant contemporary health problems in the
state / district.
Identifying high risk Pregnancies
The findings suggest that there is a need to have as suggested above, one week Continuing
Education programme to enhance the knowledge and skills of ANMs/LHVs of pregnancy
management.
Except in Udupi/Dakshina Kannada and Kodagu districts where Institutional
deliveries have become a rule in all other districts where domiciliary deliveries dominate, the
improvement of the knowledge of ANMs with intensive training should be given serious attention.
ANMs/LHVs must have knowledge of measuring blood pressure, testing urine for albumin and
sugar and keeping these records for all pregnant women (at least I readings for a woman).
These services should be provided in the yield to women by ANMs apart from. TT injections, I FA
tablets. It should be followed by blood test of each woman for haemoglobin content at least at
PHC level.
It may be noted that we had trained Field Investigators of NFHS II Survey to
measure haemoglobin of all women in the sample at their home in each village. It was possible
because very simple to use technology was made available from USAID.
It should not be
difficult to obtain this technology by the state government for use of ANMs/LHVs. The time taken
for the test is very little-just 1 minute per woman at their door step. Unless minimum package of
services are provided to all pregnant women and each high risk pregnancy is identified and taken
to nearest referal unit for safe delivery, MMR will continue to be very high.
Identifying high risk babies needs serious attention. Knowledge of Acute Respiratory Injection is
very poor among the respondents.
suffering
NFHS II reports that about 34 percent of children were
from ARI in Karnataka indicating the serious nature of the illness and its
consequences. The present study found that ANMs were confused when asked to distinguish
between the symptoms of diarrhea and dysentery. As 15 per cent of children in the state were
found to be suffering from these illness improving the knowledge of ANMs and LHVs in
identification of these illness and ARI is to be given immediate attention.
It was, however,
satisfying that Oral Rehydration Therapy (ORT) is universally known not only to ANMs but also to
mothers.
Immunisation coverage in the state has shown gradual improvement as seen by the service
statistics. We came across a report in Gulbarga that a baby afflicted by polio in a village was
living next door to the sub-centre. But looking at the crowd in Immunisation Centres with several
agencies participating, a child might have missed immunising. ANMs were found to be well
versed with immunisation process and were confident that all children in their area are protected.
-74While in Udupi Rotary, Lions, Womens Organisations, College Students and many enlightened
women participated in pulse polio in a big way even in rural areas such support in Tumkur and
Gulbarga was more concentrated in District towns.
Respondents knowledge about benefits of exclusive breast feeding and weaning was
appreciably good and needs periodic updating. Their understanding of India’s population and
legally approved age at marriage for males and females was found poor that needs to be up
dated.
The most glaring lacunae reported by ANMs and LHVs in their training is lack of communication
skills and inadequate attention to it in any of their training. Simple observation is that to combat
with strong traditional practices having serious adverse impact on women and children like
squeezing of colostrum milk needs intensive campaign. It would be effective only when ANMs
can play an important important role. Similarly introduction of spacing methods to young married
couples would be facilitated greatly if ANMs are properly trained to convince the young village
couple of its advantages.
Most cruc'al issue to be considered here is that training, upgrading skills and information
becomes inevitable to improve overall health status measured in several ways. The goals set in
the health sector can be achieved when such relevant training programmes bring in qualitative
changes in the services provided to clients. If all that is told in training programme is difficult to
put in practice because of lack or absence of infrastructure, equipment and other supplies the
purpose of training cannot be served.
It was observed that vast expansion of health care services - personnel during the decade is not
followed by adequate care and required resources. The quick expansion perhaps created a
problem of finding professionally trained personnel. A look at the staff position at district level is
surprising if not shocking. If health care service delivery is ensured with or without these large
number of vacancies, it is in itself an indicator of quality care.
At policy level, it is desirable to think of a district or a group of districts for intervention.
For
example in Gulbarga and Tumkur and such districts there is need for greater attention to improve
the management of pregnancies and their outcomes which may need more resources like
improving PHC/Sub-Centre infrastructure, equipment to ANMs such as BP instrument, chemicals
to test urine, haemoglobin/blood test etc. Where as in Udupi, Dakshina Kannada, Coorg with
good adequate support from private sector this problem is not there. But AIDS is looming large
in these districts with large out migration of males and females.
We heard reports of AIDS
deaths caused in every village we visited with documentary evidence.
All the deaths had
occurred to the return migrants and it seemed as if they all came home only to die.
-75At state level there is a uniform policy of resource allocation for health sector. If some districts
perform poor as indicated by several indicators it would be necessary to ensure that
administration in these districts are pulled up. The poor perception of people regarding the
public health care system in health poor districts needs serious attention.
Precious public
resources deserve more productive use. The backward nature of some districts is known for
long for over four decades and these districts have remained at the bottom even now. Unless
some fundamental change is brought in the administration for improvement they will continue to
be at the bottom.
u
I
000000000000000000000000000000000000000, ffffff
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GOVERNMENT OF KARNATAKA 0
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TASK
FORCE
ON
HEALTH
AND
FAIVHLY
WELFARE
. &
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A Commissioned Research Study
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FEMALE
HEALTH
WORKERS
LN
KARNATAKA:
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AN ASSESSMENT OF THEIR TRAINING .
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By
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Dr, Ramesh Kanbargi
0
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CENTRE
FOR
SOCIAL
DEVELOPMENT
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- 0
No.8, Shantishree, Na.garabhavi Post
0
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Bangalore
560
072.
0
^0
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u,
^'4
FEMALE HEALTH WORKERS IN KARNATAKA :
AN ASSESSMENT OF THEIR TRAINING
$
•
By
Ramesh Kanbargi
Centre for Social Development
4)
Introduction
©
Health status of people in India has shown remarkable improvements
©
during the last two decades. The Crude Death Rate (CDR), infant Mortality Rate
(IMR) and Crude Birth Rate (CBR) have shown sharp fall and key health
‘3
indicator Life Expectation at Birth’ which was about 42 in early Fifties has
crossed 60 years in the early Nineties. Wide differentials across states in India,
a
however, have persisted throughout suggesting the need to take corrective
measures to bring in much desired equity in health to reach the goal 'Health For
All by 2000’ India has committed at Alma-Ata in 1978 (See Table 1 for
differentials).
The data presented in Table 1 clearly brings out the fact that Southern
States - Kerala, Tamil Nadu. Karnataka and Andhra Pradesh have shown
relatively better performance as compared to Hindi speaking BIMARU States -
•3
■a
Bihar, Madhya Pradesh, Rajasthan. Utt^r Pradesh and Orissa.
Wide differentials within state by rural-urban residence, gender and social
class exist across the districts.
The Human Development Report 1999 -
Karnataka provides CDR, CBR and Life expectancy at Birth for all the districts
45
that reveal the differentials.
IMR another sensitive health indicator shows that
Dakshma Kannada reported the lowest IMR (27) in the state while Gulbarga,
9
'3
Bijapur,
Bellary had IMR about 3 times higher than Dakshina Kannada district
There is other strong evidence to support the IMR estimates - institutional
deliveries in Dakshina Kannada accounted for 77 percent while in Gulbarga it
was only about 27.9 percent suggesting the strong negative association between
IMR and institutional deliveries - safer deliveries.
;ii)
©
®
1)
2
>7
TABLE 1 : HEALTH SITUATION IN INDIA AND SELECTED STATES
IMR 1996
State
□
o
Maternal
mortality
ratio 1986
R
U
T
R
U
T
India
77
46
72 •
9.7
6.5
9.0
580
AP_______
Karnataka
Kerala
Tamil Nadu
73
63
13
60
38
65
53
5.9
5.4
8.4
25
394
439
16
39
14
53
9.2
8.6
6.3
8.7
Uttar Pradesh
Rajasthan
MP________
Bihar______
88
90
67
60
61
85
85
97
54
65
7_1
96~
31
46
48
Orissa
©
CDR 1996
102
73
99
Maharashtra
58
Gujarat
68
61
6.0
6.6
10.7
9.6
11.8
]0_6
7 1
7.6
6.9
11.2
7.5
8.2
8.7
8.3 I 6.2
Ud
7.6
6.2
247
8.0
372
10.3
9.1
111
10.2
10.8
7.4
7.6
Sex
CBR
Ratio
1991
1996
927 , |
ITS
972
960
1036
974
22.8
23.0
18.0
19.5
920
879
34.0
627
910
931
911
971 7
32.4
32.3
32.1
27.0
934
934
23.4
507
813
844
439
373
II
25.7
Source: 1) Family Welfare Programme in India, 1996-97, Government of India
2) Mari Bhai P.N., 1995.
The latest data-set (1998-1999) collected in National Family Health
Survey and Reproductive and Child Health Survey (NFHS II and RCH) provides
a
valuable insights^for effective policy inferventions to reduce the disparities across
districts by rural-urban residence, social class and gender. • Findings from both
the surveys suggest that the out reach services of maternal and child health hold
the key to bridge the differentials and these services are to be delivered by
Female Health Workers popularly known as Auxiliary Nurse Midwives (ANMs)
and Lady Health Visitors (LHVs).
The Present Study
The present study is an attempt to examine the role of these grass root
level female health workers and adequacy of their training to discharge their
1
I
I io
3
A
responsibilities satisfactorily that can help to reduce considerably the disparities
4^
observed across districts
•f'A
Objectives
Taking into consideration the major midwifery responsibilities assigned to
□
the ANMs and LHVs after a rigorous foundation training of 18 months the study
proposes to achieve the following objectives.
1. To examine the knowledge of ANMs regarding the Ante-Natal care service
and its delivery to pregnant woman.
9
2. To assess their knowledge of identifying the high-risk pregnancies and
ensuring safe delivery that will help to reduce maternal mortality.
3. To examine the knowledge of supplementary nutrition to be advised and
supplied to all pregnant women to reduce malnutrition.
4. To examine their knowledge of identifying high risk infants
and measures to
be taken to ensure their survival to reduce IMR further
5. To identify inadequacies in the training of ANMs/LHVs if any, and suggest
corrective measures.
The Sample
The study was conducted in three districts of Karnataka that differ widely
0
in indicators relevant to reduce IMP and MMR.
These indicators were drawn
from the RCH Survey (First Phase - Kanbargi et.al., 1998). They are
J
1)
3
J
Percent women who received full Ante-natal care package (At least 3 ANC
visits + 2TT injections and 100 IFA Tablets)
2)
Percent institutional deliveries.
3)
Percent children in 12-23 months age who did not receive any
immunization.
4)
Percent women who had knowledge of all modern contraceptive method
'4$
Based on these criteria following three districts were selected
0
>
H
4
A
SUJ-CTION OF Till SAMPLI DISTRICTS
TABLE 2
Districi/State
Udupi (DK)
2 Tumkur
■3
Fuji ANC ] Institutional
(percent) <
deliveries
(percent)
78.9
68.7
76,6
48.4
C hildren not
j immunised
j
(percent)
;
|
0.5
0~5
Family Planning
knowledge of al I
modern methods
J’erccnt
j
3 Gulbarga
27.9~ JZ 31.1___}
21.2
State
52.2
jl
Source. Rapid Household Survey ROH, 1998, KanbargT et.al 1
____ ______ ___ 52.4 ZLZ L
__
70'7
”
40.8
^27.2
46.1
3
3
The three Districts selected differed maximally in several other variables
also. For example the percent girls marrying before 18 years - legally approved
age was highest in Gulbarga about 59 percent, 29 percent in Tumkur and only 5
■3
per cent in Udupi (which was part of Dakshina Kannada then. We selected Udupi
District based on the data of Dakshina Kannada district as data for Udupi are yet
=3
to be made available). The observed early marriage and its impact on CBR is
3
clearly reflected in these districts (Gulbarga 32. Tumkur 24.7 and 21.4 in Udupi).
The three selected districts - one highly advanced - Udupi, one with
3
medium progress - Tumkur and one backward - Gulbarga in terms of
3
9
demography and health would be able to provide insights sought in the
functioning of the ANMs and LHVs in the state
For data collection 8 Taluks 22
©
PHCs and 87 sub centres were selected randomly
©
these details.
The following table provides
a
»
3
TABLE 3 ■THE STUDY AREA
5
.3
1
J
District
Udupi
Tumkur
Gulbarga
S>
Total
O
3
2
Taluks
1) Udupi
2) Kundapur
i) Gubbi
ii) Madhugiri
iii) Kunigal
i) Afzalpur
ii) Gulbarga
iiij Chitapur
8 Taluks
PHCs
SC (ANMs)
8
26
6
41
<8
20
22 PHCs
87 ANMs
I i't
5
Methodology
The relevant data was collected from all ANMs available in the selected
"-’"S
PHC/Sub-Centres
by
employing
survey
methodology
A
standardised
questionnaire was constructed for administering to each ANM/LHV in the
<-3
selected PHC/Sub-centre. The administering of the questionnaire was preceded
■5
by a brief introduction about the survey and assurance that the information
collected will be kept confidential and used only for research purpose.
In PHC
we met the medical officer (MO) and other staff present and briefed them about
the study. We assured all that they will not be harassed by Health Department or
any authorities for sharing their honest views on the functioning of the Health
Care Services.
3
There were focus group discussions to get insights in the functioning of
3
the Institutions that provided valuable information. This information is exploited
to supplement the hard data collected in the survey.
Each questionnaire administered to ANMs/LHVs took over an hour. The
9
9
interviews were abrupted often when many ANMs broke down who were to be
consoled to start the interview again
The respondents reported that it is first
a
time in their entire service someone is enquiring about their problems and
3
welfare. When they were asked whether they would be happy if their daughter
3
(those having one) was offered ANMs job, it was revealing that most of them
9
reported that they do not mind if their daughter goes for agricultural labour but
9
they don t want them to become an ^NM like their mother.
9
It indicated harsh
working environment they are situated in, their frustration and.helplessness.
>
Data and Analysis
9
The brief profile presented in Table 4 suggest that most of the Female
9
Health Workers are currently married, have at least 10 years of schooling and in
their middle ages with long experience
As there are limrted opportunities of
advancement in the career they feel dejected struck with the same work for
>
years
3
for the day to free themselves and lead a relaxed life
■)
9
3
Those who were on the verge of retirement were eagerly looking forward
u
■o
<>
'3
□
□
TABLE 4
FEMALE HEALTH WORKERS IN THE STI JDY AREA
A PROFILE (87 ANMs and LHVs)
S')
h
I
Variable
Age (years)
4
I -requency
Per cent
31
23
35 6
37 9
26.4
04
77
06
4.6
88.5
6.9
II
17
41
14
13.3
20.5
49.4
16.9
I
9
Below 40
40 - 49
50 - 58
5
©
2
“V •>
Marital Status
$
Single
Currently Married
Widowed/Divorced
3
No.of living children
0
&
3
O
o
0
J
9
2
3+
I
4
i
Ii
I
Education
Below SSLC
SSLC Pass
PUC
PUC Length of Service
(in years)
Less than 5
5 - 14
15 - 29
30 +
r
IS
54
I 1
04
!
I
I
■
20.7
62.1
12.6
46
I
I
»
9
22
39
17
1Q.3
25.3
44.8
19.5
<3
3
©
One of the major problems faced by the respondents was shortage of
housing - only 40 percent of them had housing facility provided by the
3
Government, whereas 23 per cent of ANMs were residing in rented houses in the
i3
sub-centre villages. Another 23 percent were in a rented house in the sub-centre
village and the rest 37 percent were commuting to their place of work that
3
J
i 19
required about an hour
•J
Udupi had an excellent net work of public transport with
very good road that was found to be a very important factor to improve
accessibility to health care services whereas Gulbarga had bad roads or no
roads and poor public transport that badly affected easy accessibility
Tumkur
can be placed in between these two districts with some area with good roads ■)
Kunigal section whereas Madhugin was having serious problem of roads and
public transport. It would be of interest to mention here that during our visit to
observe an ANC camp at a sub-centre village in Gulbarga we had to leave our
3
car at a point and hire a Land Rover jeep to reach the Sub-Centre as the road
was full of boulders and ditches which only jeep could negotiate with great
9
difficulty. To cover a distance of 15 kilometers it took an hour at high cost.
3
Lady Health Visitors have to supervise the work of ANMs
9
9
area we could get only 10 LHVs who had to cover on an average 40 villages in
addition to their administrative work of compiling service statistics from each
ANM on maternity, immunisation, etc
3
In the study
The fact as reported by both LHVs and
ANMs is that supervision/work monitoring in the villages has almost ceased to
exist.
Many senior ANMs recalled that when they joined service they had to
■9
cover larger areas - population but they used to enjoy the work
9
team spirit, co-operation and guidance from M 0 and DHO.
>3
very seriously. The Medical Officers provided home visits to sterilised cases for
9
3
J
follow-up services.
good.
There was a
Work was taken
Deliveries were supervised and post natal care then was
Now hardly anybody bothers about supervision and monitoring.
ANMs
feel lonely and helpless in the job as there is neither any help nor guidance and
no supervision but if anything goes wrong they will be held responsible
The
information collected from ANMs show that exceptionally large number of villages
J
11 to 18 villages were to be covered by 13 ANMs in Tumkur. Whereas in Udupi
and Gulbarga despite vacancies that add burden to ANMs work they were found
3
9
to be covering about 3-4 villages as size of population is large. As over half of
the ANMs were natives .of the same district they were quite familiar with
sociology and culture of the area. While more villages add only to travelling time,
size of the population, average number of couples to be served in RCH seem to
a
>
3
■J
be well within manageable limits of ANMs with very few exceptions
/
u
X
The Foundation Course
The female health workers have to complete the foundation course
specially designed for them to be eligible for consideration for the job
But some
had 2 years training while over 80 percent had completed 18 months course at
different District Head Quarters. Surprisingly it was found that there was a long
time gap before they got the job. About 20 percent had joined after 3 - 4 years of
their completion of the course and they took considerable time to refresh their
training skills they had almost forgotten. Indeed, 6 ANMs had joined service after
5 years gap. In addition to the foundation course LHVs have to undergo another
6 months training to become LHV.
They were asked to assess the quality of their foundation-training course
Q
in terms of (a) Curriculum (b) Duration (c) Regularity of Faculty (d) Quality of
o
training (e) Practical training in hospital and (f) Practical training in the field.
Their response was classified in 3 categories. The distribution of responses are
3
reported below.
3
TABLE 5 : ASSESSMENT OF THE FOUNDATION TRAINING BY
THE TRAINEES (PERCENT)
0
©
$
©
a
9
[T
2
J
6
Curriculum
Duration______
Regularity of Faculty
Quality of training
Practicals in hospital
Practical in field
Good
lair
Poor
78_2
34.5 ~
70.0*
J5 0
63 2.
25.3
2 3
f •• ——
2T
23
24.1
64 4
19.5
25.3
HZ
59.8
80
19,5
11.5
3.4
i
Can'l sav :
2 3
3 4 '
It is to be noted that 18 months duration is divided as 12 months theory
and 6 months practicals in hospital and field.
The majority of ANMs (63.2
3
percent) cpnsidered that duration was too short as they had to complete 10
□
theory papers. It is also reflected in the assessment of practicals in hospital as
0
57.5 percent reported that on job training was too short to master the art of good
©
©
midwifery.
9
□
3
Almost 60 percent felt that the field training that forms the most
important component of their job was inadequate.
11 ■ •
Majority of the ANMs opined that the curriculum is good but heav.ly biased
towards theory whereas most important for their job is field work where they have
to
manage
themselves
with
midwifery
that
put
heavy
responsibility.
Communication skills which they need most in their field work was found to be
lacking. It seems there is an assumption, that all ANMs have that skill.
3
During discussion with ANMs we asked how confident they were when
they conducted the first delivery of their career. Majority response was they were
3
very shaky.
Few were fortunate to have a LHV who was good to instill
confidence in them giving guidance in the conduct of delivery that went a long
way in building their confidence.
But many were not that fortunate but could
manage the situation without any serious problem
O
How the training received several years back is relevant now?
3
respondents mentioned that except midwifery hardly anything is relevant. AIDS.
RCH, Target free approach are all new and are relevant now.
3
Several
More skills are
required for day-to-day work and in recording them properly in the registers
provided.
3
3
Section I
O
In this section we have tried to review the training programmes that
□
respondents have completed and how they perceived their utility in their day-to-
day work. The major programme in this regard was the Child Survival and Safe
3
Motherhood training followed by seyeral other short term skill knowledge
□
enhancing programmes. -
3
Child Survival and Safe Motherhood (CSSM) Training
£
Reduction in maternal and child mortality was highlighted in the National
3
Health Policy 1983. The sustained high levels of immunisation programme that
9
increased contacts of female health workers with women
□
demonstrated that about 2million children were saved during 1984-92 (the
3
J
3
9
and
children
difference in child mortality rates of 1984-92 which was monitored). It was
u
3
.7)
Id
3
followed by Universal Immunisation Programme that envisaged that every child
would be protected by all the preventable killer diseases of children
3
5
In order to accelerate the declining trends observed in child mortality
'Child Survival and Safe Motherhood’ programme was launched in August 1992.
3
It was fine tuning of the earlier programme with emphasis on quality and
3
outreach,
it is very relevant for this study to consider the objectives of CSSM
programme and examine the ANM/LHV training impact on their performance
The CSSM had set the following goals:
1. By 1995
a) Eliminate neonatal tetanus.
b) Reduction in Measles by 90 percent deaths by 95 percent.
3
9
2.
By 2000
a) Elimination of Poliomyelitis.
b) Reduction in diarrhoea deaths by 70 percent.
3
c) Reduction in ARI deaths by 40 percent.
a
d) Reduction in maternal mortality to 2 per 1000 deliveries.
e) Reduction in IMR to 60 or less per 1000 live births.
f)
Reduction in under 5 mortality to 10 per 1000 children under 5
years of age.
g) Reduction of perinatal mortality to 35 per 1000 births.
$
3
5
I
In order to equip the Female Health Workers for the huge programme
massive training programmes were launched in the states.
An earlier study
conducted in Karnataka that covered Channapatna and Hoskote Taluks (all
PHCs and Sub centres) found that CSSM training given to ANMs/LHVs had
3
$
■J
significantly improved their midwifery skills and improved immunisation in the
area resulting in reduction in IMR (Kanbargi, 1997)
In the study area only 60 percent of the respondents had undergone
CSSM training.
The duration of training varied between 3 days to 21 days at
different locations where the training was imparted
&
9
3
&
It was not possible for us to
verify the wide ranging duration and the reasons for it
However, most of the
11
■r/
11
respondents expressed their appreaat.on for proving trammg that refreshed
their memory.
There is hardly any continuing education programme for them
An important fact that came out during the study was how CSSM changed some
age old practices that were routinely followed.
For instance, babies were given
bath soon after birth that often led to comphcat.ons.
The CSSM trammg has
changed .t. Now baby is kept warm for a day before giving bath. This practice
may reduce considerably the incidence of diseases peculiar to childhood.
The
trammg also, as reported by all those framed, enhanced them knowledge on ANC,
PNC and midwifery skills many of whom had learnt 20-25 years back. The five
cleans or Pancha Shuchitwa was very much valuable learning
Some of the
respondents expressed their happiness that CSSM training not only improved
3
them skills but was accompanied by a booklet and a Disposable Da, Kit (DDK).
The booklet which should be g.ven to every ANM/LHV as they reported it has
proved invaluable for them for all time. (Unfortunately the Research Team could
not see the booklet).
9
The respondents were asked about other sk,l| based short term spec|a]
training programmes that are imparted
There does not seem to be any
systematic approach in organising these training programmes nor there seem to
t’3
be any compuision that say those who have put m 20 years ot service shouid
0
have some minimum number of training programmes
a
told us that often they do not know that the.r colleague from other sub-cenlre had
As one ANM (very senior)
gone for a trammg programme about which MO had not even informed others
3
II
was only after her return they leaml. This aspect, it is hoped. Js covered by other
study by Dr Mehta and Dr Shivram.
J
We had listed 10 important trammg programmes to check how many of
them were attended by the respondents
They were trammg programme
pertaining to Malana, Cataract. Tuberculosis, Family Planning Target Free
)
Approach. RCH, Leprosy. AIDS. IUD. MPW. MTP and an open ended others
3-
Others category included IPP and continuing education programmes that were of
)
©
>
tJ
>
relatively longer duration were appreciated by the respondents
The ANMs
opmed that the programmes were broad based and more practical
response and ratings recorded are presented below
The
u
12
TABLE 6
Training
C')
©
•9
Malaria
Cataract
TB
Target free
RCH
Leprosy
AIDS
IUD
MPW
MTP
Others
TRAINING PROGRAMMES AND THEIR ASSESSMENT
No.of AN Ms I
trained
15
60
23
59
37
67
39
18
20
04
45
Percent
Very good
69.0
26,5
67.8
42.5
77.0
44.8
20.7
23.0
4.6
51.0
j
t
266
25_O_
J7.4
16.9
32.4~
19.4
41.0
61.0
50.0
100.0
46.7
Rating
Some what
useful
~~ 60.0 ~
_1LL
__6 5_2 ~
^59.3 '
Not
useful
]3_3~
33 r
1Z±_
__ 54J_
55.2
35.9
33.3 _ '
45.O’
23.8_
13.5
~25.4
23.1
5.6'
5.0
48.9
4.4
■3
The rating and percent trained for different health programmes reveal
3
some interesting facets.
3
were repeated.
3
disliked by most of the respondents. It was reported in all sub-centres that the
Even during our discussion the findings in the table
Short term programmes particularly one-day training was
faculty would arrive, generally, late and by the time the programme starts it is
time for lunch and post lunch session - after heavy lunch is not very conducive
for learning. The administration might have to confront with several problems in
©
3
encouraging training courses lasting for at least a week. Given the large number
of vacancies in the sub-centres, withdrawing ANMs for training for a week will
certainly disrupt the skeletal services that reach the community. Arranging right
5
resource person for the programme, communicating with the trainees etc do
pose hurdles in efficient organisation. However, given the rating of the trainees
and assessment of the utility of these programmes it may be more productive to
3
enhance the duration and enforce discipline of the resource persons
3
9
There is also the problem of the size of the trainees.
An elderly ANM
•3
reported that she was one of the 30 trainees in a programme and was sitting in
3
the back row, hardly could hear what was lectured and instrument to be used
■3
3
3
IM
‘•)
11
«ss
was only one which she could not see at all
By the end of the day she thought
she would not have missed anything by not attending it
A shocking observation which the earlier study (Kanbargi, 1996) had found
was substantiated here that only one in five ANMs knows how to insert an IUD
It is widely acknowledged now that Indian Family Planning Programme is
3
synonym with massive female sterlisation as they account for 80-90 percent of all
$
acceptors.
3
sterilisation what can be done7 This argument is hollow as the eligible women
©
The programme managers argue that if women prefer only
who need contracepting method are not even fully aware of the choice they have.
The district level information provided in Table 2 makes it very clear.
3
9
female sterilisation which is universally known in rural areas.
It is only
Spacing methods
ignored in the family welfare programme need urgent redressal
3
Section II
Review of Training Impact: Insights from the Field
©
3
3
3
This section has tried to review the impact of training programmes on day-
to-day practice of the respondents.
It is classified as (I) Antenatal care, (ii)
Identification of high risk pregnancies - (during Ante-natal care), (iii) Midwifery
services and (iv) child care.
These are all part of safe motherhood and child
survival programme which is being implemented in the state for few years now.
As it was revealed that only 60 percent of respondents have undergone CSSM
training but interaction among trained and not trained possibly will improve
3
overall performance of all respondents.
Antenatal Care
a
>
i
The antenatal period is of great importance in determining future course of
events for an expectant mother.
During pregnancy traditional practices are
followed despite some modern knowledge.
It surely influences the health care
seeking behaviour of women and their health status that will have a great bearing
on outcome of the pregnancy.
©
One of the most important fact that affect
pregnant women's health is the suggested strict diet regime - severe restrictions
on food - what to eat and what not to eat. The strong dietary taboos can further
u
r*v
It
□
adversely affect the nutritional status of women most oi whom are already
malnourished.
But there are also traditional norms that put restriction on
activities that may have some beneficial impact
The knowledge about conception is widely known to all - pregnancy is
recognised by the absence of periods or nausea. If the ANMs are regular in their
0
beat and meet all the potential women they are likely to know that a particular
3
woman has missed her period and if she had a fairly regular cycle guess that she
3
is pregnant. The care should start from registering such women.
3
The recently completed RCH survey (Kanbargi et.al., 1998) considered at
least 3 ANC visits to each pregnant woman during her pregnancy, 2 anti tetanus
injection and supplementing nutrition by providing folic-acid tablets for 100 days
as minimum package to be ensured to each pregnant woman. The survey found
3
wide variations across districts ranging between 78 percent in Dakshina Kannada
a
- Coorg districts to only 21 percent in Gulbarga.
There could be a variety of
reasons to be explored. Many researchers have questioned the efficacy of this
%
approach in reducing maternal mortality in the states e.g. a study conducted in
Kanakpura rural areas found “ante natal care provided by the government was
only contact service and are often routine that leaves much to be desired.
Weight of most of the women was not recorded, not haemoglobin estimated nor
3
urine test done.
This is in marked contrast to services provided by private
practioners. Apart from providing tetanus toxide and iron folic acid very little is
done in government health care” (Jayashree Ramakrishnan et.al., 1999).
3
3
•ii?
3
The findings from the present study fully agree with the above
observations. The questionnaire had a check list of 14 items like (I) Registering
a pregnant woman which should be the beginning of the service and when is it
done? When a woman informs about pregnancy or during 3 - 5 months of
pregnancy?
It was assumed that ANM is supposed to visit the households
routinely and during her visit a woman may report that her periods are post
poned or missed. However, the respondents could not distinguish the nuance
and the objective behind splitting the question in two parts and it was of not much
use in over 50 percent of respondents, (ii) When they start supplying IFA Tablets,
(iii) When the Tetanus Toxide injections are given, (iv) When is the blood
3
3
□
15
pressure measured, (v) When urine test is done, (vi) when is the blood test done,
(vii) when is the weight taken, (viii) when is the abdominal examination done, (xi)
when is the vaginal examination is done, (x) Whether diet advise is given (xi)
Whether advice on breast feeding given (xi) Whether the woman is informed
about possible complications in pregnancy (xii) Whether contraceptive advice is
□
given to either post-pone next pregnancy or avoid it and lastly whether need for
9
post-natal check-up is explained? The following chart provides the responses of
3
ANMs/LHVs to these questions.
TABLE 7 : ANTENATAL CARE KNOWLEDGE : PERCENT
SI
3
I
2
3
__ 4_
__ 5_
O
__ 6_
9
__ 7_
8
Ji
j
3
IO
Hr
Hr
13
14
3
Check list
No
Registration___
IFA tablets
TT injection
BP_________________
Urine test__________
Blood test_______
Weight test______
Weight taken
Abdominal check
Diet advised
Breast feeding ad vise
Pregnancy coniplicati ons ex p I a i n e d
Contraception advised__________
Post-natal
————check
——advised
________
Frequency
Yes
No
100.0 _0_
100.0
0_
98.5
1.5
92.0
8.0
96.6
34
93, M 67
96,5 " 3.5
JOO.O^ __0__
747
2_5.3
100.0 . 6
100 0 ' !
83.9
£6_l_
94.3 " 5.7 ~
86.0
I4.0
Most of the ANMs were aware of what is ANC and its importance.
But
3
they had problems with discharging these responsibilities because of lack of
3
instruments required like BP instruments and stethoscope, chemicals needed for
5
testing urine etc.
In addition many ANMs were not sure what is high BP that
need attention? Weighing machines were provided to only 10 percent of ANMs.
3
Only one ANM in a sub-centre (Gulbarga) showed me two weighing machines one for just born babies and other for adults. She had another weighing machine
for babies who can be placed in the panel for weighing.
0
5
■a
3
F
But this was an
3
l(»
exception, checking haemoglobin content and RH - ve was not possible even in
Community Health Centres and PHCs.
It was clear that the knowledge of ANMs is not fully exploited in providing
3
quality care during pregnancy. To explore further we visited two ANC camps in
3
Gulbarga district - one held in a sub-centre and another at a CHC The Registers
3
maintained revealed that in CHC about 20 percent of women were examined for
blood pressure and taken their weight. It was reported that large crowd about
3
•3
100-150 women makes it impossible to provide the text book - prescribed
services to all pregnant women.
The sub-centre clinic was held in a school - an apology for quality service.
There was one table and a chair courtesy the school and the room was
3
partitioned by a thin dirty bed sheet for examining women. Hardly there was any
3
privacy. There was a crowd of 50 - 60 women at noon still waiting for their turn to
•3
be examined. The Lady Medical Officer was tired but committed to do her best
'3
to the pregnant women who had walked long distances to come here. They had
very little choice as the ANM staying in the sub-centre village was hardly
equipped with her needs. She had hired a room at the back of the school she
3
had to collect water from a well and go to field for her natural calls Her husband
3
was staying in Gulbarga.
3
We observed that because ANMs have not been provided with required
facilities they request the pregnant women to come to a ANC camp held once in
a
a week or once in two weeks
The Sub-Centre we observed held ANC camps
every week and serves about 10 near by village women. The camp naturally
gets crowded making it difficult to do all required tests for each one A seasoned
medical practioner will take the blood pressure if she has reason to doubt
3
otherwise in such situation no. Maintaining record of blood pressure, weight gain
4
chart that immensely help in identifying high risk pregnancies/babies and
3
planning safe deliveries is not possible.
If the ANMs who are trained for ANC
and used only for distributing IFA tablets and abdominal check-up it is gross
3
3
3
3
J
under utilisation of their talents and putting more pressure on limited resources at
the Sub-Centre causing great inconvenience to women clients
17
<7
The ANC section has two very important questions that are generally
ignored. One was whether the expecting mother knows when she is expecting a
baby - probable date of delivery. The ANM should be able to suggest the same
We observed 82 out of 87 were aware how to estimate the date of delivery
Another crucial factor is where it will take place?
It is crucial because during
ANC period there will be clear indication regarding the type of delivery - whether
it will be normal or complicated.
Depending on the need ANM can suggest the
place. If it is going to be a normal delivery certainly can take place at home. If
not, the family has to arrange for a hospital delivery including the resources. But
surprisingly only two in three ANMs reported that they often suggest to women
where they should go for the delivery. But the rest said it is to be decided by the
-9
9
family based on their economic situation
Our broad impression was, as
mentioned early, the ANC means 3 visits to pregnant woman, 2TT injections and
IFA supply of 3 months.
Though it may be considered as minimum needed,
much more has to be done to do justice to CSSM programme and improve the
0
situation of women and children.
Identification of High Risk Pregnancies
0
Identification of high-risk pregnancies is the first and single most important
□
step to be followed by going to a referral hospital fully equipped to provide
0
efficient services to ensure safe delivery.
Q
The responsibilities of the ANMs and LHVs listed in the Training Manual
prepared by State Department of Health and Family Welfare under India
Population Project (IPP IX) include urine test and blood test of all pregnant
women for albumin, sugar and hemoglobin contents during their home visits.
0
It
also mentions that at least 50 percent of the deliveries are to be conducted by
ANMs and the rest conducted by Trained Dais are to be monitored or supervised
=3
G
by ANMs.
The questionnaire has prepared an exhaustive list of symptoms that
indicate high- risk pregnancies
Each ANM was asked whether they know what
constitute risk to pregnant woman
□
O
The list prepared included risks related to last
pregnancy termination, history of systemic illness reported complaints during
u
IX
pregnancy in addition to the generally known factors like first birth or higher order
births, height of the woman, status of blood pressure, etc.
The knowledge reported in the following tables is based on combined
responses - some spontaneous and others received after a little probing
©
The
responses are presented in two formats for the convenience and understanding
of the reader.
©
TABLE 8 : IDENTIFICATION OF HIGH RISK PREGNANCIES
©
Symptoms
SI
No
2
2
J
a
4
5
a
6
G
o
e
7
8
9
10
Age less than 18 and over 35 years__________
Is* or 4th and higher order births
Current pregnancy within two years of previous
Height less than 4\ 10"
______________________ __ ________________ i
Abnormal weight gain - over 10 kg. Weight gained
during pregnancy_______
Sustained high blood pressure over 140/90
Poor weight gain 5 - 6 kg only
Mai presentation of foetus__
Weak or no movement of foetus
Convulsions in pregnancy
Not
aware
percent
1 1.5
88 5
74 7
25.3
62_l_
37.9
8j_6 n ■ i8 4
: '47.T“
52 9
Aware
(percent)
5(Hy
4SLi
78.0
5T0
70.0
r
49 4
51.7 ~
46.0
3(') ()
It may be mentioned here that many ANMs in Tumkur District reported
that for this interview they had spent two sleepless nights to go through their
Q
notes/books of training period to refresh their memory like they used to prepare
•3
for their theory examination. However, the information provided in Table 8 and 9
is disappointing picture.
•3
problems in responding as they frequently said “we have forgotten many things
taught long back”.
a
It was the respondents in 50+ age who had more
There were two respondents who were deaf and posed
problems for communicating effectively.
It may be noted here that most of the respondents knew that short women
constitute high risk during their pregnancy but they could not define what is
short? Similarly they knew that sustained high blood pressure during pregnancy
carry high risks but did not know exactly what is high blood pressure
a
e
As
]
U3
19
£)
mentioned earlier most ANMs do not possess the instrument and those few who
-■O
had it, was not in working condition.
I ABLE 9 : IDENT1EICA LION OF HIGH RISK PREGNANCIES
9
SI.
No.
1
©
History of last pregnancy
Not Aware
Percent
64.4
57.5
55.1
35.6
42.5
44 9
55.1
60.9
16.1
44 9
39 I
713
71 3
77 0
57 0
83.0
28 7
23 0
43 0
17 0
32.2
44.8
48.3
35.6
62.1
52.9
36 8
18 4
67.8
55.2
51.7
64 4
37.9
46.9
63.2
81 6
i) Last pregnancy terminated as
a) Abortion
b) Still birth
c) Premature birth
&
Aware
Percent
ii) In complicated delivery with
prolonged labour ended with
2
a) Retained placenta
b) Sepsis
c) In neonatal death
Systemic illness
9
(i) Heart disease
(ii) Diabetics
Q
•9
(iii) TB
i
(iv) Hypertension
i
I-----
i3
©
9
Woman complains of
(i)
(ii)
(iii)
(iv)
(v)
(vi)
(vii)
(viii)
Breathlessness
I
Excessive tiredness
Palpation
PufTmess of face
Tightening of ring/bangles/chappals
Vaginal bleeding
Pain in abdomen
Fevers
The responses presented in tables 8 and 9 reveal inadequate knowledge
about identification of high risk pregnancies among the ANMs. The focus group
discussion clearly brought out the problem of ensuring safe deliveries even in
£
&
&
t*
cases of identified high risk pregnancies as the required facilities were not
I
|
u
20
available even at Community Health Centres supposed to be first referral
centres
An example of a maternal death reported in one PHC area would explain
the situation on ground level. The woman who delivered a baby with the help of
a trained Dai and developed complications on third day. She was bleeding. The
PHC kept her for a day with medication. The bleeding did not stop and she was
advised to go to District hospital in the night.
$
transport and resources,
The family could not arrange
instead they took her home and she died next day.
Some enquiry was conducted and the case was hushed up.
The data collected on ANC services and ability to identify high-risk
pregnancies reveal that there is a long way to go to achieve effective reduction in
□
maternal mortality and infant mortality. As noted earlier ANC means three visits
to pregnant woman, 2TT injections and 100 IFA tablets.
Even this minimum
package of services have made considerable impact in bringing down IMP in the
state,
further
decline
depends
upon
improving
the
services
of ANMs,
infrastructures of PHCs and CHCs to reach the goal of IMR 30 mentioned in the
a
policy statement of 2000.
Institutional Births
©
Institutional deliveries are meant to provide safe motherhood and the
©
resultant significant reduction in maternal deaths. Wide variations were observed
in them in the selected districts - from ^bout 79 percent in Dakshina Kannada to
3
only 21 percent in Gulbarga. ANMs in Udupi reported that mapy of them have not
conducted a single delivery during last five years because women prefer to go to
3
maternity homes or Government hospitals at District level.
The private sector
J
health services in Udupi - particularly the Manipal Hospital have expanded their
3
maternity services to rural areas that has almost ensured safe delivery to any
3
woman - poor or rich. Our visit to a remote place in Udupi where we had to cross
3
3
a river to reach the village revealed that just a telephone call to thfe Manipal
Hospitals maternity home situated at a distance of 14 kilometers will provide
them not only free delivery but also free ambulance service to transport the
pregnant woman to the hospital
□
&
The public-private co-operation observed in the
21
district is really remarkable to try in other poor districts like Gulbarga or Bellary
J
that can improve accessibility to good care and go a long way in ameliorating the
sufferings of poor women.
As a contrast to Udupi ANMs who have not conducted a single home
delivery during last five years, committed ANM in Gulbarga where there is hardly
any choice for most rural women reported that she conducted 120 deliveries this
year of which 20 were high risk whom she referred to CHC and ensured safe
births. Another ANM reported to have conducted 94 out of 99 births in her areas
this year - 5 being conducted by a trained dai. These two ANMs stay in the sub
centre quarter and a visit there will convince that they were model sub-centres.
The two ANMs were residents tpere, available any time for service, had BP
instrument, weighing machines for babies and adults, providing good ANC by
testing urine, keeping records of weight to know the gain, recording BP of all
women and ensuring the pregnant woman at least one check-up by a lady
medical officer to confirm that every thing is OK with all her clients. The outreach
programme might have conceptualised such sub-centres as models.
But they
are exceptions now as ANMs having no housing facilities stay in a place where
she can get a house on rent and naturally night deliveries can not be attended by
her.
Identification of High Risk Babies (Who weighed less than 2500 gms at the time
of Birth).
The data collected in Reproductive and Child Health (RCH Phase 1)
survey in the selected three districts revealed that only about 7 percent of babies
born in rural areas in Gulbarga district were weighed after birth and 58.3 percent
of them were under weight (less than 2500 gms). On the other hand in Udupi
(Dakshina Kannada) 62 percent babies born were weighed and only 13 percent
of them were under weight and in Tumkur about 28 percent of babies’ weight
,''=h ■
was recorded and 20 percent of them were reported weighing less than 2500
gms. These findings present a grim picture for Gulbarga and also to some extent
Tumkur that certainly fare better than Gulbarga for underweight babies who carry
high risk of death. Though one of the simple measure to reduce this incidence of
H
5
22
low weight babies is to improve the nutritional level of the mother by
supplementing her diet and providing IFA tablets, the ANMs should have
knowledge of the under nourished mother and the need to supply IFA tablets to
them in their area.
The RCH survey reports that in Gulbarga where the proportion of low birth
weight babies is highest in the study area only 48 percent of pregnant women
3
©
had received IFA tablets, it was 87 percent in Tumkur and 92.3 percent in Udupi
(Dakshina Kannada). It is difficult to understand why this simple low cost remedy
available is not taken seriously in Gulbarga where it is absolutely essential.
□
It would be interesting to note here our observations and-the community
perceptions about how these essential services are delivered by ANMs.
Our interaction with community leaders and women in particular provided
■a
surprising data. We met a Lady Panchayat Chairman in Gulbarga who was in
3
her late forties, literate and was having concern for women’s issues including
3
their health.
3
a
©
She said that the ANM stays in the village (only village she is to
serve as it is quite large with 3500+ population), has a telephone at home and
also keep some essential drugs for emergency
She conducts most of the
deliveries in the village by charging anywhere between Rs.300 - 1000 depending
upon the economic status of the family.
But she never visits any home for
providing services. People have to call her on phone or meet her personally if
J3
they require any service - of course at a price. The Lady Panchayat Chairperson
□
did not know that ANM is supposed to visit all families in- her jurisdiction to
3
enquire the welfare of women, their pregnancies, children health etc.
Even her
husband and many others who gathered there during our focus group discussion
reported ignorance and said the panchayat will issue a letter to the Medical
3
Officer in this regard soon to ensure her services to all homes in the village. It
&
would not be surprising in such situation that poor and scheduled caste women
□
may not be able to avail her services free.
This was not an exceptional example in Gulbarga
In three more sub
centre areas we observed similar things. Absence of good roads and transport
facility may be important hurdles to ANMs in addition to inadequate housing
&
a
11
21
facilities. But administration both in the health department and at Zilla Parishad
should try to improve the situation to ensure accessibility to health care for all.
Rarely, except in one we could see a chart showing ANMs’ travel programme for
the week usually displayed in all PHCs.
3
$
It was also surprising that many
ANMs/LHVs in Gulbarga were not found wearing uniform white saree during
working hours. But in Tumkur and Udupi we did not see any ANM/LHV not in the
uniforms.
However, an effort was made to know respondents’ abilities to identify
©
high risk new born babies (who weigh less than 2500 gms) by check-listing some
symptoms.
TABLE 10 : IDENTIFYING HIGH RISK NEW BORN BABIES
(WEIGHING LESS THAN 2500 gms)
&
&
_______ Symptoms_____
Aware (percent)
Refusal of feed_________
Increased drowsiness
____ 78.2____ _
56,3
_75.([ '
Difficult breathing
Cold to touch_______
Yellow staining of skin _
Convulsions
Others
____ 62.0
____ 26_4_
14.9
The data presented in Table IQ reveal that there is much to be desired
3
3
However, some ANMs were aware that if the baby is cold, they would keep it
under 200 watt electric bulb to improve the body temperature of the baby.
Acute Respiratory Infection (ARI)
3
Only about half (52 percent) of the ANMs were aware about Acute
Respiratory disease and 85 percent of them had knowledge of at least one
3
3
•3
3
symptom of ARI and also were aware that it is an important reason for high IMR
u
>■?>
'i
*.z
3
24
Pneumonia
Most of the ANMs (91 percent) were aware about pneumonia and more
than half of them knew one or more symptoms of pneumonia like excessive
drowsiness, respiratory grunting, convulsion and inability to drink.
Diarrhoea and Dysentry
•e
Diarrhoea, a major killer of infants and its symptoms like passage of
watery stools 3-4 times a day was known to 92 percent of ANMs.
However,
there was confusion among many in distinguishing diarrhoea from dysentry
which has symptoms like blood in faeces, abdominal cramps, fever and weight
loss. Only one in five respondents were aware that diarrhoea/dysentry is a major
killer of infants.
All respondents were aware (100 pr cent) of dehydration that
follows dysentry/diarrhoea and could mention all the symptoms like restlessness,
a
decreased skin turgor, dry mouth-tongue, sunken eyes and lethargic appearance
of the baby. Management of dehydration through measures such as giving ORS
■£
or home made syrup of sugar and salt, plenty of fluids, and continue breast
feeding was known to all respondents.
$
The strong emphasis given to the child immunisation was reflected in
every respondent knowing what immunisation is to be given when. Liquid IFA,
however, to be given to malnourished babies was known to only one in four,
perhaps it is not supplied in the state,
0
small IFA tablets.
It was reported that children are given
i
■j
Knowledge about Cold Chain
3
While immunisation coverage has shown remarkable improvement over
time, quality of immunisation has remained a question to be answered.
4
Is cold
chain maintained to ensure the required vaccine potency? We wanted to test
whether personnel who play a key role in immunising children know about cold
chain?
It was revealing experience for the research team which visited a Primary
Health Centre in Gulbarga district. It seems a diary is to be maintained and the
temperature shown on the thermometer of the new type refrigerator in the PHC
0
d
a
i I ■J
25
3
a
v/here vaccine is stored is to be recorded by the Medical Officer
We were
surprised the recording in the diary was up to date with recorded temperature,
date and signature of the Medical officer but the thermometer that indicates
temperature was not working for several days and not repaired. It was also clear
from the observation of the diary that all the entries for the month were made the
3
3
3
‘3
previous day.
Neither the staff nor the clients who receive were aware of the
importance of maintaining cold chain to ensure effective immunisation
Compare this with what was reported by almost all respondents in Udupi.
They said that the immunisation day for them will become a nightmare if power in
the area was shutdown even for half an hour as mothers would object for
<3
immunising their children as there was power shut down yesterday as such what
O
guarantee is there of the vaccine potency? With all the explanation by the ANMs
O
about the advantages of new freezers that they have, some mothers would still
prefer to go to private practitioners for immunisation. These observations, though
accidental, reveal the casual approach adopted by qualified responsible authority
whom the illiterate and ignorant community trusts and it deserves serious
consideration in the department to ensure that there is responsible approach to
(3
immunisation.
O
percent
of
Under the circumstances it was not surprising that about 40
respondents
expressed
their
ignorance
about
the
required
temperature to maintain the vaccine potency.
&
O
3
Infant Feeding
There was a question to check the respondents’ knowledge on exclusive
breast-feeding.
What does it mean?
How long a baby should be exclusively
3
breast-fed? Response of all the respondents was that babies should be breast
«a
fed for 3 months. They also knew the advantages that exclusive breast-feeding
3
provides more nutrition (90 percent), protects against infections (87 percent) but
3
only 46 percent knew about its contraceptive effect. The RCH survey 1998 found
that in Gulbarga babies being breast fed within two hours of birth accounted for
3
9
i&
3
$
&
only 9.5 percent while it was 36 percent in Tumkur and 47 percent in Dakshma
Kannada District.
Continuously repeated advantages of cholostrum milk that
provides effective immunisation to babies is almost denied in Gulbarga
The
u
26
general opinion of ANMs was their advice during ANC and delivery does not
-x
make much sense against the strong traditional beliefs that still govern the
community behaviour.
Weaning
3
We also enquired whether the respondents are aware about weaning?
3
And when to start it? Each ANM reported that breast milk will be inadequate to
©
babies growth after three months and babies will have to be introduced to some
©
other semi solid foods like Ragi Sari’, Rice Ganji’, Bele kattu or liqufied pulses’
etc. which can be prepared at home with locally available food.
Few of them
reported that they also suggest to mothers to go for baby food -available in the
market. More than 70 percent of ANMs in Udupi reported that weaning food also
can be purchased from market.
a
While the latest WHO recommendation is that exclusive breast milk should
continue for 6 months and only afterwards weaning foods be introduced, all
available evidence in Karnataka show that there is need to improve the
understanding of mothers in rural areas about the advantages of cholostrum milk
and exclusive breast feeding.
Surveys have reported wide spread practice of
squeezing cholostrum milk and feeding just born babies with variety of liquids like
$
sugar syrup and castor oil with enormous health hazards.
t9
reported that during Mother’s Club meetings as well as during ANC they explain
The respondents
all the advantages of breast-feeding ’including cholostrum milk however, the
□
3
outcomes are poor.
In this regard there is need to consider for vigorous
campaign and improved IEC programme.
Several babies, we saw in ANC
camps in Gulbarga and Tumkur convinced about the poor health status of
3
surviving children. They were looking thin with sunken eyes.
3
under-nourished mothers even though supplied IFA tablets were not regularly
It is possible that
consuming them to derive the benefits.
0
General Knowledge
We perceived ANMs/LHVs as backbone of rural health delivery system
They are the link between the vast rural illiterate women and modern health care
<0*
i I .-■
27
*•»
providing PHCs.
They are expected to visit every household in their area and
are familiar with each of the household that make them not only a health worker
but a friend, philosopher and guide to those women
During their visit they may
conduct mothers meeting to provide them important information on their own or
have to answer some questions raised by their clients.
3
Therefore their
knowledge and advice carries great impact as such this study attempted to
assess how familiar they are with the population problem - particularly whether
3
3
3
they knew that India's population has crossed 100 crore mark. We asked what is
India's population and gave three hints - 50 crore, 150 crore and 100 crore.
Only 46 percent of them could say it is 100 crore.
It was noted earlier about the low age at marriage of females and its
consequences on IMR, MMR and also fertility levels.
Marriages before a girl
e
attains 18 years of age are legally prohibited. But its impact is negligible on the
&
marriage age.
Only 79 percent of respondents were aware of legally approved
age at marriage of boys and girls.
9
One in five respondents were not aware
themselves and they may not have discussed about it in the meetings of
mothers.
If female age at marriage continues to rise as slowly as is observed
despite all efforts then what are the options left to policy makers to reduce its
o
consequences? Or should this area be left as nothing can be done as it is
9
parents of the bride and groom who decide the marriage and who are not
bothered about the age? Marriage is certainly a complex social and economic
issue. Good harvests see more marriages in any village and droughts few or no
•a
a
marriage and difficult to bring interventions to drastically change the pattern.
In' this situation female health workers can play a very important role of
motivating the young married couples to postpone the first birth by a couple of
years or till the young woman attains 20 years.
a
The focus group discussion
revealed that talk about contraception will begin only after the couple has one or
two children and intensive efforts begin only after 2 children. It is obvious that if
sterilisation is considered as the only suitable method for the couple by the ANM,
»
there is no alternative.
But can they not advise them to use condoms or safe
period or even least harmful orals that are available in the market? They are not
trained to motivate couples for adopting spacing methods
a
a
H
2X
The focus group discussions also brought out some interesting problems
ANMs face in the field.
It was reported that the distribution of IFA tablets to
pregnant woman generally starts in fifth month of pregnancy. If given soon after
registration of pregnancy of the woman and the pregnancy is terminated in
9
abortion women hold the ANM responsible for it. Because it is she who supplied
3
IFA tablets saying that her health will improve and on the contrary she had
3
abortion. Such news spread very fast in villages the whole village may turn out
3
hostile and ask her not to give those tablets to any pregnant woman in their
3
village. Similarly motivating for contraception is confronted with the problem of
child survival. If the only son among the two the couple has, dies, ANM will not
be forgiven for motivating them to accept sterilisation. So to play safe they said it
3
is better a couple should have two sons and a daughter before undergoing
tubectomy. It is not surprising that NFHS II found 90 percent of sterilised women
>3
had not adopted any other contraceptive method before. Distribution of Pill and
Condom through public sector, therefore, constitute insignificant proportion in
3
£
®
9
rural Karnataka.
This background is aptly reflected in the responses of ANMs/LHVs as 18
percent of them could not say what is safe period and explain it correctly. But 95
percent could explain what tubectomy is and how it is performed because they
reported that they explain it to all potential acceptors
■®
a
j
Medical Termination of Pregnancy
»
Abortions were legalised in India in early 1970s and the number of legal
abortions have increased significantly over the time as also approved places for
■3
conducting abortions. But rural women are deprived of this facility as most of the
3
PHCs in the study area do not have the equipment or person/approved by the
3
government to provide abortion facility to women. None of the ANMs are trained
<3
to conduct MTP and when we asked them when would they recommend MTP to
women? It was disappointing that none of them had suggested any woman to go
for an abortion. Looking at the clandestine abortions reported and observed by
the hospital records showing sepsis/infections caused by quacks while aborting
and admitted to hospitals in serious conditions, there is need to examine what
3
29
J
ANMs can do in rural areas. While ANMs took a moral stand and their response
was very firm in reporting that they neither perform nor recommend MTP to any
woman that does not reflect reality.
■J
The job responsibilities listed by the Department of Health and Family
3
Welfare 1999 clearly has mentioned that ANMs should identify women in need of
0
MTP and inform them the nearest approved place for MTP to obtain an MTP. We
think there is an urgent need for a debate on the issue of providing this facility to
»
rural needy women.
5
The Eligible Couple Register
a
a
Eligible Couple Register the Female Health Workers are supposed to
It is a valuable
maintain and keep it up to date with all relevant information.
document that guides in her work.
It has all information she needs - how many
currently married women are there by contracepting status and number of
children, helps in identifying children is need of immunisation, and women in
need of advice on nutrition, etc.
A
general
complaint
emerged
in
all
our
a
meetings was the shortage of EC Registers - some places not supplied for 7 - 8
o
years and ANMs have to purchase a Note pad and record the information to the
a
best of their abilities.
Non-supply or irregular supply certainly creates serious
problem in compiling service statistics from Sub-Centre.
We wanted to learn from ANMs whether still they feel EC Register serves
©
an important purpose and help them. There was a unanimous response that it is
important and they should be supplied EC Register so that they will be able to
2)
a
a
a
a
a
improve their performance.
Mothers Meeting
The respondents also informed that they routinely conduct mothers’
meetings and discuss different health issues and about nutrition. They think that
these meetings will become more effective if the ANMs are provided with
educational materials for use during the meeting to make the meetings more
productive.
»
a
»
♦
u
30
J
Advise to Adolescents
v.'^
n
The needs of the adolescent girls that were ignored for long is getting
attention now.
There are special programmes designed for their benefit to
improve their knowledge about personal hygiene and health.
There were few
reports of providing Tetanus Toxide injection to these adolescent girls. What was
3
interesting to learn from many ANMs was that often in mothers meeting some
adolescent girls also participate and when the topic of contraception / pregnancy
is to be discussed they are asked to go out as they need not learn about
3
3
3
>
£
contraception because educating these unmarried girls in Family Planning
methods because of the fear of using them before marriage.
Given the sea
change that is being realised through recent research on changing sexuality in
the society and the AIDS threat becoming more and more serious there is need
to think about what should be the policy for these girls.
Most of whom are
illiterate and ignorant of many vital issues concerned with their own person.
If
they are educated about contraception will that enchance its use after they get
married?
Summary and Conclusions
The short term intensive study was carried out in three districts of
Karnataka State that widely differ in health and demographic indicators.
The
main objective of the study was to assess the various training programmes the
□
grass root level female health workers ’(ANMs/LHVs) have undergone, extent of
J
their utilisation by them in their day-to-day work.
3
The study went beyond the
stated main objectives to examine whether providing training per se will improve
health care services as its effective exploitation is related with a host of other
factors like infrastructure, equipment and team spirit at PHC level from where
%
these services are organised, supervised and monitored.
The focus of the study was confined to those training programmes that
were designed to improve the health status of women and children — more
3
specifically in reducing further IMR and MMR. For this intensive study selected 3
a
districts - Udupi, Tumkur and Gulbarga. From these three districts 8 Taluks and
£>
&
$
d
22 Primary Health Centres were selected.
All Female Health Workers
11
5
31
(ANMs/LHVs) numbering 87 of these centres were administered a standard
questionnaire that was specially constructed to check their skills required in their
work. The 87 respondents were covering a population of 2, 61, 155.
9
9
All respondents had successfully completed the foundation course - 18
months and few had 2 years training programme. The gap between the
completion of course and joining the service for many was
large and few
exceptional cases it was 4-5 years.
3
The general impression of the respondents regarding their training that
3
some had completed 30 years back was that there was inadequate attention to
practical hospital training and training in field work. An indication of this was the
3
9
&
reported shaking of hands during the first delivery conducted by most of them.
There were one-or-two exception to this general observation. An ANM in
Gulbarga mentioned she had the best opportunity of conducting 24 deliveries
during her training period under the able supervision and guidance of a
gynecologist. It was suggested that training programmes should be need-based
and practical in real life situation and not just lecturing with lot of information.
>
There was long gap between Foundation course and the next most
■:i)
important training programme related to maternal and child health viz. CSSM
•9
training.
The findings show that still 40 percent of ANMs have to undergo this
programme that has great relevance to reduce further IMR and MMR.
$
It was shocking to find that most of the ANMs are not trained to insert IUD.
a
Policy studies have repeatedly highlighted the urgent need to enhance use of
9
spacing methods particularly among rural women, as it will have direct good
impact on the health of women and children. This needs serious attention
9
Similarly ANMs/LHVs need to be more sympathetic to women’s need for
Abortion.
Whether they can be trained to perform medical termination of
9
pregnancies is a technical question to be decided by experts, we strongly
recommend that at least MTP service be made available at PHC level and
$
ANMs/LHVs should be trained in the legal aspect of MTP and when they can
9
recommend it to needy women.
9
>
3
3
l»
In addition to CSSM, a host of training programmes have been conducted
for the respondents.
A general observation is that the short term training
u
3
12
3
programmes of one or two days have been rated as not very satisfactory by the
respondents. There was a strong suggestion of all respondents in Tumkur and
?)
Gulbarga that Continuing Education programme for a week should be a regular
feature to update their skills and knowledge of maternity and child health. This
programme should be holistic and may cover other relevant contemporary health
1
problems in the state / district.
Identifying high risk Pregnancies
3
The findings suggest that there is a need to have as suggested above,
one week Continuing Education programme to enhance the knowledge and skills
£
3
of ANMs/LHVs of pregnancy management. Except in Udupi/Dakshina Kannada
and Kodagu districts where Institutional deliveries have become a rule in all other
districts where
domiciliary
deliveries
dominate,
the
improvement
of the
knowledge of ANMs with intensive training should be given serious attention.
a
ANMs/LHVs must have knowledge of measuring blood pressure, testing urine for
albumin and sugar and keeping these records for all pregnant women.
These
services should be provided to women in their homes by ANMs in addition to TT
injections and IFA tablets. It should be followed by blood test of each woman for
3
&
■3
haemoglobin content at PHC level.
It may be noted that we had trained Field
Investigators of NFHS II Survey to measure haemoglobin of all women in the
sample at their home in each village. It was possible because very simple to use
technology was made available from USAID.
It should not be difficult to obtain
this technology by the state government for use of ANMs/LHVs. The time taken
9
3
e.
for the test is very little-just 1 minute per woman at their door step. Unless
minimum package of services are ensured to all pregnant women and each high
risk pregnancy is identified and taken to nearest referal unit for safe delivery,
MMR will continue to be very high.
Identifying high risk babies also needs serious attention.
Knowledge of
Acute Respiratory Infection is very poor among the respondents.
NFHS II
reports that about 34 percent of children were suffering from ARI in Karnataka
indicating the serious nature of the illness and its consequences. The present
study found that ANMs were confused when asked to distinguish between the
&
3
II
5
symptoms of diarrhea and dysentery. As 15 per cent of children in the state were
found to be suffering from these illness improving the knowledge of ANMs and
LHVs in identification of these illness and ARI is to be given immediate attention
3
It was, however, satisfying that Oral Rehydration Therapy (ORT) is universally
known not only to ANMs but also to mothers.
□
Immunisation coverage in the state has shown gradual improvement as
revealed in the service statistics. We came across a report in Gulbarga that a
baby afflicted by polio in a village was living next door to the sub-centre. Looking
»
at the crowd in Immunisation Centres with several agencies participating, a child
may miss immunisation. ANMs were found to be well versed with immunisation
process and were confident that ail children in their area are protected. While in
3
Udupi Rotary, Lions, Womens Organisations, College Students and many
enlightened women participated in pulse polio in a big way even in rural areas
3
such support in Tumkur and Gulbarga was more concentrated only in District
9
towns.
3
Respondent s knowledge about benefits of exclusive breast feeding and
weaning was appreciably good and needs periodic updating. Their understanding
of India’s population and legally approved age at marriage for males and females
was found poor that needs to be up-dated.
3
The most glaring lacunae reported by ANMs and LHVs in their training is
&
lack of communication skills and inadequate attention to it in any of their training
3
Simple observation is that to combat with strong traditional practices having
3
serious adverse impact on women and children like squeezing of cholostrum milk
needs intensive campaign. It would be effective only when ANMs can play an
important important role.
Similarly introduction of spacing methods to young
married couples would be facilitated greatly if ANMs are properly trained to
J
3
convince the young village couple of its advantages.
Most crucial issue to be considered here is that training, upgrading skills
and information becomes inevitable to improve overall health status measured in
several ways. The goals set in the health sector can be achieved when such
relevant training programmes bring in qualitative changes in the services
provided to clients.
t
F
If all that is told in training programme is difficult to put in
11
5
3
34
3
practice because of lack or absence of infrastructure, equipment and other
supplies the purpose of training cannot be served
It was observed that vast expansion of health care services - personnel
during the decade is not followed by adequate care and required
resources.
The quick expansion perhaps created a problem of finding professionally trained
3
personnel. A look at the staff position at district level is surprising if not shocking.
a
a
a
If health care service delivery is ensured with or without these large number of
vacancies, it is in itself an indicator of quality care.
At policy level, it is desirable to think of a district or a group of districts for
intervention. For example in Gulbarga and Tumkur and such other districts there
is need for greater attention to improve the management of pregnancies and their
>
outcomes which may need more resources like improving PHC/Sub-Centre
3
infrastructure, equipment to ANMs such as BP instrument, chemicals to test
urine, haemoglobin/blood test etc.
Where as in Udupi. Dakshina Kannada,
Coorg with good adequate support from private sector this problem is not there.
But AIDS is looming large in these districts with large out migration of males and
females. We heard reports of AIDS deaths caused in every village we visited
with documentary evidence. All the deaths had occurred to the return migrants
■a
and it seemed as if they all came home only to die.
*
At state level there is a uniform policy of_resource..allQcalipn for health
a
a
sector. If some districts perform poor as indicated by several indicators it would
be necessary to ensure that administration in these districts are pulled up. The
poor perception of people regarding the public health care system in health poor
districts needs serious attention.
Precious public resources deserve more
productive use. The backward nature of some districts is known for long for over
J
four decades and these districts have remained at the bottom even now. Unless
d
some fundamental change is brought in the administration for improvement they
will continue to be at the bottom.
a
a
a
3
□
Nayak Committee recommended that PRIs should have powers o‘ transferring
•2)
group 'C and D’ employees, the State government is yet to accept it.
The Present Study
In this background of one step forward and two steps backward policies
persued during the last two decades the present study has attempted to examine
the working of Public Health Care System under the contemporary Panchayat
Raj System in Karnataka.
Objectives
The main objectives of the study are :
0
1)
and the officials of health departments at district level and below and
Q
3
To identify areas of confrontation/friction between elected representatives
identify the underlying causes as attitudinal, legal, procedural and others.
2)
To examine the legal procedural factors that need modificabon for smooth
effective functioning of PRIs and health functionaries.
•3
3)
To study the disparities in health indicators across the districts and across
social class within the districts and how PRIs intervention can reduce
them.
o
□
4)
To study the delivery of public health care services, identify best practices
followed that can be replicated in the state to improve the outreach
services.
©
o
J
Data and Methodology
I
Considering the limited time and resources it was deeded that the study
would confine to three districts of the state. The required data was collected from
various elected representatives at district, taluk and gram panchayat levels, from
health staff working at various levels like District Health Officer, Taluk Medical
3
3
Officer Medical Officer at PHCs, PHUs, CHCs, Para med.cal staff, staff dealing
with administrative work and most importantly the general public from 31 villages
randomly selected.
It was focus group discussion on various issues that
provided valuable insights for the study.
<3
3
3
3
F
The general public, however, was
administered a questionnaire to understand the extent of their participation in
PRIs and their understanding of quality of health care services dehvared
At the outset we met the members of the Karnataka Government Medical
Officers Association - a strong body of over 500 medical officers as its members.
The discussion revolved around various issues confronting them in general like
the reported corruption in the department - particularly charges against the
medical officers, their perception of decentralised governance and its pros-cons
on their functioning and the contemporary service conditions.
©
S
■D
3
Emerging Issues : Confrontation
The prolonged discussion with the office bearers at the state brought out
the issue of working under decentralised system of governance and their strong
resistance to it. It was also revealed that in the current situation all the medical
officers would not aspire for the post of District Health Officer as compared to the
earlier days when there was a rush to hold the coveted post that carry not only
3
enormous responsibilities but also a high status — equivalent to any other district
level high officials like Deputy Commissioner. Today he is at the receiving end
0
only - ZP will hold him responsible for every thing that may go wrong like a
cholera cases, malaria cases detection in his area which rightly cannot be
3
considered as his responsibility only. It is concerned with water supply or supply
of DDT for spraying that cuts across the departments.
0
The health department officials also are harassed by the elected
0
representatives as revealed by the Association of office bearers. It was told that
□
DHO has left with little time to attend to his enormous responsibilities because of
several meetings he has to attend during a month (at least 6 statutory) and there
are visits from Ministers that need DHOs presence and there is hardly any time
left for his work that results in poor supervision and monitoring the health
3
programmes in the district.
In addition, the elected representatives who are
■0
drawn from different socio-economic background and new to their work do not
Q
know how to conduct themselves with the bureaucrats who expect respect -
3
regard from every one. The Association expressed strong reservation about the
0
O
3
3
3
I I
way Medical Officers are treated by the elected representatives and reported that
it was most inappropriate.
In addition to the above mentioned confrontations the Association was
more disturbed with the way promotions were given, how a very junior medical
officer became his senior boss because he possessed a Diploma / Degree in
Public Health. Their view was that public health and its intricacies can be learnt
by any medical officer through his experience and he may perform better than a
person who possesses the degree/diploma in public health.
3
It is not very
relevant for this study to deal with this issue in detail as the ZPs or TPs are not
authorised to deal with such issues which lies with the State government. It was
clear from the above discussion that the strong resistance to work under PRI by
D
the Karnataka Government Medical Officers Association was not on any
ideological or legal - structural issue but based more on their stray - scattered
$
experience with some elected representatives. The meeting, however, provided
valuable insights for conducting the study.
The Study Area
3
©
2)
The study was to be confined to three districts but another district was
added to it based on the reported problems of confrontation between health
bureaucracy and ZP
there.
The three
districts were
selected
on
the
achievements in health sector. Udupi - a newly carved district is much ahead of
most of the districts in the state in terms of education particularly female
©
education, health and also other development indicators.
Tumkur is situated in
the middle level and Gulbarga district is still a backward district (Table 1).
Table 1 provides valuable insights in the existing disparities in the selected
districts in terms of health and education. Udupi is an advanced district, whereas
Gulbarga
3
has retained its backward status during
last five decades
of
reorganisation of States.
Tumkur has performed better than Gulbarga but is
3
poorer compared to Udupi.
Thus the findings from this study would present a
O
representative picture of the state.
3
J
'J
I.’
5
Table 1 : Development Indicators in the Selected Districts
J
District/
State
Crude
Birth Rate
1999
Udupi
Percent
women
contracepting
Percent
safe
deliveries
Crude
Death
Rates
1990-91
Percent
females
literates
1996
19.7
2
63.7
3
91.5
4
7.0
Tumkur
24.1
61.3
63.5
Gulbarga
30.1
39.2
State
22.5
58.1
Per capita
income
1995-96
(Rs.)
5
78.5
Percent
children
aged 12-36
months
immunised
fully
6
86.0
8.2
51.1
88.0
2047
47.7
10.7
30.9
25.3
2431
68.2
8.5
52.7
70.5
2558
7
2632
Source: 1,2,3 and 6. RCH Survey 1998 (Phase 1)
4,5 & 7. Human Development Report (Karnataka) 1999, p.78, 255, 212
$
The presentation of the report will be in four sections. The first section
would present the health status of people and highlight the observed disparities
3
by social class and caste.
3
disparities, what the PRIs can do to improve the situation and the third part would
3
present the findings of the data collected from the PRI visits followed by
The second part would discuss, given these
summary of the findings and recommendations.
3
©
Section I
Health status of a population is determined by several factors including
□
health care services.
3
cultural and political factors.
3
multidirectional and complex, it is increasingly being realised that an integrated
It is closely associated with genetic, social, economic,
Although interaction among these factors is
approach to development would minimise conflicts and undesirable side effects
3
of sectoral approach. But what should be the critical mix of these interventions to
obtain the desired results is not very clear and planning in most of the countries
and at states within the country is still dominated by sectoral approach.
3
The
significance of health care services is that they can reduce pain, sufferings and
deaths many of which could have been minimised by an integrated approach to
3
3
3
9
i
I
□
I >
development. The health care services have to ensure quality at an affordable
J
cost to the population. There are differentials in access to health care services in
India and also in the State of Karnataka by urban / rural residence Good health
care services are concentrated in urban areas and do provide a choice to people
- either avail public health care services - which are also relatively better in
3
urban areas as compared to rural, or and also avail private health care services
that are more concentrated in urban areas.
Residents in rural areas have to
increasingly depend on public health care services particularly deprived sections
like Scheduled Caste and Scheduled Tribe population or those living in remote
‘9
inaccessible areas where either private services are not existing or scarcely
a
available.
3
3
£
If public health care services are not easily accessible it will have
more adverse impact on rural poor particularly the SC/ST population.
In order to improve the accessibility to public health care services the
Central and State governments have been trying to expand these services
hoping that all sections in rural areas are benefited from them. As a result it is
$
observed that during 1960-61 on an average a Primary Health Centre (PHC)
3
served 81,000 population whereas at present (1996-97) a PHC serves only about
■3
21,500 persons. Similarly a female health worker (ANM) was serving about 8000
0
persons during 1980-81 while in 1996-97 she is serving only about half of that
population.
These public health care services are supposed to be free and
therefore the poorer sections who may find private health care relatively
9
expensive may use them more than the affluent rural population. Particularly the
women belonging to SC/ST may'benefit from the free care provided by the
3
government.
But intensive research studies carried out in the state present a
different picture which is very disturbing.
'3>
It would be in order to note how the public health
care services are
delivared before presenting the observed disparities reported in the research
studies.
Looking at the disproportionately high mortality and morbidity among
women and children at national and state level del.vary of services are
3
J
concentrated on women and children.
The grassroot female health worker
popularly known as ANM provides these basic services.
In order to make child
u
. .1
H
births safe she is trained to provide antenatal care at the home of the pregnant
women in her area that has about 4000 population. On an average there are 165
She has about 500 - 600 eligible
- 170 eligible couples per 1000 population.
women some of whom need this service. The ANC package includes a list of
services that she is supposed to provide to every pregnant woman to ensure safe
delivery, survival of woman and her baby.
The following table provides some
insights into how these services widely differ among the community by caste,
economic status, education of the woman and by rural/urban residence in 10
districts of Karnataka.
$
Table 2 :
•J
3
SI
No
i)
No ANC
2)
First ANC visit during
3
a)
b)
c)
3
3
Access to Antenatal Care by Social and Economic Background of
Women in 10 Districts of Karnataka 1998
Type of service
Residence
Caste
Education
Type of House
i 3)
First Trimester
Second Trimester
Third Trimester
All 3+ ANC visits
Rural
Urban
SC/ST
12.9
51
ITT)
52.6
28.9
5.6
72.0
20.1
2.3
48.5
29.4
74.0
Others
8?9
18.9
0.6
5.1
62.0
25.1
4.0
42.7
31.7
6.8
88.0
68.7
81.0
SSLC +
Kuchha
221
Pi'^oa
3? ~
84.1
14.5
0.8
37.9
32.4
80. .
15.0
7.1
1.:
65.3
95.9
58.9
92.6
Percent women
4)
Whose
taken
weight
was
41.7
77.5
37.1
56.1
32.9
58.7
23.5
80.9
5)
Whose
recorded
B/P
was
57.2
86.3
49.8
70.3
46.3
78.0
39.7
90.4
»
3
%
J
3
6)
Who were given IFA
tablets
72.5
72.5
66.9
75.2
65.9
77.7
61.1
78.
7)
Who were given 2TT
injections
65.0
78.7
58.9
72.3
56.5
75.0
49.0
84.
8)
Whose
abdominal
check-up was done
72.2
91.9
74.4
84.2
69 7
97.4
65.3
93.
Total No.of women
2222
896
772
1811
1571
692
685
61$
The data clearly brings out the differential access to the public health care
$
□
3
services in the State. It is the Scheduled Caste women, illiterate and those who
n
15
p
j
J
live in kuchha house, in other words ‘poor’ are relatively more deprived of these
essential services. Though we do not have data on infant mortality and maternal
mortality the NFHS II reports very high IMR in rural Karnataka areas for SC/St
and illiterate women.
The information on place of delivery also reveal differentials by caste.
While for the state as a whole RCH First Phase reported 52.4 percent
institutional deliveries it was only 42.4 percent in rural areas while it was 77.3
percent in urban areas. Among Scheduled Caste women only one in 3 deliveries
were in an institution whereas it was 57 percent among others. Out of those who
lived in kuchha houses only 29.6 percent were able to go for delivery to a health
3
I
facility while those better of 81.7 percent delivered in a health facility. It is worth
noting that the home deliveries of SC women mainly were attended by
C;-‘
neighbours/relatives or untrained dai (74 percent).
In other words, even those
who give birth at home are deprived of ANMs’ or trained dais’ services that
increase the risks associated with child-birth among the poorer sections.
The new bom babies are protected against killer diseases by vaccinations.
The data provided by the RCH Survey reveal wide disparities in its utilisation and
poor accessibility.
t .*• *
Table 3 :
6'
Type of
Service
Accessibility to Immunisation Services in Karnataka by Social Economic Background of Children Born During 1.1.1995
to 10.6.1997 (percent not received)
Residence
Gender
Caste
Education
Housing
Rural
Urban
M
F
SC/ST
Others
lllit-
10 yrs+
Kuchha
Pucca
O Polio
61.8
30.8
53.0
53.0
69.7
50.0
72.6
22.9
75.5
22.9
' 2)
BCG
18.5
9.4
13.7
18.2
27.6
11.5
26.6
1.3
34.6
4.7
I 3)
DPT
18.3
11.3
14.7
18.1
26.6
12.6
26.7
1.1
32.6
5.2
4)
Polio
11.6 |
8.2
9.0
12.3
17.3
8.2
17.8
1.4
21.7
3.7
5)
Vitamin A
52.8
49.2
49.8
53.9
59.1
48.0
61.2
35.6
66.1
39.7
/.5->
; 1)
I
C-’-
.■<v
11
1(.
,7*
The differentials observed at state level hide the regional differentials
which are more pronounced. The following table provides these differentials in
the selected districts.
7)
Table 4 :
Access to Antenatal Care in the Study Area by Socio-Economic
Background of Women 1998 (per cent not received)
District
Residence
•7
3
Caste
Education
Housing
Rural
Urban
SC/ST
Others
Hit.
10 years +
Kuchha
Pucca
Udupi
2.0
00
5.2
00
4.7
00
2.2
00
Tumkur
4.8
2.4
5.9
3.8
8.5
00
4.8
00
Gulbarga
34.0
14.8
28.5
26.8
35.5
3.1
32.1
27.2
©
3
3
3
The tables 4 and 5 are self explanatory and in this background it was not
surprising that the RCH survey reports maximum number of infant deaths in
3
Gulbarga district (17) during the reference period and all in rural area whereas
3
Tumkur reported 9 deaths — 8 in rural areas whereas Udupi reported only 3 infant
3
deaths all in rural areas.
3
3
o
Table 5 :
District
Access to Immunisation of Children Bom During 1.1.1995
to 30.6.1997 (per cent not received)
Residence
Sex
Caste
Education
i
Housing
Rural
Urban
M
F
SC/ST
Others
Hit.
10 yrs
Kuchha
Pucca
Udupi
15.0
8.0
17.0
10.0
20.0
13.0
17.0
4.4
15.0
14.1
□
Tumkur
13.0
6.0
11.4
12.8
16.0
11.5
13.7
3.00
20.0
4.5
3
Gulbarga
80.0
53.6
76.0
73.3
78.9
73.8
83.4
25.0
72.3
45.2
□
9
a
□
©
©
□
J
The information for 10 districts of Karnataka and the 3 districts in the study
area bring out dearly that delivary of public health care services do not reach all
those who need them because of various factors.
Given the skewed distribution
1"
5
"5j
CA-
of basic health care services related with maternity and child survival it is not
surprising that health outcomes differ widely among districts - regions and also
social class in the state.
.
Reasons for such poor delivery of public health services in Gulbarga as
compared to other districts were not difficult to understand.
The Research
Teams visit to Community Health Centres. Primary Health Centres and Sub
Centres revealed that many of these health centres do not function regularly.
Infact, the day of our visit to selected health institutions in Gulbarga they were
S
locked and we learnt from the villagers that medical officers are very irregular in
o
attending to their work. Similarly the ANMs instead of visiting the households in
©
the sub-centre jurisdiction expect that women or children with problems should
■3
come to them. No PHC had displayed the scheduled travel programme of ANMs
as is done in other districts. It is not, therefore, surprising that old women in the
neighbourhood or village ‘Soolagitti’ (village untrained dai) conduct most of the
;,5
deliveries in rural areas (every 3 of 4).
.3
The problem is more complicated by the large number of vacancies
3
particularly of ANMs which is crucial in ensuring delivary of health care services.
0
When the vacancies of ANMs by taluks and PHCs within taluks were obtained
o
from the DHO s office and examined we were in for several surprises.
In the
district of Gulbarga about 28 per cent - more than one in four positions were
vacant for ANMs (see table 6) and the LHVs.
Supervision of their work and
monitoring the performance has stopped for several years. The result of such an
o
apathy is very clearly reflected in sevferal indicators reported earlier.
3
major cause for poor performance reported by the staff at PHC/CHC was the
3
existing poverty in the rural parts of the district where traditional practices still
One of the
dominate and the department cannot be blamed for all the ills in health sector.
<3
B
©
3
*3
3
u
Table 6
Vacancies of Female Health Workers (ANMs and LHVs) in
Gulbarga District by Taluks
DistrictATaluk
SI.
Per cent Vacant
No.
P -V
ANMs
484/134
58/00
39/2
57/18
40/11
41/10
57/15
35/13
48/17
56/18
53/20
27.7
0.0
30.8
31.6
27.5
24.4
26.3
37.1
35.4
32.1
37.7
I
LHVs
j Per cent
83/40
6/0
10/2
6/4
9/7
8/1
10/5
7/2
7/5
10/7
10/7
48.2
00
20.0
66.7
77.8
12.5
50.0
28.6
71.4
70.0
70.0
Vi
■'T
3
S>
' Gulbarga Dist.
Gulbarga Taluk
Jevargi
i Aland
Afzalpur
5)
Chincholi
6)
Chitapur
7)
Sedam
8)
Shahpur
9)
10) Surpur
11) Yadagir
1)
2)
3)
4)
3
9
Note: P
Total Positions: V - Vacant Positions.
9
•3
But the traditional practices have to continue because the modem health
services provided by the public services have miserably failed to entrench in the
0
society.
It was repeatedly emphasised that rural people prefer to conduct
deliveries at home and ANMs are helpless.
a
©
But when there are so many
uncertainties in the services — medical officer may not be there, drugs may be in
short supply and ANMs posts are vacant and naturally people stick to their
traditional practices.
The positions of specialists in the district showed that 37
per cent positions were vacant.
9
In Udupi district also about 30 per cent of ANMs positions were vacant but
J
easy accessibility to quality care in Private Sector Hospitals either free or at an
3
affordable cost has not made any adverse impact on the health of women and
children.
Most of the births about 92 percent take place in institutions that has
a
sharply reduced Infant Mortality Rate in the district (lowest in the State).
3
ANMs working in sub-centre reported that most of them have not conducted a
■3
single delivery during last 5-6 years as there are maternity homes run by
o
□
The
missionaries, Manipal group and other private trusts that provide a choice to
everyone irrespective of their economic position. The public make an informed
-
choice of public and private services and have benefited to a large extent as
revealed by several indicators.
3
Tumkur district placed in between these two extremes provide different
problems. The public health care providing institutions generally work regularly.
Our visits to several PHCs, CHCs and Sub-Centres convinced us that there is
.3
regularity in attendance of the staff to a large extent except in a few pockets. But
accessibility to the services is severely restricted to the poorer sections because
??
of corrupt practices in these institutions.
The Medical Officer in a PHC working
for more than 15 years, people reported, has ensured that the Lady Medical
□
3
3
officer’s post remains vacant. A child birth conducted in this PHC will cost about
Rs. 1000/-.
If there is a LMO this income will be reduced to a large extent.
In
another PHC it was found that LMO frowns at ANMs if they conduct home
deliveries and insists that they should bring delivery cases to the PHCs and
.9
charges a minimum of Rs.500/- per delivery.
3
complained of harassments by the MOs and LMOs. With Malaria incidence still
3
high in some pockets spraying of DDT has been stopped for 3 years and water
3
sources like wells have not received chlorination to make tnem safe for drinking.
Efficient and competent ANMs
The public health measures have affected badly.
'&
The vacant positions in the department has its own adverse impact but is
not severe as there were only 15 percent ANMs’ and about 20 percent LHVs’
9
positions were vacant for varying periods some for 4-5 years that has
□
compounded the problem of outreach services in the district’. Even then there is
some semblance of service in the district. The buildings and other infrastructure
3
are in poor shape and are begging for some action to improve but not received
any attention from authorities.
5
3
3
What the Panchayat Raj Institutions Can Do?
The decentralisation of governance in Karnataka in its first 'avatara' came
with the perception of “Power to the People'.
3
J
3
J
The 1983 Act was based on the
7J
2u
principles enunciated in the Ashok Mehta Committee Report
The objectives of
the Act were to give highest priority to rural development, increase agricultural
development, eradicate poverty and bring in overall development.
To attain
these objectives the Act provided maximum degree of decentralisation both in
Planning and implementation.
>1
But there were unresolved issues, with the planning structure at the
'I
national level and state level is it feasible to have district planning with the
>
consent of people and their participation? If not how the PRIs would participate -
9
only implementation of the plans that come from the State with resources? Who
o
would ensure ‘good governance’ at lower levels? And How? are not cleared yet.
©
But the State government that provides resources to PRIs - resources that have
9
reached four to five fold increase during the decade believes that there has to be
greater transparency, social justice and accountability in PRIs to achieve the twin
goals
of
development
decentralised
and
governance
at
social
justice.
sub-state
The
level
are
voluminous
more
writings
concerned
on
with
reservations, elections, provisions of rules, rights and procedures to be followed
3
than assessing what positive changes the new system has achieved and how to
9
improve it further, which can reduce the ‘politics only’ attitude observed at PRIs.
O
3
9
Despite our serious efforts to find some special studies that have examined
functions of the health sectors under decentralised system we could not trace a
single except the evaluation report submitted in 1989 that praised PRIs
eloquently for the good changes they had observed.
□
We conceptualise a very simple mechanism that exists in PRI system to a
3
large extent useful in streamlining the functioning of health-care service delivary
j
3
system and bring in much needed discipline in the sector. The importance given
to holding gramasabhas’ of village voters who are ultimately the masters can be
exploited. Already in six districts “Citizens Initiatives in Elementary Education” an
NGO initiative to activate Grama Sabhas to improve primary education is going
3
9
3
9
3
3
□
J
on.
People who are not happy with the delivary of services, can bring it in the
meeting which will be passed on to Gram Panchayat that in turn can reach Taluk
and Zilla Parishad for action. The ZP based on the resolutions passed by the
U>
3
3
Gram Sabhas can keep themselves abreast
of developments in health sector
and plan for its improvements.
The Zilla Panshad also has a statutory Committee called "Standing
Committee on Health and Education” that includes elected ZP members and also
some experts co-opted. They have to meet once a month and transact business
3
pertaining to health.
However, the role of Zilla Panshad in decentralised
governance and planning is one of a facilitator and co-ordinator.
Integrating
plans submitted by Taluk Panchayats, approving employment generating action
plans, allocation of resources to development programmes and monitoring
©
functioning of Taluk and Gram Panchayats. The President and Chief Executive
Officer (CEO) have been endowed with powers to supervise and inspection.
•1’V*
3
3
&
However, CEO has upper hand (section 180) to ask any record from TPs and
GPs pertaining to property, recovering arrears of land revenue, and supervise
and control the execution of ZP works.
Gram
Panchayats are entrusted with
regulatory,
licence
- giving,
prohibitory, supervisory and sanctioning powers. They have powers for taxation
3
and acquire movable and immovable properties.
©
promoting health and educational services are other responsibilities entrusted
Providing civic amenities,
with Gram Panchayats.
©
‘3
3
The Taluk Panchayat have controlling and supervisory powers over Gram
Panchayats. They are perceived as highly resourceful and powerful intermediary
level institutions. They approve employment generating action plans, they give
concurrence to action plans pertaining to education, health and family welfare
etc. The executive officer can supervise in functioning of PHCs, Sub-centres and
report to DHO for action. He does not enjoy powers to take disciplinary action on
J
health staff.
There is a mechanism to receive the public grievances regarding health
care services t..,_
ail the
UIC HUVVC
,IUI Grama baDrias
through
powerful
Sabhas for further actjon {o |mprove
'3
3
3
3
J
the equity and accessibility - both if there is a desire. In addition lhe Taluk
- - is a desire.
Medical Officer has supervisory powers to report for action to DHO. DHO is
to DHO.
head of the department and is responsible officer at district level.
In addition
H
there is Executive Officer at Taluk Panchayat with supervisory powers and report
his findings to DHO. It is very clear from the above that there are enough ways
and means to improve the health care services directly through PRIs, through the
live of control existing in the departments and also more importantly through the
Grama Sabhas.
Given the situation described in the study area it would be in
order to examine how they work.
7)
'J
The Grama Sabha
P
The Gram Sabha is a statutory requirement that provides a unique
0
opportunity to village residents to vent their grievances which will reach the
concerned authority for redressal. It also provides an opportunity to the voters to
make their elected representatives accountable to them.
One of the main
architects of decentralisation in Karnataka considered Gram Sabha as a "mors
powerful weapon created for the sake of accountability is Grama Sabha which
will not be elected nor has it vested with any executive power. But it is going to
play a crucial role in real politics because of their voting power and all elected
members are accountable to Grama Sabha”. It is mandatory on the part of PRIs
3
©
75
&
to explain their activities within the jurisdiction of the village. It also leads to right
to information.
Section II
How the Grama Sabhas are conducted if at all they are conducted?
3
Whether people bring their grievance^ to the forum?
3
conducted in the study area enquired from the randomly selected 82 heads of the
The Household Survey
households whether the Gram Panchayat, Taluk Panchayat or Zilla Panshad of
7?
their area are taking any interest for the improvement of the local PHC?
Not
surprisingly in Tumkur and Gulbarga districts the response was an emphatic No’
from each head of the household (100 percent in negative). They were very firm
about their view.
But in Udupi district one in four felt that they are trying to
improve further the services in PHC (Table 7).
3
■a
3
H
The selected heaos of the households were also asked whether there was
any discussion in the Grama Sabha meeting held recently on the functioning of
the ANM. LHV, PHC doctor and PHC.
The findings of these are presented
below.
5
3
9
□
3
Table 7 :
Peoples Assessment of PRIs interest in Public Health
SI
No
Activity
D
2)
Udupi
j_____________ ________ ' Yes
No
PRIs try to improve the 23.0 77.0
I
■ PHC
i Gram Sabha Discussed
I about the Functioning
I
Of ANMs
8.6
i fl
Of LHVs
8.6
I ii)
Of MO in PHC and 8.6
iii)
PHC
91.4
91.4
91.4
Districts
Tumkur
Gulbarga
Yes
No
Yes
No
00
100.0 00
100.0
I
TotaJ___
No
Yes
11.0
89.0 i
13.0
13.0
13.0
11.0
11.0
11.0
87.0
87.0
87.0
12.5
12.5
12.5
87.5
87.5
87.5
89.0
89.0
89.0
3
3
3
It is clear from the data that public view of PRIs interest in improving
health care service delivery of PHC level or about the functioning of crucial
personnel like ANM, LHV or MO of PHC is extremely poor. An important route to
0
bring critical assessment of health services for improvement was found to be
9
very insignificant.
9
9
The Bureaucracy
There are multiple authorities who are supposed to supervise functioning
of their subordinates, monitor the performance and enforce discipline in the
health department. They are Taluk Medical officers, Executive Officers at Taluk
J
3
3
D
Panchayats, Chief Executive Officer, President at ZP and also DHO the
Head of
the department of health at district. In addition to all these levels of supervision,
there is another Deputy Secretary 1 in ZP who is entrusted with supervisory
powers who will report to the CEO.
With so many authorities entrusted with powers to ensure free flow of
□
0
3
J
services it was surprising that Public Health Care Services are of so poor quality
u
24
-
in the two districts of the study area viz. Gulbarga and Tumkur. Our discussion
with the young and energetic CEO in Gulbarga was surprising. He was unaware
of the way PHCs are functioning in the district. On the contrary he said often he
receives representations from people to retain some Medical officers in their
place and cancel the transfer order issued that gave him an impression that the
MO must be good and therefore people want to retain him. We met the Deputy
5
Commissioner of Gulbarga also and briefed him about our observation. Both the
'?
CEO and DC asked for a copy of our findings for initiating action against erring
?)
officials in the health department.
©
Secretary (Dy S 1) and briefed him of our observations and he was noncommital. Our discussion with the Secretary ZP Council, Gulbarga was little
Similarly we discussed with the Deputy
revealing. He reported that the meetings of the Standing Committees on Health
and Education mainly deal with approval of plans, proposals and programmes.
J
There is hardly any scope to discuss about the services their quality or its out
reach to all sections of the society.
How well the DHO is informed about the
3
happenings in his department? Does he also think that everything is fine with the
□
functioning of PHCs, CHCs and Sub-Centres in his district? Our discussion with
•
him was frank and free. He is aware about the irregular attendance of Medical
•3
officers and has initiated disciplinary action against one or two.
disciplinary action takes a very long time.
But taking
There are interference from higher
authorities, elected representatives to thwart these initiatives because the
©
authorities take a benevolent view of such things and consider it on humanitarian
©
grounds — the person accused is marrited and have children why punish him/her?
3
The whole work culture in the district reflects that even for a petty issue there is
9
interference from the highest authority.
Every one in public service has links
upward and use it to save himself from any punitive action.
Tumkur district was slightly better as the Executive Officers at Taluk level
3
also visit some PHCs and reported that if the MO is absent on the day it will be
□
□
that report or not was not clear. DHO Tumkur is aware about corruption that is
53
making public health care services inaccessible to the poor in the district but
3
o
©
©
reported to DHO for treating it as leave without pay.
But whether DHO acts on
7)
SV
reported like Executive Officer at Taluk level that they have not received a single
complaint from people in this regard and hence cannot act without evidence
It was in Udupi that the in-built mechanism of monitoring and supervision
was working. Even the MOs appointed on contract basis are regular in their work
and provide service to the people.
If there is regularity in the functioning of
health institutions that itself satisfies the clients who arrive there for relief.
Our
visit to PHCs, CHCs and some remote-placed Sub-Centres was very satisfying.
9
Perhaps if one wants to see what is equity and accessibility to health care
3
services should visit this part for getting acquainted with. The results are visible.
ZP Presidents
3
3
3
The Executive Head of the district is the President and certainly they can
make considerable impact on the quality services provided and their accessibility
to people. The Presidents of the ZPs in the study area were very enlightening.
In addition to 3 ZP presidents of Udupi, Gulbarga, and Tumkur, we met ZP
President of Kolar. They were all young, educated and enthusiastic about their
□
3
office that they were holding only for few months.
The women presidents of
Tumkur and Udupi were keen to improve health services. One of them was very
young, just married with no experience of either politics or holding a public office.
But her father was a leader and was holding a public office by getting elected.
3
The other was having some experience at Gram Panchayat.
Tumkur ZP
President was keen to learn the ropes of administration to act and improve. She
©
had visited some PHCs and believed that women still prefer to give births at
home as it is more convenient.
3
She was aware that some-MOs and ANMs are
not regular and was planning to discuss with the administration for possible
action.
The Gulbarga ZP president was very open and said that “MOs not only
.5
are irregular but also sell the medicines in the open market. For days they do not
visit PHCs. But I do not have powers to set things right”. The President said that
3
he would set things right in two weeks if he had powers. He was sorry that the
a
State Government that belongs to his party is not receptive to their views
3
3
■3
3
3
u
2o
The ZP President of Kolar was more dynamic and when we met he had
visited a PHC (where he had gone for attending a public function) on the request
of the public who complained that the MO is very irregular.
Indeed MO was
absent when the ZP president visited the PHC. He called DHO to know how they
can take action against such officials.
He reported that he is new (like other 3
presidents) to the intricacies of the administration and though he attended some
training programmes organised for ZP presidents he has a long way to go to
3
master the art. He had kept a Rule Book prepared by the state government and
would refer to it often when he had some confusion. He was also of the opinion
that ZP has little scope to bring in discipline among the staff working in the district
on deputation. He often requests the DHO to be strict and wants to support him
□
in improving the health services for the benefit of the people.
The Vice Presidents
The Vice Presidents also echoed the views of their Presidents. ZP cannot
take any action. They have to write to the Government for action and there are
a
•3
©
3
0
long delays or no action. Vacant positions in the Health Department is reported
routinely to the Government for filling but nothing is heard from them. The CEO
position was vacant for 2 months and during that time DC was incharge CEO.
One can imagine how things will move.
It was clear that transfers, recruitments
or suspension of any health staff is not vested with ZP. Under the circumstances
poor accessibility and inequity in health care services become the order of the
day and both elected representatives 2nd the bureaucracy become used to it.
a
It is to be noted here that none of top leadership in ZP-- elected members,
members of the Standing Committee on Health and Education, CEOs and DCs
were totally aware of the disparities that exist in the health status of people in
•J
different districts, by gender, caste and economic status within the districts. The
next line of authority Deputy Secretary 1 were also equally ignorant of health
•3
outcomes, indicators and job responsibilities of various categories of staff. The
3
Administration at Taluk and Districts were busy with construction of new
3
structures, equipments or drugs more than their use for public good. There was
&
a
a
11
a unanimous demand in fumkur, Kolar and Gulbarga that there is need for
4V'
training to make them more informed and effective.
Why the DHO does not
provide them the insights of the Department? He has no time as all his time is
spent in the meetings.
The DHO also has several constraints.
Since he has
hardly any time his visits to Primary health Centres have reached minimum. It is
only when a dignitary like District-in-charge Minister (another authority over all
the happenings in the district) has a public function he may visit a PHC. The staff
at PHC could recall the past practice of frequent visits of DHO for supervision. It
was not only to their PHC but even to a nearby PHC would keep them alert with
a chance visit to their PHC on the way back.
This practice has almost
disappeared now.
3
3
a
This brief description provides how the in-built mechanisms to ensure
accessibility to health care services have become ineffective. It is not surprising
that the health status of people in health poor districts continue to be poor even
though public resources — more valuable looking at the scarcity, become less
.3
and less productive. One of the important reasons for the observed delay could
a
a
be the faster expansion without consideration to the enormous resources needed
3
'5
for it. Earlier the quality of services, as reported by senior staff was much better.
Now even though the scarcity of equipment, maintenance of assets etc. is
reported to the authority may not be heard that leads to the weakening of the
authority because of the inability to solve it quickly. The only positive change is
©
the improved drug supply after decentralisation.
©
unsatisfactory in health poor districts. •
Rest every thing is highly
3
Section III
Areas of Conflicts
Given the situation described so far where lies the conflict between the
health bureaucracy and ZP or PRIs? The focus group discussion often led to
a
mudslinging exercise.
D
harassment of personnel. To start with, the bottom line ANMs complained that
That PRIs arrival have lead to more corruption and
elected representatives demand service on priority basis, call the ANMs to their
sJ
a
a
a
j
II
j
residence even for headache and stomach ache and demand medicines free and
often ANMs have to bear the costs. As most of them (elected representatives)
are not educated their behaviour is curt and without etiquettes and manners that
hurts ANMs. The MOs at PHC complained similarly in addition they reported that
-J
the elected representatives question them if an ANM is not posted in a sub
centre which is not under his powers.
The DHOs office complained of
interference in day to day administration by the Elected Representatives.
A Taluk Medical Officer complained that there was out break of cholera
9
because of the contaminated water supply by the Taluk Panchayat. When he
■5)
reported that water supply has to be improved by taking some measures like
chlorination, he was abused for dereliction of his duties. When they send a
proposal to repair a collapsing building to DHO with a copy to ZP the CEO just
3
does not bother.
Medicines are not supplied regularly.
They dump several
useless drugs which are of no use. PHC and MOs indent is often ignored.
The Quarters of ANM built by the PR! are of extremely poor quality. An
3
ANM was in tears to report how she has to cover the roof with polythene sheet to
■3
protect her from leakage and to re-do the electrification to save from the shocks
spent Rs.3,700 from her pocket. Complaints made to DHO, ZP and TPs were of
□
no use.
She was told that she has to stay there the Quarter on which lot of
money is spent to make it according to the specification given.
A meeting with all medical officers of a Taluk brought out their vent against
elected representatives.
A LMO reported that new PHC was built but the
quarters for staff are not. The PHC is in the outskirts of a village and no body
■J)
dare to stay there in the night not even a watchman,
If they had constructed
housing along with the PHC it would have facilitated
Another LMO who
commutes to PHC every day from Gulbarga complained that the people and
elected representatives harass her to stay in the PHC quarter which she has not
occupied because there is no water, electricity and building is 25 year old needs
repairs. They are not keen to do anything to facilitate the services. Most of the
drugs that ZP supplies are about to expire and become useless.
9
in
3
i ne months Feb-March are two months when ZP administration is too
busy tc approve medical reimbursals of staff of Health Department and they not
even consult the DHO. Registers required to compile statistics are not supplied
for over a decade. All files move only if currency notes are enclosed with them.
RCH building fund of Rs. 10 lakhs is lying for over an year but even the plan is yet
3
3
to be made and approved. Nothing moves.
Taluk Medical Officer has to write to DHO who in turn has to forward to ZP
for any action. Taluk Medical officers can not even sanction Travelling bills of his
subordinate staff and those who approve it may not know whether the travel was
made to those places. ZP sanctions all such TA bills with a cut of 10-20 percent.
Even the DHO s office in Gulbarga has several stories of delays.
3
Power
connection to his office is not done though they have spent Rs.37,000 for it about
19 months back but ZP is still silent. The list is endless.
What ultimately emerges is that the conflict arise from multiple points of
authority with not a single source taking any interest in improving things.
The
question that arise is who should set things right with quick decision to solve the
3
3
problem.
It is only CEO who is authorised to act after waiting for instructions
from the Government on any of the complaints made. We did not come across
any such action except issuing a memo or deducting a days salary in some one
or two complaints against ANMs. But suspension orders can be issued only by
3
the Government.
©
MO or other officials. ZP elected members or a Minister interfere and nullifies all
efforts.
Generally when there is such a serious complaint against a
Some ZP Presidents had oomplained against unclean PHCs and a
couple of staff coming late when they had visited.
3
The PRI elected members have many stories against the health staff.
Irregularity, showing unconcern and asking money were very common.
It was
J
surprising a lady member of the Standing Committee on Health and Education
3
whose husband (aged 44 years) died on Jan 4,h 2001 because of the neglect of
3
MO in treating him.
3
3
treatment for acidity the previous day to his death.
3
3
He died of massive heart attack and MO had given him
He did not check his blood
pressure nor examined him. But she did not complain as he is well connected.
d
But the elected members of such statutory high power committees also are
ignorant as reported by many about the health situation - no idea about death
rate, infant deaths or maternal mortality which are very high in their area and
there was a strong demand to enlighten them on health issues to strengthen
them and to improve the situation.
In addition the bureaucrats at ZP believe that Medical Officers at PHC
■■■I
CHC and district office lack badly administrative skills and management skills to
3
work in a team. The lack or absence of such skills go on accumulating and turn
into major issues. We also believe that managing the staff is an art that many
£
medical graduates who join the service as MO at PHC may not have and already
some programmes to train them as managers of PHC is on.
3
3
The proceedings of the Standing Committee on Health and Education of
Tumkur District however reflects what we noted about the district.
It says “
administration in health department has collapsed and DHO has no control over
3
his department” (page 4 of 24/10/2000).
3
suggestion that priority should be given to patients in rural areas by the Medical
3
Officers.
■3
3
It also notes the ZP Presidents
It also questions about MOs saying that there is no medicines in the
PHCs and prescribing drugs to be purchased by the patients in the market.
The proceedings of Udupi ZP’s Standing Committee that meets every
month regularly reveal that there is evidence of some efforts to improve the
O
services further.
O
any complaint to make about the functioning of the PHC they are provided a post
3
card free and they can mail it to the Concerned authority for action.
3
such complaints the Committee resolved to examine such complaints and
3
3
Based on
recommend action to be taken (either terminate the services of contract MOs or
transfer them).
3
PHCs in Udupi display boldly that if the visitors to PHC have
It also instructed the DHO to recruit group ‘D; employees on
temporary basis in place where there is need to ensure cleanliness of health
institutions.
It notes of disciplinary action by issuing show cause notice to
unauthorised absence of a Taluk Medical Officer to consider his absence as
3
S
O
3
3
leave without pay. These resolutions certainly indicate the efficient mechanism
'I
of receiving complaints and quick action within the limitations of ZP which are
worth emulating by other ZPs in the State.
The proceedings of Gulbarga ZP is silent on the situation in health service
delivary system in the district but emphasise more on building model Primary
~:i
Health Centre, resource mobilisation, etc. that shows there is no in-built
mechanism of receiving public grievances or they are ignored.
3
Section IV
Summary of the Findings and Recommendations
The intensive study carried out with time constraint has been able to
.j)
3
3
effectively explore a complicated area ignored so far in academic circles. The
policy statement issued recently on population by the Government of India has
given the prominence to PRIs that they deserve.
It is brought out by the study
that multiple power centres and poor co-ordination among them for effective
decision making is hampering the smooth functioning of ZP and Health
Department at district level.
Appointment, transfer, suspension are the crucial
3
areas where ZP acts only as a Post Office.
0
approves they cannot act. The key post of DHO has been weakened because of
3>
interference of elected representatives.
Unless the State Government
Even simple act like posting a
Laboratory Technician from a place where there is no serious demand for his
a
$
services to a place where there is an out break of an epidemic is resisted by
highest authority. Infact instructions come to him if he acts in his way he will be
in trouble.
Such instances have demoralised him.
another place has become just impossible.
'3
-J
Transferring an ANM to
Time constraint is imposed by
several meetings he has to attend. This was the view of all high officials also in
Bangalore that they find little time to work in their office.
The Grama Sabha - a most powerful instrument the people have to air
3
their grievances for redressal and which is g.ven
3
decentralised system of governance is almost non-functional as found in the
J
household survey responses.
3
districts that meeting is not announced by Tam-Tam (drum beating) and contrary
O
3
3
J
3
lot of importance in
People complained in Gulbarga and Tumkur
it is held when most of the residents go for work and only few whom they want
attend it and non complaints are entertained.
The Udupi District that is in the
forefront in health sector has developed a good system of receiving public
grievances directly by the authorities concerned and redressal is quick. In other
two districts complaints are unheard and neglected on the ground that there are
no written complaints.
Decentralisation is still in infancy in the state and suffers from several
constraints to be effective government at district level.
How to monitor the
functioning of the system of health care services delivery? Is not known to even
top officials like CEO, Dy. Secretary 1 and other officers at Taluk levels. Official
inspections are more ceremonial and unproductive even though such inspections
by different categories of authority are rare and routine.
3
$
There is no effort to
understand the problems and solve to improve the performance is not seen any
where except in Udupi. Therefore there was a strong demand to enlighten them
with one day programme at ZP for all concerned officers. The officers in health
■3
department were not even aware of research finding that should guide them in
3
their work.
The guiding principle of any public health care service delivery is equity
9
3
■3
and universal accessibility. The state has a very very long way to go to achieve
it. Even then equity and universal accessibility will not be an automatic fall back
from expanding services or bringing in a semblance of quality in care. It can be
achieved by monitoring crucial services like basic primary care which is
absolutely missing at ZP level. Therd is need to intensify the efforts, if already
9
there are, to reach the goal of equity. For this there is need-to equip PRI elected
members, general public about the importance of health and its effective
utilisation.
The elected representatives have to develop responsibility towards
their activities. They come from diverse socio-economic and cultural background
9
and over the years grow as leaders. They have started asking questions about
services which is in the right direction.
Health personnel who were used to
departmental control are perturbed over the authority of representatives.
a
They
9
will have to realise that their services are for them and they are the real masters
in a democratic system. There is nothing to worry.
But till the PRIs become more effective in their functions the department
has the crucial role to play. Efficiency and quality care and ensuring its outreach
.J
of services have to be managed by them which will go a long way in building of
1
credibility of the department which is at a very low ebb now. PRIs will be happy
and stop interfering if they are convinced about good services to all.
The main questions that still remains to be answered is how decentralised
the state is really? Can ZPs be considered as Local Self Government? A short
3
term study such as this would not try to explain the extent of decentralisation in
the state today.
D
3
It seems there is a make-believe effort to show we are
decentralised while all the powers are centralised with the state (because of
several reasons stated and believed). One of the important factor for the mess in
health department is the multiple power centre without any direction - pulling the
cart in different direction.
.3
The lost aura of DHOs and reluctance of efficient
Medical Officers to occupy this role reflects very clearly the situation.
If health
care services are to be improved his position has to be strengthened.
Such
studies ideally need at least an year but an effort is made here to bring out
several complex issues that a longitudinal study should explore in the future.
3
Recommendation
1)
There is an urgent need to mtake ZPs to consider health sector as an
important input in development and to educate officials ranging from Chief
Executive officer to Executive Officer at Taluk level on monitoring health
J
services and on health indicators that reflect it.
There is unbelievable
ignorance in the administration and also in the health department who are
)
major health care providers in rural areas on the status of health of their
people.
2)
The Elected Representatives from Gram Panchayat to ZP level also need
to be educated about importance of health and their role in monitoring
Q>
i
34
health outcomes. Only ensuring presence of doctor or supply of drugs is
not adequate to achieve equity
Monitoring plays a crucial role and it is
totally absent at all levels.
3)
The Health Department should be made responsible in improving health
care services in the districts and they should be ensured the support of
ZP. TP and GP in carrying out their responsibilities efficiently.
there is need to build-up the credibility that is lost.
For this
The health services
would be considered good if the indicators of health improve and become
comparable with the best in the state to start with.
9
4)
There is an urgent need to establish fool proof mechanism to receive
public grievances for redressal as is effectively done in Udupi District.
Strengthening Grama Sabhas would play an important role if they are
□
conducted properly. PHCs in health poor district should provide free post
3
cards to public who should mail it to responsible authority for redressal
and quick action on the complaints will strengthen this mechanism in due
course of time.
5)
not is a wider question we would avoid answering here. But they can play
3
an important role within the powers they enjoy now. Just calling an erring
3
officer and reprimanding him in public will do the trick. Even an indication
e
that they are serious will go a long way than proceeding on legal terms.
6)
s
Whether ZP Presidents should be fully empowered for taking any action or
The ZP and health bureaucracy at district level should learn to respect
each other and the need to uncterstand their complimentary role. Health is
a technical subject best known to health staff and they need all the
3
>
3
©
3
0)
□
■3
□
support, encouragement and appreciation when they do a good job.
Health staff should realise that elected members to PRI though may not
be educated represent peoples views and respect them for that
need to meet informally for achieving this by both.
There is
- ~
0000000000000000000000000000000000000000tf%
0
GOVERNMENT
OF KARNATAKA‘
0
.. ..... .
0
0
0
TASK FORCE ON HEALTH AND FAMILY WELFARE
0
0
0
0
0
A Commissioned Research Study
0
0
I 0
0
0
0
0
0
I 0
0
0
0
0
0
I 0
0
0
0
0
0
0
0
I 0
0
0
0
0
0
I' 0
0
0
0
0
DISPARITIES
IN
HEALTH
AND
HEALTH
CARE
SERVICES
I1 0
0
0
(Draft Report)
0
0
0
0
I 0
0
0
0
0
0
I 0
0
0
0
0
0
I 0
0
0
0
0
0
0
1 0
0
0
0
0
By
0
0
0
Mr. As Mohammed
0
0
St. John's Medical College
0
0
Bangalore
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
&
0
000000000000000000000000000000000000000000
I
■vi-'-
METHODOLOGY
Given the constraints of time available only quantitative data that is available from the
follov/ing secondary sources on various characteristics was collected.
1.
2. '
3.
4.
5.
6.
7.
Multi Indicator Cluster Survey - 1998 - UNICEF
Rapid Household survey under RCH project, Karnataka State - 1999
Human Development Report, Karnataka State - 1999
Directorate of Health and Family Welfare Services, Govt, of Karnataka
Sept.2000
ICDS - Women and Child Development Department Report - Nov. 2000
Census of India 1991, Karnataka State District Profile 1991.
Rural Development Panchayati Raj Department, Statement on Below Poverty
Line Families, Govt, of Karnataka
Data was checked'for its quality and quantity and regional disparities were assessed
on the basis of available data on indicators in following essential categories:
(Annexure- I)
>
>
>
>
>
Health Determinants
Health Status
Health Resource Allocation
Health Care Utilization indicators and
Over all indicators
Each indicator in the above-mentioned categories was standardized and algebraically
added for each district. The total was re-standardized and a composite index as
Standardized “Z” Score was obtained for each district, which gives the relative position
of the districts on the scale in Karnataka State.
It has been observed in many studies that lower class and caste suffer with
disproportionate burden of diseases and mortality. Different types of morbidity and
mortality have different patterns with respect to the age, sex and social class. So to
assess the equity with respect to these characteristics, it is necessary to get the
primary data in disaggregated form at various levels right from taluk to state level.
However, disparities in health on the basis of class, caste, age, sex and the religion
could not be assessed, as data does not exist in disaggregated form for districts of
Karnataka.
2
I
I
I
I
i
I
I
FINDINGS - A
disparities in health determinants of districts
DISTRICTS
Edn15+
HHP
Cwater
73.3
41 g
41.8
82.7
33 4
97.2
gg
Bangalore Urban
Bangalore
Rural
y.ai
lydiui e rxurai
ELC98
IN KARNATAKA STATE
90
26.4
ABPL TOTAL
INDEX
85
2.80
66
0.55
ACCIatrin
79.4
96.3
... ...
isSBBBOSliil
"“"f................................... i2 a- ■- as. aj
Belgaum
Bidar
Chamrajnagar
Chitradurga
Chikkamagalur
Davengere
Bakshina Kannada
5^,ai?v?c^
37.5
41.5
49.8
55.3
49
71
53 5
70.6
35.8
45.1
32.8
36.9
30.1
/ o. /
00.7
18
18
77
77
-0.23
90.3
96
‘ 96.8
88
98.6
98.6
60.5C
67.1
72.5
74.4
69.6
69
—
"
12.3
6Q
99.9
75.4
39
-0.30
-0.29
0.14
0.37
0.24
1.35
> H
86.8
99
84.5
93.3
70 O
78.3
75.4
56.5
80.9
a
3.5-2
29.1
Q* V**
■if’'*;1
'
20
30
40.5
36.3
73.4
n on
J
64
59
72
66
78
g-,
Q2Q
69
82
61
-0.02
0.19
0.47
0.37
591
535
544
43__2
36.3
55.3
Mysore
41-S
41.5
f-o
_ 35.8
95.5
95.9
85.9
85.9
67 1
19
44
70
.69
0.30
0.12
Shimoga
Tumkur
Uttar Kannada
Udupi
56.2
47.2
62.2
71
35.6
45.3
34.1
30.1
94.8
99
97.1
98
78.9
77.5
79.4
69
31.8
19
38
60
68
69
70
79
0.48
0.39
0.78
1.20
Hassan
Haveri
Kodagu
Kolar
ffisEssaar--Mandya
39 g
Bffissssms,
19.2
29.1
Most of North Karnataka Districts are
3
t
14
16
44
poor in health determinants.
FINDINGS - B
DISPARITIES IN HEALTH STATUS OF DISTRICTS IN KARNATAKA STATE
DISTRICTS
U5 MR
Bangalore Urban
67
%Normal
under 5
45.34
Bangalore Rural
Bagalkot
67
88
44.83
34.56
Belgaum
Bjjapur
69
88
36.41
4.95
1 37
94
7?
_Chamrajnagar
89
44.5
0.12
1.66
4.9
API
Malaria
1.06
Pt. Prev
TB
1.88
0.21
3.3
1.88
1.3_7
10.1
7.1
0.26
-0.53
*43.19"
0.52
. .........
.lasziz"'
40.37
1.09
1.67
-0.47
^W^^^S^OO
.?5
Chikkamagalur
□avengers
Dakshina Kannada
Dharwad
_Gadag
Incident TOTAL
DIARR INDEX
5.8
0.05
104
46
95
95
47.11
34.61
51.59
41.21
33.07
0.41
0.12
2.58
0.28
0.39
1.6
1.52
1.34
1.19
1.19
15.3
11
4.3
20.9
14.1
ZT
Kodagu
95
35.42
0.15
1.19
145
0 07
5461
OU
0 94
16
2 11
v,c,,luyd
-^ore
84
49
28
49.28
8940.68 40.68064
6 55
-i1.68
co
1.66
^1*03^^
8.5
5.5
-0.18
-0.34
Haveri
!Tz
Shimoga
Tumkur
Uttar Kannada
Udupj
88
102
69
46
39.25
47.37
45.22
55.41
0.12
1.62
0.13
0.56
1.17
0.86
1.34
0.09
-0.27
1.16
-0.05
125
00°
S5ai«J
13.1
10.9
11.9
1.1
0.77
-0.11
1.68
2.76
•
U5MR which is available only for 1991 has been
extra po/ated for newly formed
distncts as they have been part of old districts.
@
°fHKcCa9u' UK’ UduP'’ DK' Chamrajnagar and Bangalore Urban was
W Health status
m°St °f
region districts has
Disparities in Health Status have been assessed on
U5MR
: Under five Mortality Rate - probability of dying in between birth and age
5, expressed as number of deaths among children under the age of five
per 1000 live births.
%Normal
: Percentage under five children whose nutritional status is within normal
limits based on weight for age.
API MALARIA: Annual Parasite Incidence of malaria, which is number of confirmed
cases of malaria per 1000 population under surveillance.
PtPrv.TB
: Point Prevalence of Tuberculosis includes pulmonary and extra
pulmonary tuberculosis ca&es per 1000 population.
Incident diarrhoea: Percentage of children below the age of five reporting current
diarrhoea or diarrhoea during the last two weeks.
As no single indicator can adequately describe the situation it is desirable to
concentrate on limited number of specific indicators. Child health indicators are more
sensitive to Socio-economic differentials, and investment in child health has long term
impact on equity.
Therefore under-five mortality, incidence of diarrhoea and
percentage of normal children have been used for assessing the health status. These
indicators also reflect the nutritional health and health knowledge of mother, availability
of maternal and child services including prenatal care, income and food availability in
the family, the availability of clean water and safe sanitation and overall safety of the
child’s environment. These measures are also sensitive measures of gap in health
status that are generally judged to be avoidable, unnecessary and unfair.
Other indicators of health status included are API malaria and point prevalence rate of
tuberculosis including extra pulmonary TB which are the leading causes of deaths
among communicable diseases.
c
findings -c
Sa^kI sta?eT’ PRlMARY HEALTH CARE FAC,LmES ,N districts of
districts
PHC/LAKH
MOW/LAKH
PARA/10,000
g^g^gEgBSs^g^ia
Bangalore Rural
5 27
---Bagalkot gigEg7' B~B>'3 02
rZiiX"1’
^ry34g
S7
■
dM?
TOTAL
INDEX
0.16
7- .
ms -V
sssaafeza^
Bijapur
Bidar
Chamrajnagar
Chitradurga
Chikkamagalur
Davengere
Dakshina Kannada
3.80
3.78
4.60
5.58
7.69
5.44
3.72,
Gadag
Gulbarga
Hassan
Haveri
Kodagu
Kolar
3.61
4.34
7.29
4.77
5.90
4.63
5.16
5.72
9.09
5.68
10.55
6.14
3.23
3.95
3.28
7.60
3.34
Mandya
Mysore_____
' 5 59
57g
8.41
8.28
4.46
-0.56
-0.27
1.34
-0.15
2.38
-0.09
^50^
0.60
0.95
Shimoga
Tumkur
Uttar Kannada
Udupi
5.30
5.14
5.57
5.71
7.64
6.88
8.40
5.24
4.27
3.33
5.20
3.02
0.65
0.17
1.15
-0.06
5.11
6.80
<5.86
7.84
10.62
6.02
4.95
3.51
3.61
2.85
4.81
4.89
2.71
3.62
...
325
©
s^e"
-0.44
-0.12
-0.30
0.93
2.01
-0.09
-0.45
-
had
Many Ncrth Karnataka districts and even Bangalore Urban lack in Primary
Health Care facilities.
7
7
Disparities in Health Care Facilities have been assessed on
PHC
: Number of Primary Health Care Centres per lakh population
MOW : Medical Officers working per lakh population
Para : Para Medical (Staff Nurse, BHE, Lab. Techn., ANM and Male workers) working
per 10,000 population
These indicators refer to how resources actually are allocated. Primary health care
provided by network of PHC and sub-centres with community participation is first level
of contact between the individual and health system. Majority of prevailing health
complaints and problems can be satisfactorily dealt with at this level.
These indicators reflect the distribution of Government health care resources in
different districts of state and of the provision of health care. The purpose of health
sen/ices to improve the health status of people.
J
FINDINGS: D
^SrXak!IN UTluZATI0N pattern of health services in districts of
DISTRICTS
Immunization
ANC3
Bangalore Urban
^Bangalore Rural
77.7
83.7
86.9
85.8
Safe DEL.
CFPU
92.9
60.1
63
80.7 77.6
_85.9
:BagaJkJt}s®O
TOTAL
INDEX
0.75
MJ
§041
MSPur
•
53.2
94
83.9
83.9
Chamrajnagar
Chitradurga
Chikkamagalur
Davengere
Dakshina Kannada
Dharwad
Gadag
92.7
88.4
83.5
88.4
86.0
74.8
74.8
70.3
94.9
91.6
92.2
89.1
72
66.5
43.4
75.1
93.4
75.9
94.5
80.1
78.3
91.5
80.4
56.2
"assan
Haven
Kodagu
Kojar
92.8
74.3
94 g
75.1
38.3
805 84.2
80.5
83.6
85.6
_ ,_56.1
94.3
75
cn
60.6c
85.4
78.2
Mandya
Mysore
Rai oh
Shimoga
Tumkur
Uttar Kannada
Udupi
90.6
60.4
57.8
90.7
97.5
61.3
47.1
-0.35
65.4
59.9
-0.31
0.82
1.38
0.32
1.08
0.23
-0.27
71.4
59.9
63.7
61.2
61.2
75 T
61.2
70.6
57.1
88
92.7
8(12
83_3
37.6"
83.3
73.3
77.5
65.4
92.9
88
89.9
86
90.9
67.6
81.2
85.9
72.3
92.1
83.9
69.3
77.8
88.6
89.5
61.3
66
63.7
84.9
93.9
71.7
o^"
- • 0.10
1.07
0.22
0.13
0.74
0.92
0.45
0.89
0.99
Most of North Karnataka Districts have poor utilization pattern of existing Health
services
<5
Disparities in Utilization of Health Services have been assessed on
Immunization
: Percentage of 12-23 months children completely immunized with
BCG, DPT-3/OPV-3 and Measles
ANC3
: Percentage of pregnant women who have received 3 or more
ANC visits received during recent pregnancy
TT2
: Percentage of ANC received TT2/Booster during recent
pregnancy
Safe Del.
: Percentage of deliveries conducted by Trained Health personnel
■ during recent delivery.
CFPU
: Percentage of current users of any Family Planning methods
<
<
Utilization of Primary Health Services included the utilization of Public and Private
health services.
Utilization of services is expressed as the proportion of people in need of a service who
actually receive it in given period. A relationship exists between utilization of health
care services and health needs and status. Health care utilization is also affected by
factors such as availability and accessibility of health services and the attitude of an
individual towards his health and the health care system.
Utilization of public health services is often inequitable with the higher quality, more
expensive services disproportionately used by more privileged segments of society.
ic
•»
i
FINDINGS - E
distribution OF districts ON THE BASIS OF VARIOUS CHARACTERISTICS
OF KARNATAKA STATE:
districts
Bangalore Urban
Bangalore Rural
HEALTH
DET.
2.80
0 55
do] gaum
_q 23
Chamrajnagar
Chitradurga
Chikkamagalur
Davengere
Dakshina Kannada
Dharwad
Gadag
-0.29
HEALTH HEALTH HEALTH
UTILIZ. FACILITY STATUS
0.75
-1.55
0.05
0.56
___
_
016 _
0.26
-0.31
0.82
1.38
0.32
0.14
0.37
0.24
1.35
0.26
-1.05
1.08
0.23
-0.27
-0.30
0.93
2.01
-0.09
-0.45
-1.68
-0.56
^assan
-0.02
0.24
1.34
^a'Ieri
Kodagu
2S23L
0.19
0.47
0.37
0.10
1.07
0 22
-0.15
2.38
-0 09
™Va
.rlY^,gre
0.30
0.12
0.13
0 74
oW
OPS
Shimoga
amkar
Uttar Kannada
0.48
0.39
o.78
o.qT^^S
0.45
0.89
0.17
1.15
1 20
0.99
-0.06
.WargaF'^”-
I
TOTAL
0.92
0.54
0.52
-1.00
0.09
-0.27
1.16
-0.05
-0.43
-0~18
0.31
1.20
0.13
1.06
-0.20
-0.71
0.00
0.07
2.11
/1-05 _
0.45
0.13
1.80
-0.07
^uJq8-'O^
-0.18
-0.34
0.27
0.43
5*3^
0.77
-0.11
1.68
2.76
0.93
0.35
1.41
1.15
Complete Hyderabad-Karnataka region including districts of Bidar, Gulbarga,
Raichur, Koppal, Bellary, Bijapur and Bagalkot lack in Health Determinants,
Health Status and Health Utilization including availability of Government Primary
Health Care services.
Districts like Beigaum, Gadag also have negative indices but at low level.
®
Chamaraja nagar district has negative value of indices except on health status.
This may be due to few indicators on health status have been taken from
Mysore.
®
Dhawad and Bangalore Urban were also lacking in Government Primary Health
Care services.
<
I
©
Kodagu, UK, Chikkamagalur, Udupi, DK, Shimoga and Bangalore Urban districts
have good Health Determinants, Health Status, and Health Utilization of existing
Health Services.
12
LAST 7 DISTRICTS ON THE BASIS OF VARIOUS INDICES
OVERALL
HEALTH DET.
Koppal (95)
Koppal(96)
HEALTH
STATUS
Beilary(97)
| HEALTH
UTILIZATION
Gulbarga (99)
GOVT.HEALTH
PRIMARY
Dharwad (95)
Gulbarga (94)
Raichur (96)
Kolar (85)
Koppal (97)
Bangalore (U)
(94)
Raichur (94)
Gulbarga (89)
Bagalkot (93)
Bagalkot (90)
Bellary (94)
Bellary (89)
Chitradurga
(84)
Bidar (81)
Raichur (92)
Raichur (85)
Bagalkot (94)
Bij'apur (87)
Gulbaga (/7)
Bellary (85)
Bellary (81)
Bidar (79)
Bagalkot (87)
Raichur (76)
Bidar (84)
Belgaum (78)
Bijapur (79)
Gadag (85)
Koppal (75)
Belgaum (76)
Koppal (73)
Figure in brackets indicates the position on 100 point scale
TOP 7 DISTRICTS ON THE BASIS OF VARIOUS INDICES
OVERALL
Kodagu (4)
Uttar Kannada (8)
Chikkamagalur
(12_________
Udupi (13)
HEALTH DET.
HEALTH
STATUS
Bangalore (U)(1) Udupi (1)
HEALTH
UTILIZATION
Chikkamagalur (8)
GOVT.HEALTH
PRIMARY
Kodagu (1)
Dakshina
Kannada (9)
Udupi (12)
Dakshina Kannada
Chikkamagalur (2)
Kodagu (2)
(14)____________
Uttar Kannada
Kodagu (14)
Hassan (9)
Udupi (16)
Uttar Kannada (13)
Shimoga (18)
Mysore (17)
Uttar Kannada (19)
Chitradurga (18)
Bangalore U (23)
Shimoga (26)
(5)
Dakshina
Kannada(15)
Shimoga (18)
Uttara
Kannada (22)
Bangalore (R)
29)_________
: Shimoga (32)
Bangalore-U(18)
IKodagu (32)
Dakshina
Kannada (12)
Shimoga (22)
Chamrajnagar
(30)
Bangalore-R
(40)
Figure in brackets indicates the position on 100 point scale
However, disparities in health on class, caste, age, sex and the religion could
not be assessed, as data does not exist in disintegrated form for districts of
Karnataka.
Relationship in between Health Status and Health Determinants among the
Districts of Karnataka State:
HEALTH
STATUS
LOW
HEALTH DETERMIh ANTS
MODERATE
HIGH
LOW
BELLARY
GULBARGA
KOPPAL
RAICHUR
CHITRADURGA
KOLAR
BIDAR
MODERATE
BAGALKOT
BIJAPUR
GADAG
DAVANGERE
' BELGAUM
CHIKKAMAGALUR
DHARWAD,
HASSAN, HAVERI
MANDYA, MYSORE
TUMKUR
HIGH
CHAMARAJNAGAR
BANGALORE (U)
DAKSHINA KANNADA
UTTAR KANNADA
UDUPI, KODAGU
SHIMOGA,
BANGALORE (R)
Observed Agreement 19/27 - 70.4%
Kappa Coefficient: 0.532,
P = 0.000059
It is obvious from the above table that the districts with the low value on health
determinants have low health status and districts with high value of health determinants
have the high value of health status with an agreement of 70.4% and Kappa Coefficient
0.532, which is significant.
in
Relationship in between Health Status
and Primary Health Care Facilities among
the Districts of Karnataka State:
HEALTH
STATUS
PRIMARY HEALTH CARE FACILITIES
MODERATE
HIGH
LOW
LOW
BELLARY
KOPPAL, RAICHUR
GULBARGA
KOLAR
BIDAR
CHITRADURGA
moderate
. BAGALKOT
BANGALORE (U)
BELGAUM
DHARWAD
BIJAPUR
DAVANGERE,
'GADAG, HAVERI
MANDYA.TUMKUR
CHIKKAMAGALUR
HASSAN
MYSORE
DAKSHINA
KANNADA
UDUPI,
BANGALORE (R)
CHAM RAJ NAGAR
KODAGU
UTTAR KANNADA
SHIMOGA
HIGH
Observed Agreement 12/27 - 44.44%
Kappa Coefficient: 0.1234,
P = 0.1862
Government Primary Health Care services and health status are not very much related
vnth observed agreement of 44.44% and Kappa Coefftoient 0 1234 which is S
significant. I his may be due to the utilization and availability of private health services.
lh0USh “ haS 9°°d ^ment Primary
HeaTh"Care seXs'5 '0W Hea'lh
5
u
Relationship between Health Status and Utilization of Primary Health Care
services among the Districts of Karnataka State:
HEALTH
STATUS
LOW
MODERATE
__ UTILIZATION OF PRIMARY HEALTH SERVICES
LOW
MODERATE
HIGH
BELLARY,
GULBARGA, BIDAR
KOPPAL, RAICHUR
KOLAR
CHITRADURGA
.BAGALKOT
BELGAUM
BIJAPUR
DHARWAD,
* DAVANGERE
HASSAN, HAVERI
MANDYA.GADAG
TUMKUR, MYSORE
BANGALORE (R)
CHAMRAJNAGAR
HIGH
BANGALORE (U)
CHIKKAMAGALUR
DAKSHINA KANNADA
UTTAR KANNADA
UDUPI, KODAGU
SHIMOGA
Observed Agreement 19/27 - 70.4%
Kappa Coefficient: 0.532,
P = 0.000059
All districts with high health status continue to use Primary Health Care services and
the districts with low health status have low utilization of primary health care services.
The above table, observed agreement and kappa coefficient denotes that the health
status is more related to the utilisation rather than the availability of services.
Relationship in between Primary Health Care Facilities
and Health Facilities
Utilization among the Districts of Karnataka State
HEALTH
FACILITIES
UTILIZATION
LOW
LOW
PRIMARY HEALTH CARE FACILITIES
MODERATE
HIGH
MODERATE
GULBARGA
BIDAR
■BANGALORE (R)
BIJAPUR
CHAMRAJNAGAR
DAVANGERE,
GADAG, HAVERI
MAND YA, KOLAR
TUMKUR
DHARWAD
HIGH
..
BELLARY
BAGALKOT
BELGAUM
RAICHUR
KOPPAL
BANGALORE (U)
DAKSHINA
KANNADA
UDUPI
HASSAN
CHITRADURGA
MYSORE
CHIKKAMAGALUR
KODAGU
UTTAR KANNADA
SHIMOGA
Observed Agreement 18/27 - 66.7%
Kappa Coefficient: 0.474,
P = 0.00031
's dear from the above table the relationship between Primary Health Care utilisation
an
nmary Health Care facilities is significant where observed agreement is 66.7%
and Kappa Coefficient is 0.474. This shows the availability of health services leads to
utilization of the health services.
In case of Bangalore Urban though the availability of government primary health care
facilities is low, the utilization of health services is high. This may be due to availability
or health care services in the private sector.
17
mgs it is clear that the Hyderabad - Karnataka region (Bidar, Gulbarga,
seal and Bellary), Bijapur and Bagalkote lack on all indicators in the
-'stegories.
.
Health requires equity in the distribution of the determinants, availability
maith care sen/ices and the utilization of health care sen/ices.
rciosed indicates the districts which require top priority (red), moderate
.-eJcw) and districts where existing facilities, utilization and health status
simained at an acceptable level (green).
OMMENDATIONS
>
Environment Sanitation including availability of clean water, housing and access to
n.e and amenities like electricity should be improved in entire Hyderabadmrnaiaka region, Bijapur, Bagalkote, Gadag, Hassan and Haveri districts. For this
scheme like Nirmal Karnataka Program under Rural Development and Panchyat Raj
should be implemented with creating awareness on sanitation and provision of
Facilities simultaneously.
•
Literacy Status 15+ should be improved in Hyderabad-Karnataka region, Bijapur
Bagalkote. Chamrajnagar, Mandya and Bangalore Rural districts.
y '’"3 :c 39 made to improve the economic status of household in HyderabadKarnataka -gion, Bijapur, Bagalkote, Chamrajnagar, Chitradurga Dharwad Gadaq
and Kola districts.
i'..;n':on status of under five should be improved in entire Hyderabad-Karnataka
region. Bijaour, Bagalkote, Davengere, Gadag and Haveri District.
’
mcidence to be reduced in Hyderabad-Karnataka region, Bijapur,
Cnitradurga, Dakshina Kannada, Hassan, Kolar and mandya districts by
oiementmg National Anti Malaria Program aggressively.
?3i3r'3
mmv^ience of TB should reduced in Hyderabad-Karnataka region, Bijapur,
Bagalkote Chamrajnagar, Chitradurga, Kolar, Mandya, Mysore and Bangalore
Lroan and mural districts by extending RNTCP to these districts on priority basis.
2 L''3r'' —ssith Care facilities to be improved in Hyderabad-Karnataka region,
u mmm cagalmote Bangalore Urban, Dharwarand Gadag districts.
•
More than establishing new primany health care facilities the utilization of existing
-a. .a care sen/ices should be encouraged. This could be done by making
e + i'.irg cr'^ary health care facilities functional in real sense through monitoring of
-' • ' Q m staff including MOH and drugs.
ANNEXURE-1
HEALTH DETERMINANTS INDICATOR
I.
c.
Prevalence and level of poverty * -1998
Educational levels * -1991
Adequate sanitation and Safe water coverage
d.
Housing * -1991
a.
b.
- 1998
HEALTH STATUS INDICATORS
IL
a.
b.
c
c.
d.
e.
f.
g-
III.
Under five year mortality rate * -1991
Nutrition of children * - Nov. 2000
Maternal mortality ratio: Not Available
Life expectancy at birth: Nbt Available
Incidence & Prevalence of relevant infectious diseases
Infant mortality ratio: Not Available
Child mortality (1-4 years): Not Available
-1999
HEALTH CARE RESOURCES ALLOCATION INDICATORS
a.
Per capita distribution of qualified personnel in selected categories eg.,
medical officers: physician, obstetrician, paediatrician, surgeons &
paramedical workers. * - Sept. 2000.
b.
Per capita distribution of services facilities at Primary, Secondary and
Tertiary levels. * -1999
h.
IV.
Per capita distribution of total health allocation and expenditure on
personnel and supplies as well as facilities: Not Available
HEALTH CARE UTILIZATION INDICATORS
c.
Immunization coverage * -1998
Antenatal Coverage * -1998
Percentage of births attended by qualified attendant * -1998
d.
Current use of contraception * -1998
a.
b.
Indicators used in the present report
I9
u
0000000000000000000000013000000000000000000
0
' VERMViE Vr OF KARNATAKA
0
SI
0
TASK FORCE ON HEALTH AND FAMILY WELL \ S E
0
s
0
3
0
Mnmissioned Research Studv
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
s
0
0
0
0
0
ROLE
OF
PRO
VI
E
SECTOR
IN
HEALTH
(
ARE:
0
0
QLALITY AND ACCESS
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Bv
0
0
0
0
A. F. FERGUSON Sc CO
0
0
MANAGEMENT CONSULTANT DIVISION
0
.w
BANGALORE
0
0
0
0
0
0
0
0
0
0
Ml
0
0
0
0
.5^
0
00000000000000000^^00000000 ' 1 0 00000000
£
.‘"r*
■u
Confidenra!
■: ? -. wv 'n Heait* Care: CvahtY & Access
1.Background
Introduction
L.l
Health care and public health being one of ■ e : -rust areas for development and
improvement, the Government of Karnataka as considered the need for review of
the current state of Health System so as to ■_ isu~e 'Health for air with equity and
quality.
1.2
In order to propose measures to improve z e public health care systems in the
State of Karnataka, the Department of Healt: anc Family Welfare (DHFW) has set
up a Task Force, consisting of eminent persors in various fields, which will examine
the issues involved and propose measures wnich could be adopted by the
Government.
1.3
In this regard, the Task Force has conducted a preliminary study and presented an
interim report dealing mainly with short-te n recommendations, which can be
implemented within a period of 6 months. It has also identified areas of concern,
which can be accomplished in the medium anc. long term.
1.4
A.F.Ferguson & Co. - MCS division (AFF) ha- been retained by Karnataka Health
Systems Development Project (KHSDP) for rev.ew of private sector role in improving
health service programs (access and quality).
Terms of Reference
1.5
The Terms of Reference (ToR) for the study is as follows :
♦
♦
♦
To review existing role of the differer c sectors viz. voluntary-not for profit
hospitals, for profit hospitals and pubfc (Government) hospitals in providing
health care services and determining the possibility of a partnership between
them
To review the various health care serv.ces offered by private sector in terms
of access and qualities and suggest improvements thereof
To review the role of private sector
in preventive/promotive and
rehabilitative Health Care deliver/
To determine the willingness of private sector to be regulated in delivery of
their services either by legislation, self-reguiation or accreditation.
Approach & Methodology
1.6
Our approach to the study included:
♦ Preliminary Study
♦ Primary Survey
♦ Analysis - Findings and RecommendaL ,ns
Preliminary Study:
1.7
This phase of the study involved the following
■\FF-MCS
h1
Str'Ct/v
■:e
in He3:tr Cjrc: Quality & Accp^
Discussions with Relevant Personnel: Detailed discussions were held
the members of the Task Force a; d other relevant personnel, regarding
u ie various aspects of the proposed study.
ueiondary Data Research: Based on the discussions, information was
^..moiled from various secondary sources viz., Government of India
j.Jications, Government of Karnata a publications, World Bank reports,
^ji research findings etc., on :ne factors affecting public health
programmes and the private sector.
1.8
A :r mar/ sun/ey of a sample comprising of pr /ate hospitals, Government hospitals,
Homing homes, private practitioners, Government doctors and alternate systems of
mccjc.ne. For every hospital and clinic visitec exit proformas from both in-patients
ano out-patients were administered to assess the quality of care delivered. The
details of coverage is given in chapter 2.
Analysis - Findings and Recommendations
1.9
ie riormation collected from the primary and secondary sources was analysed to
determine the role of private sector in public health services. The perceptions on
the existing services received from the cross section of society was considered
wnile providing recommendations on enhanc ement of private sector role in health
ca. - distribution. Recommendations are provided on the improvements in Quality
c. Ac^ass to be incorporated by the private sector in line with their proposed
additional role.
1.10
11 - various aspects of the study are presented in different chapters.
♦
♦
♦
♦
AFF-MCS
Chapter 2: Primary Survey Coverage
Chapter 3: Review of Quality and Level of Care
Chapter 4: Access to Healthcare
chapter 5: Regulation and Accreditatio n
Chapter 6: Public Private Partnerships
Chapter 7: Conclusions and Recommendations
2
i1
stnctly Conheent:at
Ro/e or p- .
>’ctcvin Health Cure; (JuaiitYAccess
2. Primary Survey Coverage
This chapter presents the objectives, methodology followed and coverage of
primary survey made as part of the study.
2.1
Objectives of the Survey
The primary survey was made with the following objectives
2.2
♦
♦
♦
♦
Comparative study of quality of services offered as perceived by patients Reviewing the level of care in private hospitals vis-a-vis public hospitals at
the Primary, Secondary, Tertiary levels to the extent relevant for the study.
Private Sector hospital review in terms of
• Physical Access
• Social Access:
• Services Availability
• Quality as perceived by patients
Involvement of private sector in national programmes
Whether the private sector can be motivated towards greater access to
society
Willingness of Private sector for regulation, self-regulation and accreditation.
Methodology
2.3
Exhaustive questionnaires were prepared covering all aspects of the study. The
questionnaire (please refer Annexure 1) which served as a basis for fact finding
were
♦
♦
♦
♦
Private Hospital Proforma
Government Doctors Proforma
Private Practitioners Proforma
Exit Proforma - Patient Satisfaction
2.4
Discussions with key Department of Health members/ Task Force were also held.
Their suggestions were duly incorporated in the questionnaires.
2.5
The concerned hospitals/health care centres were visited by the consultants of AFF
covering the following :
♦
♦
2.5.1
A tour of all services/ facilities
Detailed discussions with the management to obtain their views on key
issues.
The results of primary survey are as provided by the respondents verbally/or in the
filled-up questionnaires, these could not be verified with their documents as the
hospitals/practitioners were reluctant to provide any records or statements to
substantiate their claims especially in cases like percentage of patients provided free
treatment.
AFF-MCS
3
u
Stnctlv Confident:j!
Rde
■■■;
</c-r..v
• -ej d' Core; Quality
Access
Coverage
2.6
Adequate care was taken to make the sample representative in terms of
♦
♦
Category of respondents - Hospitals, Practitioners and Patients
Geographical Coverage - Urban/Rural composition and Spread
Hospitals
2.7
By Management: All categories of hospitals with different management styles
were part of the study as is shown in table 2.1.
Table 2.1: Coverage as per Different Category of Hospitals - Management
S.No.
1.
2.
3.
4.
2.8
Particulars
Private Hospitals_____
-'Corporate Hospitals
- Trust Hospitals_____
- Teaching Hospitals
- Missionary Hospitals
Nursing Homes_________
Indian System of Medicine
Government Hospitals
Total
<■
Number In
urban Areas
_ ___ 6 ___
_____ 2___
_____ 2
_____ 1
_____ 1
_____ 2
1
12
Number In
Rural Areas
2
1
1
7
1
8
18
Total
Number
8
2
2
2
2
9
2
11
30
By Level of Care: To the extent possible, a mix of primary, secondary and tertiary
level of care offered by different hospitals was provided for in the sample.
Table 2.2: Coverage as per Level of Care Provided
S.No
1
2
3
Particulars
Number In
urban Areas
Number In
Rural Areas
Private Sector ___________
- Primary
___________
- Secondary___________
- Tertiary
___________
Government Hospitals
- Primary Health Centre
- Community/Taluk Health
Centre___________________
- District Hospital________
Indian System of Medicine
Total
_____ 8____
_____ 2
_____ 4____
_____ 2
9_____
7
2
3
8
6^
2
9
6
2
11
6
2
3
3
1
12
Total
Number
17
X
18
2
30
Practitioners
2.9
Adequate coverage of general physicians, specialists in private sector and
Government doctors was provided for in the sample as is shown in table 2.3.
AFF-MCS
4
H
Sirictlv Confidential
Role c‘
■ >
Hey/th Cdre:
Access
Number In
Rural Areas
11
7
r
4
23
1
35
Total
Number
24
15
9
28
2
54
Table 2.3: Coverage of Practitioners
j S.No.
Particulars
Number In
urban Areas
3
2
:______
Private Practitioners
- General Physicians__
- Specialists________
Government Doctors
Indian System of Medicine
Total
1
2
3
r
r
lZI
19
Patients
2.10
A minimum of 3 questionnaires was administered to patients in every hospital and
clinic visited in the private sector. In all, a total of 112 exit proformas were
administered to patients.
2.11
Break-up as per IP/OP: Equal representation was given to both the in-patients
and out-patients in the sample as is shown in table 2.4.
Table 2.4: Break-up of IP/OP Patients
S.No.
Number In
tirban Areas
46
In-Patients (including Indian
system of medicine)_______
Out-Patients_____________
Total
1
2
2.12
Particulars
Number In
Rural Areas
10
Total
Number
56
10
56
112
56
102
Classification as per Sex of patient:
Table 2.5: Sex wise Classification of Respondents
S.No.
1
2
2.13
Particulars
Males
Females
Total
Number In- Number
Total
^Out-patients Number
patients
33
I_____ 38_____
71
22
j__ 19
41
55
57
112
Classification as per Age of Patients:
t
Table 2.6: Age wise Classification of Respondents
S.No.
1
2
3
4
AFF-MCS
Particulars
Less than 12 yrs
12 - 35 yrs
36 -50 yrs
Above 50 Yrs
Total
Number Inpatients
;
28
13
14
55
Number
Total
Out-patients Number
~ _8_____
8
33_____
61
12_____
25
_4_____
18
57
112
5
H
Srnct/v Confidential
2.14
;
Classification as per Income of Patients:
Table 2.7: Classification of Respondents on Income
S.No.
Monthly Income
Number
Out-patients
1
Upto 1000
3
Rs. 1000- Rs. 2000
2
4
3_____
2 Rs. 2000 - Rs. 3600
13
6
Rs. 3600 - Rs. 5000
11
12
5
Above Rs. 5000
18
12
—!—
Total
46
36
Note : 30 respondents did not indicate family income
Number Inpatients
±
Total
Number
3
7
19
23
30
82
Coverage as per Spread
2.15
The respondents were mainly from the urban and rural areas of Bangalore,
Belgaum, Kolar and Gulbarga.
2.16
Thus, to an extent possible, adequate effort was made to make the sample
representative in terms of both categories of respondents> and geographical
distribution for the purpose of the study.
Primary Survey for Assessing Willingness for Accreditation
2.17
For assessing the willingness of private sector hospitals and practitioners for
accreditation, a separate structured questionnaire (Annexure II) was mailed to 600
hospitals/nursing homes/Private Practitioners/Specialists through IMA and also
through distribution at IMA sponsored seminars at Gulbarga, Belgaum and Kolar. ~
2.18
The break-up of responses received is shown in table 2.8. Though responses were
received only from 36% of hospitals, the break-up of responses by number of beds,
ownership, system of medicine and services (as has been detailed below) indicates
that the sample was representative of the whole.
Table 2.8: Responses Received From Different Categories
Number of Hospitals
Number of Specialists
Number of GP's
Total
2.19
AFF-MCS
Proforma
Sent
500
50
50
600
Responses Percentage
Received
Responses Recd.
ISO
36%
35
______ 70%
40
_______ 80%
255
42.5%
____________
The respondents were different stakeholders in hospital services. Though only 36%
of responses were received from hospitals category, the responses were
representative of the whole as could be seen from the break-up of total
respondents presented below.
6
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Ro/i
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Hcalti' Cc\ • Oudlit\ S Accea
2.20
Discussions with owners of certain hospitae,
hospital administrators were also held to get a
for setting up an accreditation body.
2.21
Break-up of respondents by number of beds., 'y/vnership, system of medicine and
services provided is presented below
arsing homes, IMA members anc
of various qualitative parameters
2.21.1 Number of Beds: Majority of respondents were nursing homes having less than 25
beds as is shown in exhibit 2.1
Exhibit 2.1: Classification as per Number of Beds
Diagnostic
Centre and
Polyclinic
8%
More than 250
beds
12%
Between 101 to
250 Beds
10%
Less than 25
Beds
52%
•>
Between 20 to
100 Beds
12%
Between 26 to
50 Beds
6%
2.21.2 Ownership: Majority (62%) of the respondents had proprietorship concern as is
shown in exhibit 2.2
Exhibit 2.2: Classification as per Form of Ownership
Trust
28%
Government
4%
ar;
Al
Corporate^
2%
Partnership
4%
&W:;
roprietorshi
P
62%
2.21.3 System of Medicine: Majority (88%) of them were allopathic graduates, 6% of them
were from other disciplines and responses for other 6% were not available.
AFF-MCS
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2.21.4 Services Provided: Majority were providers
is presented in exhibit 2.3
multiple services and the break-up
Exhibit 2.3: Classification as per Services provided
Mainly
Maternity
16%4i
Any Other
(Eye/ENT
etc.)
8%
i
Mutliple
Services
76%
AFF-MCS
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foK' -'' pr^'fLoto' m Health Cere: QuyHtv f< Access
3. Review of Quality and Level of Care
3.1
Quality of service provided in hospitals are usually determined by either of the
following two methods
♦
♦
Review of service offered such as effectiveness of treatment, hospital
infection rates etc and facilities available (Equipment, Investigation, Staff
etc)
Review of patient's perception of the quality
3.2
This study has focused on review of level of care and quality in the private sector
through exit patient perception of quality. This was conducted through a detailed
patient survey, wherein around 102 exit proformas were administered to patients
visiting Hospitals, Private clinics etc. In addition, around 10 patients from an
alternate system of medicine namely Ayurvedic Medicine were covered. This chapter
presents the findings of the survey on review of quality and level of care.
3.3
In order to retain the distinction between Allopathic medicine and the Indian system
of medicine, for the purpose of review of patient perception, the observations from
the patients of Ayurvedic hospital have been indicated separately.
Quality of Service
3.4
The quality of service offered by the private sector has been reviewed on the
following parameters :
♦
♦
♦
♦
♦
♦
♦
Patient Expectation
Repeat Visit / Recommendations
Doctor - Patient communication
Nursing care
Ward Staff Support
Support Services
Administrative Support
Patient Expectation
i
3.5
Quality of care is perceived to be high, when the expectations of patients with
respect to outcome of service is met.
3.6
Majority of the patients were of the view that their expectations of service were
either fully met or have been met to a certain extent. None of the In-Patients (IP)
were of the view that expectations have not been met. This holds true for the rural
sector also. Around 3% of the out-patients(OP) were of the not satisfied with the
treatment given.
3.7
Table 3.1 presents the response with regard to patient expectation.
AFF-MCS
9
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Confidential
/// Heaftn tare: Quality & Acce^
ALWe n'Pt
Table 3.1: Patient Expectation Response
Expectation :
Fully met
To some extent met
Not met
In-Patients
54%
46% ~
0% *
Total
3.8
100% ~
Ou t -Pat ients
I
49%
48%
I
3%
100% ~~~~j
In case of Indian Systems of medicine a rmajority of the
UII^ (patients were of the view
that the patient expectation were met only tosome^extent
Repeat Visits/Recommendations
3.9
Satisfaction of care and meetinc of care c
expectations, is an indicator that the
patient would visit the hospital for any subsequent illness
—s as well as recommend the
hospital to others.
3.10
This has also been reinforceo in the survey where majority of respondents indicated
that in the event of future illness they would like to visit the same hospital. Further
they would also either surely or may recommend the hospitals to others. This is true
for both urban and rural hospitals.
3.11
Table 3.2 presents the response on repeat visits and recommendations
Table 3.2 : Response on Repeat Visits and Recommendations
Response
Surely
Maybe
Not at all
Total
3.12
Repeat Visits
54 %
____ 43 %
3% "
100%
Recommend to others
_________ 42%_______
56%
_________ 2% ~______
100%
__
ASKPa5^n/Te ?0Spital Survey findin9s' 70 % Of the patients are repeat
patients.40 /o of the patients went back for the same complaints and 60% for fresh
complaints. This reinforces the response received from patients.
Doctor - Patient Communication
3.13
A Doctor's role is critical with respect to perception of the patient in regard to the
quality of any hospital/clinic. Most patients visit the hospitals for consultation with
specific doctors. The doctors role is reviewed both in terms of technical capabilities
as well as the comfort level the patient perceives with the doctor. As an average
patient would not be able to judge the technical capabilities of the doctor more
often, on successful treatment, the confidence on the doctor's capabilities rise. The
different factors reviewed in the exit proforma survey are:
♦
♦
♦
Communication on the illness and treatment process
Sense of Comfort
Opinion on treatment
Doctor Behavior.
aff-mcs
10
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f A...-.
Communication on illness and treatment process.
Responses were elicited on whether adequav information was provided by the
doctor about the illness and treatment meted o/. it must be noted that extent for
requisite information would vary from paticn* to patient. Around 84% of the
patients were fully satisfied with the explanations given. In cases where the patients
felt that adequate information about illness has r.ot been provided, they were barely
satisfied with the doctor's service. Thus, the sur/ey indicated that communication
played a key role in the overall satisfaction of the patient on the quality of services.
3.14
Sense of Comfort
The comfort level felt with the doctor plays a key role in removal of most
apprehensions of patients. The patients were queried on whether they felt free to
talk to the doctor regarding their concerns and worries. Majority of the patients
were at a comfort level with regard to patient- ooctor communication. In the rural
areas, almost all patients with an exception or two, were very comfortable with the
doctor communication.
->.15
Opinion on Treatment
Empirical studies have proven that a physician's task competence have a significant
influence on patient decision on quality. Opinions on the doctor's competence are
formed on recovery history of previous illness as well as patient's response to
current treatment. The respondents were divided closely between 'good' and
'satisfactory' treatment. A small percentage (2%) was dissatisfied with the technical
capabilities of the doctor.
3.16
Doctor Behaviour
Doctor's behaviour with the patient were reviewed in terms of whether the doctors
were kind and helpul, indifferent or they needed improvement in the same Around
14% of the respondents were of the view that there is a need to improve behaviour
of doctors. This may be a response to behaviour of specific physicians and has been
noted in a rural nursing home as well as in three other instances..
3.17
Overall Satisfaction
3.18
Majority of the patients were totally satisfied with the overall service provided by
the doctors thereby, reflecting in the quality standards perceived by them. Table 3.3
provides the responses of the Doctor — Patient communication parameter.
Table 3.3 : Responses <on Doctor Patient Communication Parameter
Response
Commu
nication
84%
12%
Fully Satisfied
Satisfied
to
some extent
Not Satisfied
4%
3.19
Comfort Treatment Doctor
Level
_Quaiity
------ 1
Quality
Behaviour
78%
[55%
: 8i%
22%
! 43%
I 5%
i 2%
; 14%
Overall
Satisfaction
87%
11%
2%
The exit proforma conducted on |patients visiting the Ayurvedic Hospital indicated
that majority of patients (~ 70%) were only satisfied
----- to
.j some extent with the
aff-mcs
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Rcic .i-
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-ill : r ' • Health Cd^e: Oudhty S Access
doctor's treatment. While -80 % of the respondents felt that the communication
between patient doctor could have been bettei, the responses were mixed with
regard to the doctor behaviour (50 - 50 between Kind and Indifferent).
Nursing Care
3.20
Nursing care provided by the private sector was reviewed for in-patient care. High
level of interaction between nurses and patient results in Nursing care being a key
aspect in determining patient satisfaction thereby perception of quality. Nursing
care determinants reviewed were :
♦
♦
♦
Support and kindness of nursing staff
Perceived competence thereby quality of service
Prompt answer to call
3.21
The majority of hospitals and nursing homes do not have nursing manuals.
Missionary hospitals have standing orders for nurses for certain departments. Many
of the hospitals are now planning to have manuals.
3.22
The survey revealed that most patients felt that the nurses were fairly friendly and
courteous in the urban areas, while in rural hospitals it was predominantly found
that patients felt that nurses need to improve their behaviour in terms of kindness
and warmth. The feedback on quality of nursing care was equally distributed
between 'good', 'satisfactory' and 'needs improvement'.
3.23
The major hospitals had trained and qualified nurses whereas the smaller hospitals
and nursing homes have poorly trained nurses and not as per Nursing council
norms.
3.24
Majority of the patients with the exception of the rural hospitals were of the view
that the nurses responded promptly on patient. Table 3.4 presents the exit
proforma findings on Nursing care offered in the private sector.
Table 3.4 : Responses to Nursing Care Offered in Private Sector
Responses
Good (Kind & Helpful)
Satisfactory (Indifferent)
Needs Improvement
Total
3.25
Nursing Staff
Behaviour_
58 °/c?_____
12 %
30 % ~
100% "
Quality of Nursing
Care
32 % ___________
32 % __________
36 %
100%
In the Ayurvedic hospital, the responses closely distributed across the three
parameters i.e. 50 %, 30% and 20% respectively. Most in-patients were of the view
that the nurses were indifferent and the quality of nursing care was only at a
satisfactory level.
Ward Staff Support
3.26
AFF-MCS
Ward attendants are the key support staff assisting the quality care of the in
patients. Service in terms of promptness to calls and their behaviour with the
patients reflect on the atmosphere of the hospital. Around 46% of the respondents
Startly Confidential
Rote o'
felt that these attendants were prompt in their
rural) felt that they needed improvement.
Health Care Quality S Access
while 38 % (predominantly
Support Services
3.27
Hospitals are complex entities with multiple range of functions being conducted
within. Though primarily clinical and para-medical ca^e forms the key functions of
the hospital, other areas such as Pharmacy, Housekeeping, Admissions and Food
service play critical roles in ensuring quality care to the patient. Respondents were
queried on the efficiency of these services and their satisfaction from them. The
areas covered were :
♦ Medical Supply Procurement
♦ Quality of meals
♦ Housekeeping
Medical Supply Procurement
3.28
Easy availability of medical supplies in the medical/surgical shops located in the
hospital is critical to the patient especially in emergency situations. While no
respondent had any concern regarding availability, around 86% did not face any
problems in procurement of medicine from these shops.
3.29
In the ayurvedic hospital, certain section of patients (60%) had difficulty in
procuring medicines, in certain situations while the remaining 40% did not face any
problems.
Quality of Meals
3.30
Provision of hygienic and good quality meals are a rrequisite for
" smooth recovery of
the patient and also reflect on the quality of the hospital. However, it has been
observed that unless made mandatory by the hospital, most patients do not avail of
the hospital meal services. Further, the respondent's view on the quality would be
highly individualistic and subjective to factors such as taste etc.
3.31
Around 62% of the in-patients (who availed of the facility) were satisfied with the
meal quality and timely service while 38% felt that there is scope for improvement
of meal service and quality.
3.32
All respondents of the Ayurvedic Hospital covered felt that there is a need to
improve the quality and service of meals offered.
House-Keeping
3.33
Hospitals being at a high risk in terms of cross - infections, good housekeeping
reflects on the overall quality care offered by hospitals. Housekeeping has been
reviewed in the exit proformas in terms of cleanliness of wards, toilets etc as well as
provision of linen and other supplies.
3.34
Responses on cleanliness of wards, toilets and bathrooms were highly hospital
specific with certain hospitals rating very high (100 % satisfaction) and certain
others quite low (75 % dissatisfaction). This is true for both rural as well as urban
hospitals. On an overall basis, around 54% found that the toilets were clean.
AFF-MCS
13
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Stnctiy Confidential
Rvlv o'
S'.‘Ctor m Health Cci'c
6. Acte::
3.35
With regard to linen supply, most of the rural respondents had used their own linen.
This may be due to bad quality of linen supplied by hospitals; c.
or the hospitals do not
provide for the same. The responses of other patients revealed an equal distribution
between satisfactory and need of improvement parameters.
3.36
Majority of the in-patients felt that the facilities of sweeper, security and power
were adequate.
3.37
Table 3.5 presents the responses on Housekeeping facilities of the hospitals.
Table 3.5 : Responses to Housekeeping Facilities
Responses
Satisfactory________
Needs Improvement
Totally Dissatisfactory
Total
3.38
Cleaniness
ward, Toilets
Bathrooms
of
&
54 %____ J2
51 %
49 %
0 %
_ 100%
46 %
0 %
100%
Quality of Linen
In the ayurvedic hospital, all patients felt that there was a distinct need for
improvements of the cleanliness levels and the linen supply.
Administrative Support
3.39
Quick and simple administrative procedures facilitate in enhancing the comfort level
of the patient with the hospital. The administrative support was reviewed in terms
of the following :
♦
♦
♦
Admission & Billing Procedure
Attitude of Reception staff
Waiting time
Admission and Billing Procedure
3.40
Majority of the patients (76%) felt that the admission and billing procedure was
simple with none of the view that it wa<; very complicated. This is applicable to both
the rural/ urban hospitals as well as the Ayurvedic Hospital.
Attitude of Reception Staff
3.41
Around 38 % of the respondents were of the view that the reception staff was
courteous, prompt and answered their queries satisfactorily, while 57 % felt that
there was a need for improvement in their attitude.
Waiting Time
3.42
Average waiting time was determined for the levels of enquiry/registration doctor
consultation and investigation. In all the three cases the majority 'of the
respondents were of the view that the average waiting time was 30 — 45 minutes
with 56 % feeling that though long, the waiting time was acceptable. 30 % of the
AFF-MCS
14
Sr/rf/k Confidential
n Carc: Quafd'5 Access
A'j/c ' ■
respondents were of the view that the overall v.c * ng time was reasonable and
within their expectations.
3.43
In the OPD, most of tne waiting time (73%) v/as spent in waiting for doctor
consultation. The average waiting time at each stage s presented in the Exhibit 3.1
Exhibit 3.1: Waiting Time
70%-|
60%-
50%40%-
30%20%-
10%-
0%-
I
liI
Registration
□ Less than 30 min.
15%
□ 30-45 min.______
□ 45-60 min.
□ 60- 120 min
S More than 120 min
' L
Consultation
Investigation
46%
15%
69% "
54%
15%
15%
23%
______ 0%
0%
0%
8%
0%
8%
15%
Level of Care
Level of care provided in the private sector was determined through the availability
of services in the hospital and the perception of the patients of the same.
3.44
Services Availability
3.45
The various services available in the private sector can be summarised as under:
♦
♦
♦
3.46
With regard to investigation facilities the following observations have been made:
♦
♦
♦
3.47
Super speciality services are generally available in Corporate / Teaching
hospitals
The Trust and Missionary hospitals generally provide secondary level of care
i.e. internal medicine, paediatrics, general surgery etc.
Most of the nursing homes have only minimal services for emergency care.
Corporate / Teaching hospitals usually have facilities for all investigations
Missionary / Trust hospitals offer secondary level of investigations'
Most nursing homes have only basic investigation services.
This has been confirmed in the exit proformas wherein most of the corporate /
teaching hospitals had their own investigation facilities.
AFF-MCS
15
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Strictly Confidential
A j'V
;,’/yaC S-.ccr
Health Care: Ouaht}' S Access
3.48
Facilities in terms of adecuate water and power supply and the drainage facilities
were found in all the hoso:tals covered. However, water purifier facilities were not
available in the nursing homes.
3.49
While the private hospitals had adequate number of ambulances, the nursing homes
did not have any. In terms of ward facilities, the nursing homes had only general
wards and no ICU facilities while all the private hospitals covered had Emergency
wards, general wards and ICU facilities. The nursing homes do not seem to follow
any kind of standard protocols regimes.
3.50
The facilities available in the private sector are presented in Table 3.6
Table 3.6: Facilities Available in the Private Sector
Facilities
Private
Hospitals
Nursing
Homes (%)
(%)
Emergency Ward_____________
% Beds in General Ward________
ICU_________________________
ICU Beds/Total Beds (%)________
Ambulance___________________
No. of Ambulances (No.)________
Overhead Water Tank__________
Water Purifier______________
Hot Water Facility______________
Generator____________________
Elevator_____________________
Drainage Connection
Laundry______________________
Space for Washing Patients Clothes
Declared Baby Friendly by Govt.
100
___ 61
100
5-10o/o<
___ 67
1-4
100
100
100
__ 83
__ 83
100
100
83
_0
36
0
0
0
0
100
0
100
75
0
100
67
100
50
0
»
3.51
Majority of the private hospitals and nursing home laboratories-are not standardised
and none of them are participating in standardisation programme accreditated to
the 'National Bard of Accreditation of Laboratories'.
3.52
There is thus an urgent need to set up minimum standards for hospitals and
nursing homes of varying capacities and classified as primary, secondary and
tertiary.
3.53
Currently, there are no permissions from any government authority required to set
up nursing homes. As a result, there has been a proliferation of poorly planned and
ill-equipped nursing homes.
AFF-MCS
16
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Roic
Strictly Confidentidl
Vnvciic 5-'i'
- ^ejith Cdre: OudhtY S Access
Patient Perception on Services Availability
The patient perception on services availability v.a: reviewed in terms of the
following :
3.54
♦
♦
♦
♦
Extent of investigations conducted
OPD facilities such as
♦ Physical Space
♦ Drinking water
♦ Seating arrangements'
♦ Fan & Ventilation
♦ Toilet
In-patient facilities such as water, power and security
Equipment Availability
Extent ofInvestigations conducted
3.55
Investigations, normally conducted to confirm diagnosis, have become more or less
a routine matter in most hospitals/nursing homes. The patient perception with
regard to the extent of investigations conducted, elicited the response as indicated
in exhibit 3.2
Exhibit 3.2: Patient Perception on Extent of Investigations Conducted
3.56
The most common investigation done for the in-patients was Blood (70%) and
Radiological -X-Ray (62%), C.T Scan (12%) etc. A sample detailed exit proforma
None
11%
More than
sufficient
49%
Low
34%
Fairly enough
6%
was conducted for around 13 patients to determine investigations conducted
against specific illness/symptoms. Table 3.7 presents a summary of the responses
received.
AFF-MCS
17
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Stnct/y Confidentidl
A'p/c .p/
S'\i; r Health Cdre: Oudlitv & Access
Table 3.7: Illness Specific Investigations conducted
_______ Illness/Symptom
Hernia - Swelling in groin
Appendicitis
;________ I nvestiglations__________
;_B!oodJJrine, CxR etc______________
i U.S Abdomen, Routine Blood and
. Urine
________________
Lower Respiratory Liactxerfection, Chest X-ray, PA view, Routine Blood
cough, expectoration, fever
and Urine analysis_________________
Intestinal
Perforation,
Pain
in | Urine, Blood, Chest X-ray
abdomen, Fever
Amenorrhea in labour
US scanning of Abdomen
Congestive
cardiac
failure, Chest X-ray PA, Routine Blood and
breathlessness,
cough
and Urine
expectoration
Pregnancy
Blood, Urine, USG, CxR
Acute Gastritis - Pain in abdomen
Endoscopy _________
Fever for evaluation
; Blood, urine CxR etc
OPD Facilities
3.57
Availability of space has an important bearing on the level of care and quality of
service. Majority (65%) of the respondents (specifically those visiting clinics) felt
that there was a reasonably good space in the OPD while around 27 % (mostly
constituting of hospital patients) felt that the OPDs were quite spacious.
3.58
The facilities in the OPD such as <drinking
' '
water, seating arrangement, fan &
ventilation and toilet were reviewed with the various patients to determine the
extent of such facilities offered in the private sector. Majority of respondents were
of the view that these facilities were fairly sufficient. Table 3.8 presents the
responses with regard to the above.
Table 3.8 : Extent of ORD facilities
—--------------------- r
Response
Drinking
Seating
Fan and
water
Arrangement Ventilation
31%
Less____________
21% j ________ 20%
53%
Fairly sufficient
60% i _______ 64%
15% I
More than sufficient
18% i
15%
3.59
Toilet
26%
56%
7t%
Majority of the patients (~80%) of the Ayurvedic hospitals found the OPD facilities
to be less satisfactory.
In-Patient facilities
3.60
Majority of the patients felt that in-patient facility such as water, power and security
were adequate.
AFF-MCS
18
H
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Snotty m Hemth Ce'c djnht}' F Accer
Equipment A vailability
3.61
The exit proformas addressed the query of to what extent the respondent felt that
the hospital was well equipped. Around 41% of the respondents were not able to
comment on the same while 35 % felt that the hospital was well equipped.
However, this observation cannot be considered, as most patients are not qualified
to judge the extent of equipment availability in the hospitals.
Comparative review of private sector with public sector (as perceived by
the patients)
3.62
The exit proformas addressed the various reasons for visiting the private sector for
treatment vis-a-vis the public sector.
3.63
Majority of the patients visited the private sector as they were either satisfied with
the service or they distinctly preferred a private hospital over the government
hospital. This is represented in Exhibit 3.3
3.64
Specific responses were elicited from a certain section of patients on their choice of
Exhibit 3.3: Reasons for Visiting Private Sector
Near to residence
26%
1.
...
I
Satisfied with care
56%
Prefers Pvt. Sector
18%
hospital if both the private hospital as well as the government hospital were close to
one another. All of the respondents preferred the private hospitals and the reasons
for choice are :
♦
♦
♦
♦
Promptness of service
Reliability
Quality care
Better services
Overall Rating of Private Sector (As perceived by the patients)
AFF-MCS
19
Strictly Confidentid!
•'
Syclo-
he.' " Cdre: QuaHh'& Access
3.65
As discussed in the previous paragraphs, majority of the parents are quite satisfies
with the quality of service and level of care offered by the Private sector
hospitals/health care units. The overall rating of the private sector as perceived by
the patients is depicted in the chart below :
3.66
The patients visiting ayurvedic hospital have rated the hospital to be average/poor.
Exhibit 3.4: Overall Private Health Care Centre
Rating
Average
22%
»“rTsav
Excellent
11%
Bl
Good
64%
AFF-MCS
20
H
Strictly Confidential
i
'''■cipr in Health Care: Quality i>
;
4. Access to Health Care
4.1
This chapter presents the accessibility of health care services to poorer sections of
the society both in terms of Physical and Social Access
Physical Access
4.2
Physical Access has been assessed by the following
♦
♦
♦
♦
♦
Availability of Hospitals
Availability of beds in the districts
Distribution of treatment of Out-patients and In-patients over source of
treatment
Physical distance traveled to reach hospital
Means of transportation used to reach hospital
Availability of Hospitals
4.3
According to a survey conducted in 1995-96 by the Centre for Symbiosis of
Technology, Environment and Management (STEM), Bangalore, there were in
1995-96, 2,624 public hospitals (hospitals, community health centres, primary
health centres and primary health units) and 1709 private hospitals (clinics, nursing
homes and hospitals).
4.4
Thus, the number of public health sector units is only slightly higher than that of
private health institutions. In terms of number of patients treated also, the role of
private health sector is increasing (this is presented below in section distribution of
patients over sources of treatment).
4.5
The Exhibit 4.1 presents district-wise distribution of Public and Private Hospitals in
Karnataka
AFF-MCS
21
H
.
Stncth Confdent'd''
6 Access
Exhibit 4.1:
Nmter of R±iic and Private FtepetaSs in Karnes by Dstrict
E3
B»?^l - *••
. Jc-I
F^tchLr
K!jEgrWM|
.
Kferd/a
i
^4. 4
■ ■■ - ■a
Kdc^j
~K
-.fes^gr -^ai
t5L2|
E R-bicFteptsis
C Rivste Htsgtds
3
I
QJbaga
.2
(/)
Q
«r»-
re Karada
32
■
■-c
Q'lkTB^LT
W*’ W-|
■
.
-n
Z
3
g-
'. 1/__ ' a. ?-^T
Bcfer — WI
EZ
J
Edgam
ZL
■•^••&aK;i
Efert£icre(l4
____ 12
o
50
100
150
200'
2x)
333
350
453
433
Mnte cf Fbsfital
Source: Health Care Facilities in Non-Government Sector in Karnataka, STEM, 199c
Availability of Beds
4.6
The number of beds in the private sector in Karnataka :s 40,900 compared to
43, 868 beds in public sector hospitals. A vast majority of orivate sector hospitals
provide curative health care, while public sector hospitals promotive, preventive and
curative services in rural areas and only curative services in urban areas. Thus, with
the population of 44806468 (Census 1991), this translates into a mere 1.89 beds
per thousand of population.
AFF-MCS
22
Ii
Strictly Confidential
•'
Access
Exhibit 4.2:
Source: Health Care Facilities in Non-Goven/
■ .ai i icitak;
! I-
Public and Private Hosp:;:, beds in Karnataka by District
Lttara Kannada |
[
Turrkir I
Shirroga
Rai chur
Mysore
.. . aw tar
Mardya ■BOMS
Kolar
9
■
Teg]
Kodagu
I
Ftessan
C Public Haspita' Beds
Gulbarga
T ^nKcr.e Haspita! Beds
Chawed
Daks hire Kannada
Chitradirga
...;
Chikmagtir UffiMIB
Bijapur
Bidcr
Bellary
Bdgaum I
Bangalore (R) |
Bangalore (U) I
0
2000
4000
690j
10000
12000
1400Ci
16003
18000
Number o' Hospital Bed
Bed Capacity at Ayurvedic Hospital
4.7
The Ayurvedic Hospital covered h:. . :nod capacity of 325 beds in the general ward
snd25 beds in the semi-private wt'c. rith a n average occupancy rate of 30-40%
Distribution of Treatment of Out-Pat er ts over Sources of treatment
4.8
Only 27% of the OPD patients ir
Public Hospital Centre. Majority :
doctors and 22% of them from :
are seen in rural areas. The dets
Table 4.1: Percentage D:;
over So.
AFF-MCS
■1 areas of Karnataka get their treatment at
< 43.19%)- gets their treatment from private
hospital in urban areas and similar trends
i table 4.1
.ion of Out-patient treatment
: Treatment
23
H
Strictly Confi^enticii
't'
■.
..
6 A
Urban
Hural %
Type of Hcpitai
Public Hos;.,','
1.71
Primary Heah Centre I
£.47
!
1.27
Public Dispensa-v
1.23
Private hospita
1E.48
Nursing Home
1.16
0.24
2.17
Charitable Hosoca
(ESI)Doctor_____
1:36i
0.94
Private Poetor
_4_349' _
41,51
~~ 2.28
Others_________
2.19
Total
100.00i
100.00
Source:Gol, CSO,
rjjnc of National Sample- Survey No. 36^
Distribution of Treatment of In-Patients over Sources of treatment
4.9
There is almost equal distnoution of In-patient.- treatment in public and Private
sector in Karnataka Urban areas and whereas., in rural areas 60% get their
treatment in public hospita and primary healtr centre and the balance 40% in
private sector. The detailed break-up is presented in table 4.2
Table 4.2: Percentage Distribution of In-patient treatment
over Sources of Treatment
Type of Hospital I Urban % Rural %
Public Hospital
____ 48.51
55.31
Primary Health Centre |
0.39
2.71
Private hospital______
40.49
32.94
2.59'
Charitable Hospital run
1.26
by Public Trust______
Nursing Homes______
9.06
5.62
Others_____________
0.29
0.91
Total
100.00
100.00
Source:GoL CSO
ro-jno'of National Samph'
No. 364
Distance Traveled to Reach Hospital
4.10
One of the most important means of assessing physical access of healthcare
services is to identify the distance traveled by patients to reach hospitals.
4.10.1 Hospitals: The primary survey reveals that more than 70% of OPD patients across
categories use hospital within 10 kilometres of distance from their home. A very
noticeable difference is that m Urban Gove'-nmirnt hospital as much as 60% of the
patients come from a discant•? of more than 10 (ms.
4.10.2 There is no particular notice.■. differenct ir cm vussibility in urban and rural areas
in private hospitals. This is because man\ oati- n’e in rural hospitals are also from
neighboring villages. Table - .3 gives details of t 'r. accessibility
AFF-MC5
2^
H
Strictly Confioe'i'/dl
' Quality & Access
Table 4.3: Physical Accessibility by Distance Traveled
Average
Distance
from
Residence
to Hospital
< 3 km.
3-10 km.
>10 km
Corporate
A
B
Percentage of Patients Visited
Trust
Teaching
Missionary
A
B
A
B
I
A
B
N.H*
Avg.
Govt.*_
A
B
_____ I
Urban Urban urban Urban jUrban Rural Urban .Rural
___ 20
30i____ 20 ___ 20 ____ 60i
N.A ___ 20
70
___ 50
N.A ___ 55
20'
3T
60
60
20
25'
20"
30
N.A
40,
20
20|
10
Urban Rural
30 ____ 15 ___ 50
50
25 ___ 30
20
60
20
I
Source: Survey
*Only Representative cases of surveyed Govt Hospitals and Nursing Homes is presented.
4.10.3 Practitioners. A general trend that is visible is chat more than 75% of the patients
visiting General Physicians are from the radius of less than 3 kms from clinic and
another 20_25% from o to 10 kms radius. In case of specialists the percentage of
patients who came from the radius of 3 kms from clinic were in the range of 3060% (with an average of 42%) and those from a radius of 3 to 10 kms was about
30-45%.
4.10.4 Exit Proforma Findings: The exit proforma survey reveals that a lot of patients
(38%) travel even upto 10 km to reach the private hospital. However, around 53%
of the patients reside within a radii of 5 km from the hospital.
4.10.5 In the Ayurvedic Hospital around 60% of the patients travel more than 10 kms to
reach the hospital while 30% reside within the range of 3-10 kms.
Means of Transportation Used to Reach Hospital
4.11
Except in case of Corporate Hospitals, Majority (50-80%) of the patients visiting
other hospitals reaches by walking or public transport. Use of public buses to reach
hospitals is greatest in Government hospitals and teaching hospitals. Whereas in
Missionary and teaching (in that order)thospitals patients walking to reach hospitals
is also common.
Table 4.4: Means of transportation used by patients to reach hospital
Means of Transportation ________ Percentage of Patients Visited*
Corporate I Trust I Teaching Missionary
N.H Govt.
_______ 65j __25l ~
To
Own Vehicle
_______ 10 __ 20 ____ 9
________ S'___ 30________ 40
Bus________
_______ 10 __ 30 ___53
AutofTaxi
_______ T\___ 25
JO ______ 10, __ 20 ___ 17
Walk
20
I
40
70
21
30
Source: Survey
*Only Representative cases/cases ir which mh-’me:!.was provided is presented.
AFF-MCS
25
H
•. )/e o!
Strictl\ Con dentid'
-i /Vr
• sj' '■
''r- 6 Access
4.12
Exit Proforma Findings:
c transport (bus serve,
:wo-wheeler
vehicle are the common modes of transportation fo o.-.co by the patients
constituting 37%. and 53 % respectively, of the total respondents.
4.13
In ayurvedic hospital, Majority of the patients (70%) use bus as the mode of
transport to reach the hospital.
Social Access
4.14
The Social Access was examined from the view point of
♦
♦
♦
♦
♦
♦
Sex-wise distribution of patients across hospitals
Age-wise distribution of patients across hospitals
Income group profile of patients
Payments Category
Treatment of Low income group patients at Hospitals
Cost of treatment as perceived by patients
Sex-wise Distribution of Patients across Hospitals
4.15
No significant difference in treatment of male or female patients is noticed across
categories of hospitals. However, except in case of missionary hospitals, the
percentage of male patients treated is a little higher than female patients.
Table 4.5: Sex-wise classification of Patients Treated across Categories of Hospitals
Sex
Male
Female
Corporate
Percentage of Patients Visited
Trust
Teaching
Missionary
N.H Govt. Avg.
A | B |Avg.
B
A
A I B
B
A
B
Urban Urban Urban I Urban Urban Rural Urban | Rural
Urban Rural
___ 60 ___ 55
50; ___ 50 ____ 60’
60
49|
57 ___ 57
54
40'
511
®
40
45
50j
50
40
43
43
46
zn:
i
T
Source: Survey
4.16
In the ayurvedic hospital, majority (80%) are male patients.
Age-wise Distribution of Patients across Hospitals
4.17
About 50% to 80% of the patients across categories of private hospitals are from
the age group 12 years to 50 years. But there is no significant noticeable difference
in access of patients of different age groups in rural or urban areas to treatment
facilities in private sector vis-a-vis public sector.
AFF-MCS
26
u
Strictly Conftjentia!
"
Health Care: Quality S Access
Table 4.6: Age-wise classification of patients across categories of hospitals
Age Group
Profile
<12 yrs
T2-35 Yrs
36 -50 Yrs.
50 yrs.
Percentage of Total Patients Visited
Corporate ___ Trust
Teaching [Missionary N.H
A__
B
A
B
A
B
f\
B
Avg.
Urban; Urban Urban Urban' Urban Rural!Urban; Rural
20
20
TcT Jo
Jo
30
30
30
30
10i
101
3
40:
30!
2Qi
I
20
10
lo
To
30
20
60
20
15
44
22
19
10
To
60
20
Govt.
A
B
Urban
Rural
9
20
30
35
30
30
30
20
30
n n n
Source: Survey
4.18
In the ayurvedic hospital, there is an equal distribution of patients (30%) across
the age group other- than less than 12 years, which constitutes 10% of the total
patients.
Income Group Profile of Patients Hospitals
4.19
The corporate hospitals had 60-90% of the patients from the upper middle income
group and high-income group.
4.20
In case of trust hospitals, only 20% of the patients were from the lower middle and
low income groups. 30-50% of the patients were from middle income groups (Rs.
3000-5000 p.m.).
4.21
Teaching hospitals had the maximum percentage (80-85%) of patients from the
lower middle income and low-income groups.
4.22
Missionary hospital also had 60% of patients from lower middle and low-income
groups. Both the missionary hospitals visited get a lot of donations and grants from
India and abroad for charitable purposes and are hence able to provide free and
concessional treatment to majority of patients who cannot afford the cost of
treatment.
»
4.23
The nursing homes mainly cater to the miodle income and upper middle income
group, who form 75% of the total patients treated.
AFF-MCS
27
H
Pnydtc Sector m Healy
Strictly Confijentia1
Table 4.7: Inc
Income Groups
High Income Group
(>Rs. 10000 p.m.)
Upper Middle Income
Group (5000-10000 p.m.)
Middle Income Group
(3000-5000 p.m.)______
Lower Middle Income
Group (Rs.600-3000 p.m)
Low Income Group (<600
p.m.)
________ Total
Source:Survey
4.24
>i!t'ilitv A Access
ofile of patients across Hospitals
Corpora.
A
Urban! um:
40'
:
3^
50
; ercentage of Total Patients Visited
Trust___ Teaching Missionary N.H
Govt.
A | B Avg.
B
A
B
A
B
Urban Urban Rural Urban| Rural
Urban Rural
W 12.5
-^ol
20
5 "" N.A
5
5
I
20
30
io;
5
N.A
15
50
10
10
30
20
5
N.A
15
25
30
15
10
70
80
N.A
30
7.5
25
20
10
10
5
N.A
30
5
30
50
100
100
100
N.A
100 100
100
100
!
20|
__ i___
iooi
ic:
Over 60% of the patic- .t
income and lower incoma
income group.
100
ayurvedic hospital are from the lower middle
while only 10% of the patients are from the high
Payment Category
4.25
Most of the patients in y
diagnostic tests and trear
concessions, usually in th-i
: orate hospital are fully charged for consultancy,
i very minimal percentage of them are provided
f 10 to 30%.
4.26
In hospitals run by trusts
religious communities, p1:
50 to 60% of patients wc-<
was a mixed trend. A few of them, those run by
■•ee treatment to about 20% of patients and about
j?d treatment at concessional costs.
4.27
Teaching hospitals also p\:
the patients but the purpoi.
to use them as clinical tea~‘
nee and concessional treatment to about 50% of
■/eating free/at concessional rates poor patients is
: '.es for medical students.
i
4.28
Missionary Hospitals get s.
and donations from India ;
able to provide free and c: ■
■ /J amount of their funding in the form of grants
■ oad for treating the poor patients. They are thus
•tai treatment to majority (70%) of their patients.
4.29
Nursing homes usually ru” :
middle class and usual
provided any form of fre-i .
.‘ividuals, cater to mainly middle class and upper
in full for treatment. A very few of them are
• ..sional treatment.
AFF-MCS
28
u
Strictly
-''/?/
•? Quality' & Access
Table 4.8: Payment Category of Patients across Hosp::; .?
Percentage of Total Patients Visited
Payment Category (%) Corporate Trust Teaching Missionary jN.H.
Consultant_______
Full Charges________
100
30 s
50
90
0
Concessional Charges
0
30
0
10
j
Free______________
0
20
100
0
Diagnostic Tests_______
Full Charges________
90
50
20
70
Concessional Charges
60|
10
30
30
20
Free______________
O'
IQl
20
50
10
Treatment____________
Full Charges_________
90
30]
50
30
80
Concessional Charges
10!
30
5u.
70
10
Free
20i
20
0
10
Source: Survey
*Only Representative cascs/cascs in which information was provided is presented.
C
~0j
"scr
o|
4.30
From our discussions with various doctors, patients, hospitals and diagnostic
centres, there appears to be a widespread nexus between the various hospitals,
nursing homes, diagnostic centres, specialists and family physicians in ordering
unnecessary investigations, treatment in order to share the fees among themselves.
Treatment of Low income Group Patients
4.31
83% of the private hospitals and nursing homes charged low-income groups
(income less than 600 p.m.). However, 75% of hospitals and nursing homes
provided concessions in fees in treating these patients. The concessions ranged
from 15% to near about 100%. 92% of the hospitals made referrals to other
hospitals. Referrals were usually made for patients requirinc super-speciality care.
25 percent of the hospitals always ordered investigations for patients and also
charged interpretation fees. None of the hospitals had any follow-up procedure.
25 /o of them (both the corporate hospitals and a nursing home) considered it as a
sole responsibility Oi Government to provide free treatment to the low-income group
patients.
4.32
The ayurvedic hospital, being a government hospital, offered free treatment to their
patients. None of the patients were corporate patients.
Cost of Treatment as Perceived by the patients
4.33
The cost of treatment as percieved by the patients were reviewed through the exit
proformas wherein the patients were queried on the reasonability and affordability
of the charges.
4.34
^0ritY^t0^ the OPD Patients ^58%) were of the view that the charges were
reasonable ...u.i
while aroundj 30 n,
% r_iA.
felt that they
a bit high. Similarly around 76 %
of the in-patients felt that the charges were easonable while around 19% felt that
they were high.
AFF-MCS
29
h
Strictly Confident a'
^.35
Almost al! the patients met tn-.
: e.urges on their own. A few of them
borrowed funds from friends and reiw .'cw. A cross section of patients were queried
on their affordability of these expenses and a majority of them (62%) felt that the
medical care expenses constituted upto 5 % of their income. However, a sizable
number (31%) also were of the view trial the said expenses constituted more than
20 % of their income.
4.36
A sample exit survey was conducted covering patients visiting private health centres
to determine the various chrages for treatment. Table 4.9 presents a summary of
various charges incurred by the patients.
Table 4.9: Summary of Charges incurred by Patients
Health Consultation Diagnostic Treatment
Private
Charges
Tests
Centre
~ 750~
Teaching Hospital ' 250
3000
~
150
_400
'
800
Nursing Home
l__30Q0
Corporate Hospital j 1000
i 4000
:
400
Nursing Home
500
_
J_500_
' 300
300
Nursing Home
; 600
Nursing Home
' 4500
A?00
5000
450
~ ' 250_
Teaching Hosptial
1000
Teaching Hospital
600
450
j 1000
4.37
Drugs
400
300
1000
200
400
1500
500
650
The Ayurvedic patients availed of free in-patient treatment at the hospital covered.
Hence, while the in-patient charges were considered reasonable, most patients
were of the view that external procurement of drugs is as expensive as the
allopathic medicines.
5. Accreditation
5.1
This chapter presents the primary survey findings in regard to willingness of private
sector for accreditation.
Accreditation
5.2
Accreditation is a professional and national recognition reserved for facilities that
provide high quality/ of care (Lewis, 1984). It is the process by which an agency or
organization evaluates and recognizes a program of study or an institution as
meeting certain pre-determined standards. Accreditation is usually granted for the
purpose of assuring th public of the quality of institutions. The concept of
accreditation exists in many countlies. This is now also being applied to Health Care
organizations.
Need for Accreditation
5.3
In Karnataka, and in rest of India as well, the private sector is more dominant than
public sector. In fact about 70-80- . a* the tola, health care expenditure is from the
private sector. With increase in demand for health care, the private sector has been
growing at a very fast pace offering a wide range of facilities and services. The legal
AFF-MCS
30
Strictly Ccnfidentia!
._v ■,,/i ^te S.ctcr .7? ^ej/th Cure; Quality Access
regulations have not been effectively implemented to ensure a proper regulated
growth.
5.4
There is also a wide variation in their range and quality of services provided.
Presently there exists no appropriate mechanism of reliable information regarding
quality of care. There also exists no adequate system of certification for the private
organizations. There are no timely reviews undertaken to ensure that the standards
are maintained.
5.5
Though, some private hospitals do carry out Medical Audit internally occasionally
but do not share this information to the public or to the peer group. The
performance data on these hospitals are termed "Confidential documents" by the
concerned hospital management. Data for the hospitals under study was not
available and also not forthcoming especially on the number of re-admissions,
repeat operations, hospital acquired infection, blood utilisation, tissues removed etc.
There are also cases of nursing homes which do not even maintain any medical
records nor’do they have any medical audit.
5.6
There is thus, an urgent need for an agency to set standards, ensure that the
standards are met and maintained, and also provide information to public to judge
the quality of care provided.
Willingness of Private Sector to Accreditation:
5.7
The following are the results of responses received from 255 respondents. The
details of the respondents have been provided in chapter 2.
Need Felt for Accreditation Body
5.8
88% of the respondents felt that there was a need for an accreditation body which
should lay down standards and grade hospitals. The break-up is presented in table
5.1
Table 5.1: Need felt for Accreditation Body
■ .p-i;-
Need for Accreditation Body
No Need for Accreditation
Body________________
Undecided
88
8
4
Role of Accreditation Body
5.9
Majority of respondents wanted the accreditation body to set standards, upgrade
standards, assess hospitals for compliance of standards, certify quality and provide
AFF-MCS
31
u
Strictly Confidential
!' '/c of Pnvate Sectc n> Health C5re: Quality' & Access
education and information on best practices etc. Details of responses are presented
in table 5.2.
Table 5.2: Role of Accreditation Body
Assess Hospitals for Compliance of Standards
Assist in Upgrading Standards____________
Assist in Certifying - Quality Assurance_____
Educative & Informative Role_____________
Serve as Forum for Consumer Redressal
Take Punitive Action Against Hospitals
86
88
88
78
30
24
Aspects to be monitored by Accreditation Body
5.10
Majority of the respondents wanted accreditation body to monitor physical aspects,
equipment, quality and number of personnel, type of treatment, follow-up of care,
patient satisfaction. Only 42% favored monitoring of professional fees charged by
doctors. The details are presented in table 5.3
Table 5.3: Aspects to be monitored by Accreditation Body
Physical Aspects_____________
Equipment_________________
Quality and Number of Personnel
Type of Treatment___________
Follow-up of Care____________
Patient Satisfaction___________
Professional Fees Charges
96
95
95
88
80
80
42
Benefits Envisaged
5.11
Majority of respondents felt that setting up an accreditation body would help in
improving standards, aid in certifying quality and help in comparison of performance
vis-a-vis other hospitals. About half of them felt that it would also serve as an useful
marketing tool, regulate and manage competition among hospitals and create a
level playing field among hospitals.
Table 5.4: Benefits Envisaged from Setting-up an Accreditation Body
S
[Help in Improving Standards
AFF-MCS
;
-i
88
J
32
Strictly Confidential
Of
,7.'c ‘•ectO’m Health Care: Quality ft, Arrest
Aid in Certifying- Quality Assuranee
Comparison of Performance vis-a-vis
other Hospitals________________
Useful Marketing Tool______
Regulate & Manage Competition Among
Hospitals__________________
Create Level Playing Field Among
Hospitals
5.12
86
62
52
48
46
We fee! that an accreditation body would also help in
♦ Assisting organizations in improving their quality of care
♦ May be used to meet certain Medicare certification requirements
♦ Enhancing community confidence
♦ Providing a staff education tool
♦ Assisting organizations to fulfil state licensure requirements
♦ Enhancing access to managed care contracts
♦ Favorably influencing bonds rating and access to financial markets
i
AFF-MCS
33
St'/cth' Confidently-
\ ?'.■ Secty /// Hcyltti C?--: jjdhtx £ Access
Willingness to Participate in Accreditation Process
Majority (88%) of the respondents was willing to participate as soon as the
Accreditation Body. They (92% of respondents) felt there was an urgent need for
grading and classification of existing hospitals. They wanted that the body to initially
give them an opportunity for self-evaluation and then finally assess compliance by
way of an external assessment.
5.13
Organization of Accreditation Body
5.14
Independent, self-regulatory, non-profit body: In the discussions with
respondents regarding the organization of the body, the respondents were of the
view that the accreditation body should be an independent body without any
Governmental/political interference. The body should have its own guidelines/code
of governance i.e., it should be self-regulatory. It also has to be a non-profit body
managed by professional experts.
5.14.1 The body should not bring an other sort of 'license raj'. It should have total
transparency in its process of accreditation.
Responses of General Physicians/Specialists
5.15
94% of the respondents (General physicians and Specialists) felt that there was a
need for accreditation body, while only 6% felt that there wasn't any need for such
body. Majority (90%) was willing to participate as soon as it was set-up.
5.16
The accreditation body should be an external independent non-profit body without
governmental interference.
5.17
The body's main role should be to lay down standards especially the minimum
standards that are required to be fulfilled. It should mainly monitor the physical
standards and process factors in case of General Physicians and specialists,
5.18
Majority (90%) was of the view that professional fees and charges should not be
monitored.
Proposed Accreditation Body for Hospitals
5.19
We propose the framework of a workable accreditation body for hospitals. We
would like to mention that this framework is by no means a blueprint but only the
broad sketch of an idea. Various factors affecting the stakeholders as well as the
existing social, political and economic ground realities need to be taken into account
while implementing it. Much would depend on the involvement and initiative of the
stakeholders. The accreditation system itself should be an outcome of discussions
and debates on issues of concern among all the stakeholders. Collaboration,
transparency between related parties and open communication are the hallmarks of
the system whose framework we are proposing. Only then would it be meaningful
and viable.
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Objectives of the Accreditation Booy:
5.20
The objectives of the Accreditation Body should be to
♦
♦
♦
♦
♦
Assess whether hospitals comply with standards and provide recognition to
those that do.
Upgrade standards in the light of a changing health care environment
Assist hospitals to upgrade their standards
Play an educative, consultative and informative role
Act as a bridge between the various stakeholders and provide a platform for
continued dialogue.
Constitution of The Body:
5.21 The establishment of such a; body
'
calls for representatives from the various
stakeholders involved in health
' “
—
..i <care delivery.
This’ is necessary in order to make
the system acceptable to all and to ensure its creditability from the
____start
___ The
specific groups that we have identified are as follows:
♦
♦
♦
♦
♦
♦
5.22
Representatives from the hospital owners
Representatives from specialists' associations
Representatives from professional associations
Representatives from consumer organisations
Representatives from Non Governmental Organisations (NGO)
Representatives from the state government
We feel that once the system is functional, representatives from insurance
companies, financial institutions as well as legal professionals could be included.
This would further establish the creditability of rhe body.
Status and Structure:
5.23
We see the accreditation body as a non-profit, registered and autonomous entity. At
a later stage, when the body has achieved stability and creditability, legislative
support could be sought.
i
5.24
We visualize the body with a Governing Board at its helm. It would be a statutory
entity entrusted with the responsibility of managing the body.’ It would be a final
authority in decision making and an arbitrator of major issues. It would frame
policies intended to develop the system and fulfil its stated objectives evolving a
consensus would be the principle guiding all decisions. When serious differences of
opinion occur, however, the majority would have to decide. The Governing Body
would have to meet at least four times in a year.
5.25
The Board would comprise of nominees of representative associations and
organisations as well as government and other stakeholders. In its composition, it
should allow each of the stakeholders to be equally represented. This would
prevent the Board from being monopolised - and overtaken - by dominant
stakeholders. The composition of the Board could be changed every two years with
AFF-MCS
35
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Access
a fresh set of nominations. Totally, there would be 7 to 9 members. A Chairperson
and a Secretary elected by this group would nave tenures of two years each.
5.26
The composition of the Governing Board could be comprised of the following
members, with one representative each from
♦
♦
♦
♦
♦
♦
♦
hospital owners' association
medical association
two specialists' associations
the nurses' association
consumer organisations
NGOs
state government
Functioning:
5.27
The main function of the body would be to assess whether hospitals comply with
set standards, to assist them to upgrade their standards and to play an educative
and informative role.
5.28
To carry out these functions in an efficient and effective manner, staff needs to be
employed. The staff could work either full time or part time depending on the
availability of finances. There would be a Director assisted in turn by four Assistant
Directors in charge of handling specific aspects of functioning of the accreditation
system.
In other words, the four Assistant Directors would be individually
responsible for the Assessment Division, the Educational Division, the Marketing and
the Administration Division. The number of staff assigned to each division would be
dependent on the nature of work. Each division would be responsible for the work
in its own area.
5.29
This would be the constitution of the Executive Body. The Executive Body would be
accountable and answerable to the Governing Board. It would be entrusted with
the responsibility of implementing the decisions of the Governing Board.
Assessment division
’
5.30
This division would evaluate the compliance of hospitals. Two methods would be
employed to assess compliance: self-evaluation by the participating hospital
followed by an external assessment. Reconsideration of assessment findings would
also be handled by this division but with a different team of assessors. Different
assessment teams would assist this division. A team would consist of two post
graduate doctors, one health administrator and one health specialist. The assessors
could work full time or part time, depending on the finances, but would need to
undergo training in the method of assessment.
5.31
Standards with regard to physical aspects, equipment, qualification, number of
personnel employed or attached, type of treatment and follow up of care would
have to be assessed. The body should not only set minimum standards but also
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Role of
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periodically review the same, considering the changing environment and the
existing ground realities in which the consumer and provider co-exist.
5.32
One area of prime concern that the accreditation body should include in their
assessment is consumer satisfaction. It is necessary to develop a framework or
guidelines to measure consumer satisfaction in a scientific manner. The fees
charged by the hospitals needs to be examined and linked to the size of the hospital
and the kind of services and facilities that are available. Most importantly, the
needs of the provider and consumer need to be balanced.
Initially/ the
accreditation body could start monitoring physical standards but then gradually
move on to process and outcome standards. A handbook for hospital standards,
depending on the size, kind of service and facility offered should be developed'
This, in turn, would assist in the process of accreditation.
Educational division
5.33
The accreditation body would assist hospitals to upgrade standards, They would be
aided in this by a group of experts from 'various
-------- concerned
-with hospital
management. A participating hospital wanting to upgrade its standards could avail
of the services of this committee. The focus would be on educating and providing
information to the interested hospitals. Furthermore,, it would hold regular
workshops, training sessions and seminars in fulfillment of the objectives of the
accreditation body. It would also assist in disclosing the assessment findings to the
public at large. Disseminating the list of accredited hospitals could be one way of
doing this. This information would be educative for the providers and informative
for the user.
Marketing division
5.34
This division would lie at the interface of the accreditation oody and society.
Among other things, it would be involved in public relations, advertising, consumer
education and creating awareness among the stakeholders.
Administration division
5.35
It would be responsible for general administration, which would encompass
finances, human resources, operations,'documentation and legalities
The Accreditation process
Pre-Survey
5.36
The hospital first submits and application to the accreditation body together with
fees for survey.
5.37
The Assessment Division determines the appropriate standards for the participating
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5.38
The Assessment Division provides self-evaluation schedules, forms, scoring
guidelines etc. to the hospital and collects them after they have been completed by
the hospital.
5.39
The Assessment Division analyses the self-evaluation schedules and forms filled and
returned by the participating hospital.
5.40
The Assessment Division co-ordinates the assessment schedule and procedure or
protocols to be followed. This includes setting the survey dates, assigning an
assessment team, the length of the assessment and setting the survey agenda with
the hospital.
On-Site Survey
5.41
The assessment team gathers information by observing structures and processes in
the hospital during visits to different units and departments, while on a tour of the
building and by interviewing patients, the hospital owner or administrator, the
clinical and support and, finally, by reviewing records and documents.
5.42
The team uses the information thus gathered to determine whether the hospital is
complying with standards for various functions. These functions could be patient
focused (for example, assessment of patients), organisation focused (for example,
organisational performance improvement) or structure-and-function focused (for
example, procurement of appropriate equipment and its maintenance)
5.43
The team identifies the areas of partial or non-compliance with standards.
5.44
The findings from the surveyors in the team are integrated into a single report.
5.45
The findings are reviewed and validated with the hospital owner or administrator.
Post-Survey
5.46
The self-evaluation of the hospital and the findings of the assessment team are
validated by comparing them to the scoring guidelines.
5.47
The accreditation status and the appropriate recommendations are determined
through a number of stages. These are :
5.48
The compliance findings are aggregated to generate an accreditation decision grid.
This is essential as hospitals offer different kinds of facilities. Moreover, each facility
would have an individual score of compliance to the set standards. If there is a
high score in one facility and not in the other, the total average for that hospital
would still be high. Would this then be truly reflective of the standard of that
hospital? A decision grid would provide flexibility' in determining the final score such
that it would be as close to reality as possible.
5.49
The level of accreditation as minimum, optimum or excellent is determined. Also,
whenever necessary, recommendations are made.
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5.50
If indicated, the findings and final decision to be taken by the accreditation body is
reviewed.
5.51
The Accreditation Report) |(containing the accreditation
decision, accreditation
decision grid and consultative recommendations) and the derived
performance
report (for public disclosure) are sent to the participating hospital.
5.52
Lhospital challen9e the accreditation findings or decision, an appeal may be
sent to the assessment division.
y
Period of Assessment
5.53
The assessment could be done every two years.
Financing
5.54
During the initial period of three to five years, the accreditation body can depend on
grants, but the long-term objective would be to attain self-sufficiency. Corporate
houses, insurance groups and various associations could be approached for funds
The costs could also be reimbursed in part by the participating Hospital, which in
turn could be used for developing the system. The constitutive elements of the
system, namely the representative associations or organisations, could contribute to
a corpus fund. Thereafter, other incentives could gradually be offered to the
participating hospital to help expand the coverage of the accreditation body.
I
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Farticip O Lik/l•>
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in prev.nu <
6. Public-Private Partnerships
This chapter presents the private sector participation in public health programs,
need for health insurance for low-income group and scope and mechanisms for
public-private partnerships.
6.1
Public Health Programs
6.2
The Government has taken certain steps to combat communicable, noncommunicable and other major diseases which cause disability not only to improve
the health status of India's population but also to prevent and control disabilities.
For this purposes several National Health Programmes (NHP's) are carried out by
State with Central assistance.
Current Private Sector Participation in NHP's
•
Hospitals
6.3
Awareness about NHP's: All the hospitals and nursing homes visited were aware
of National health programs being conducted from time to time by Government.
However only 11% of them could right answers as to the exact number of such
programs.
6.4
Participation: 55% of the hospitals and nursing homes visited indicated their
participation in preventive programs. But their participation was more by way of
self-organized camps for treatment of poor people or participation in camps
organized by voluntary associations, IMA or pharmaceutical companies.
6.5
Major Responsibility for Such Programs: Almost all of them were of the view
that major responsibility for such programs was of the Government and the private
sector can only compliment the efforts of the Government by way of their
participation in such programs.
6.6
Envisaged Role in NHP's: None of them were clear as to the role they can play in
the success of NHP's. Most of them considered that they help by creating awareness
by way of participation in such programs and health camps, and health education
during OPD treatment.
6.7
Government Initiatives: Out of the hospitals and nursing homes visited, none of
them had any Government functionary visiting them for such programs or DHS
inviting them for CME/ training for these programs.
6.8
Government should encourage the private sector to adopt appropriate therapeutic
norms and regimens recommended by national health programs and provide
incentives to develop schemes to finance, train and integrate private providers in
case finding, diagnostics and treatment for priority health programs that are of
public health significance.
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Need for Insurance Cover
6.9
6.10
r Our primary survey reveals.that currently 70-95% of patients (other than those
getting free treatment) across categories of hospitals pay directly (i.e., on their
own). The patients' availing insurance cover ranged from 0-4% across categories of
hospitals.
The millions of individuals paying out of pocket have limited leverage in the private
health care market. Moreover, the health insurance schemes in India are based on
an indemnity basis i.e., benefits in the form of cash payments rather than services.
An indemnity insurance contract usually defines the maximum amount that will be
paid for services. In most cases, after the provider of service has billed the patient
in the usual way, the insured person submits to the insurance company proof that
he/she has paid the necessary bills. He/she is then reimbursed by the company for
the amount of covered costs and makes up the difference him/herself. The
indemnity type of contracts accelerates expenditure growth and over-servicing and
also does not give enough leverage to influence the provider behavior. In contrast,
the aggregation and application of purchasing power in large-scale pre-payment
plans could have a powerful and positive influence on provider behavior particularly
in private sector.
Current Government Mandated Insurance Schemes
6.11
India has two main systems of publicly mandated contributory health insurance The Employees State Insurance Scheme (ESIS) and the Central Government Health
Scheme (CGHS) and other insurance policies are from Government owned GIC and
its subsidiaries.
6.12
ESIS: ESIS was initiated in 1948 and became operational in 1952. It applies to nonseasonal factories using power and employing 10 or more persons, as well as to
other establishments that do not use power but employ 20 or more people (several
state governments have extended the scope). The employees covered under this
scheme are those earning less than Rs. 6500 per month. Employers currently
contribute to ESIS an amount equal to 4.75 percent of the wages payable to
employees, while employees contribute 2.25 percent of their wages. Employees in
the lowest wage group (i.e., who earn average daily wages of up to Rs. 15 per day)
are not required to contribute their share with regard to such employees. State
governments contribute a minimum of 12.5 percent of the total ESIS medical care
in their respective states.
6.13
Though the scheme is extensive in its coverage, it has come under severe criticism.
Ellis et al (1996) noted that "detailed patient surveys conducted in Gujarat found
that more than half of all survey respondents covered by ESIS did not seek care
from ESIS facilities for treatment". Another report by the center for Social Services,
the Administrative Staff College of India (1996), was similarly critical, noting
problems with "complex office procedures, abnormal delays in the settlement of
cases and lack of specialists services, non-availability of ambulance vans, and low
quality of medicines".
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6.14
Role of Private Sector //; Health Care: Quality <S Access
CGHS: The Central Government Health Scheme was introduced in 1954. It covers
16 major cities and a large proportion of Central Government employees. The
central government heavily subsidizes the scheme. The employee's contribution
ranges from Rs. 15 to Rs. 150 per month depending upon salaries. Treatment can
be obtained at from more than 300 dispensaries, clinics, laboratories and dental
units. The CGHS scheme has been criticized for slow reimbursement and incomplete
coverage of private care.
Voluntary Private Insurance:
6.15
GIC Schemes: GIC's medical insurance consists of several levels of group and
individual coverage, collectively known by the brand name Mediclaim. In general,
Individual Mediclaim function on an indemnity basis, whereby the patient (or his
employer on his/her behalf) pays the provider and is subsequently reimbursed. The
individual Mediclaim has lengthy list of exclusions and does not cover "any existing
disease or illness of chronic nature". The policyholders expect large out-of-pocket
expenses in the event of a serious or chronic illness.
6.16
Group Mediclaim policies are available to any centrally administered group or
corporate body of more than 50 persons and are also extended to dependants.
Benefits are similar to to those contained in individual policies. Employees prefer
group Mediclaim policies to the ESIS because the former offers a choice of
providers. However, ESIS is mandatory for lower income employees and requires
lower premium contributions from employers. Thus, emloyers prefer ESIS to group
Mediclaim. They often use a combination of ESIS for those earning less than 6500
per month and group Mediclaim benefits for those earning more.
6.17
In late 1996, GIC introduced a low-premium scheme, Jana Arogya Bima, that
requires payment of Rs. 70 to Rs. 140 p.a. depending upon subscriber, with a
charge of Rs. 50 for each dependant child over the age of five. The low premiums
makes the scheme attractive for rural middle class and some urban residents who
fall outside the ESIS coverage. However, Jana Arogya Bima, payments are capped
at Rs. 5000 per insured person per annum. This makes the beneficiaries to still rely
on free care in public hospitals for any major illnesses.
Primary Survey Findings
i
6.18
In our primary survey, All the respondents (hospitals, nursing homes and private
practitioners) replied in affirmative that there was a need for health insurance for
poor people.
6.19
As regards affordability of premiums by the poor people, 47% of them felt that they
would not be able to afford it, 13% of them were of the view that they would be
able to afford it if they are sure of the benefits, and the rest 40% of them were 'not
sure' as to affordability of premium.
6.20
All the respondents suggested group insurance. 7% of the respondents also
suggested individual insurance policy. By group insurance here it is meant that
insurance policy should be such that it provides for insurance cover for all the
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members of family. However, none of them were clear as to nature of the policy
and its functionality.
6.21
A sample exit survey was conducted to determine the extent of premium payable by
the cross section of society. The premium affordable ranged from Rs. 300 per year
(by the lower income group) to Rs. 500 per year (middle income group).
Public Private Partnerships
Need for Public Private Partnerships
6.22
Most of the state Governments in India are finding it difficult to expand their public
facilities to cater to the growing health care needs of their population. The
budgetary support to this sector is shrinking and currently most of it is used to
finance the recurring expenditure like salaries of employees. As a result, the non
salary component has reduced dramatically. The areas affected most are the
secondary and tertiary facilities and basic facilities in remote areas. Many state
Governments are hence, exploring the options of promotina public-private
partnerships (PPP's) in health sector.
6.23
The health needs of the community are changing fast. The number of deaths due to
non-communicable diseases has increased and are likely to increase
disproportionately in future. This health transition will place considerable demand
on the Government to expand and upgrade their facilities in curative and tertiary
areas to meet the health care requirements of population in coming years.
6.24
Recognizing the severity of financial crunch particularly in super speciality care, The
Government of India in its national Health Policy of 1982 had recommended
"...planned attention would also require to be devoted to the establishment of
centres equipped to provide speciality and super speciality' services, through a well
dispersed network of centers, to ensure that the present and future requirements of
specialist treatment are adequately available within the country".
6.25
Currently in Karnataka, about 50% of the in-patients and 60-70% of the out
patients get their treatment form the private sector. Given the role of the private
sector in the state, there is a need to fqster PPP's to influence the growth of private
sector with public goals in mind.
Focus of PPP's
6.26
In general, the focus of public private collaborations has been on (Bhat, 1998)
Developing Strategies to utilise untapped resources and strengths of private
sector
♦ Enhance the capacity to meet growing health needs
♦ Reduce financial burden of Government expenditure in speciality and super
speciality care
♦ Reduce regional and geographical disparity in health care provision and
ensuring access
♦ Reaching to remote areas or targeting specific groups of population
♦ Improving efficiency through evolving new management structures.
♦
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Primary Survey Findings
6.27
All the respondents were willing to provide free or concessional treatment to low
income group patients and take part in National Health Programs, if adequate
support from Government was provided.
6.28
The support expected from Government was in terms of subsidies, grants, IT
exemptions, and Schemes from Central and State Governments for free drugs and
free vaccines. The table 6.1 provides the details
_________ Table 6.1: Support Required from Government
Subsidies____________________________
Grants _________ ,
____________
IT Exemption__________________
Central State Schemes for drugs & Free Vaccines
80
67
50
50
Scope for PPP's
6.29
From our literature survey and efforts of other state governments in this regard, we
feel that the following areas could be explored for PPP's
6.29.1 Clinical Service Tie-ups: There could be tie-ups with regards to hiring out
services of doctors, management of PHC's, tertiary and high-tech curative care etc.
Some of the clinical service tie-ups efforts of other state Governments are listed
below
♦
♦
♦
AFF-MCS
When West-Bengal was facing problems with regard to manning of primary
health centres, it hired the services of private doctors on contract basis
under the supervision of Panchayat Samities.
In Gujarat SEWA-Rural was handed over the entire primary health care
services in entire district by the State Government. The Government was to
provide finance to entire PHC services in SEWA-Rural Project area. The
SEWA Rural had the responsibility of managing the PHC's (including the
freedom to recruit its own workers). SEWA-Rural was to fulfil the same
targets which the government set for time to time.
In Tamil Nadu Government took the initiative to invite industry to adopt a
local PHC, health sub-center or district hospital. The.industry was given
responsibility of building, maintaining and equipping facility and the
Government was to provide staff and medicine.
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6.29.2 Non-Climcal Areas of Tie-ups: The areas of non-clinical tie-ups could be many
like hiring out of ambulance facilities, Contracting out services of catering, laundry
security etc. The states of Maharashtra, TaminNadu, and West-Bengal have initiated
such arrangements.
6.29.3 Technology Tie-ups: The technologies such as CT Scan, MRI are very expensive.
The Government can subsidize the investment or provide other incentives like
duty/tax exemptions and in return purchase the services for poor people.
6.29.4 IEC Training: Government can have tie-ups with private sector specialists for IEC
training, CME, updates for conducting regular training programs.
Mechanism for Collaboration
6.30
Joint Ventures: In JV, Government's contribution can be in the form of cost of
land and it can be treated as part of equity capital of the proposed organizations for
providing speciality and super specialty care. The Government contribution can be
in the range of 26% to 49%. In cases were cost of land is less than 26% of the
total share capital, the government can contribute additional resources to meet the
requirement. As a return on its equity capital, the facility should provide for free
care to certain percentage of OPD and IPD 'poor' patients. Care needs to be
exercised in choice of partner and clearly defining the 'poor' patients. Appropriate
mechanisms needs to be put in place to check that the free care is offered to
intended beneficiaries.
6.31
Subsidizing Inputs/Providing Fiscal Benefits: Another form of PPP could be in
the form of Government providing inputs to private party at subsidized rates and/or
fiscal exemptions. The Government of Rajasthan announced policy of providing land
at subsidized rates and also included other fiscal benefits to institutions interested in
setting up health facility. The quantum of facility depended upon whether the
facility was to be set-up in rural or urban areas The fiscal incentives that were
announced were
Exemption from payment of sales tax on purchases of medical equipment,
plant and machinery
♦ Exemption from payment of pctroi on medical equipment, plants and
machinery whether imported from abroad or other state.
The one other form of incentive could be providing finances from banks and other
state financial institutions at subsidized rates.
♦
6.32
Contracting-out Services: As has been stated earlier, there could PPP through
contracting out services both in clinical and non-clinical areas. Some of them are
♦
♦
♦
♦
AFF-MCS
Hiring services of doctors to man Primary health centres
Hiring vehicles for ambulance purposes
Contracting of services in the area of diet and catering, laundry, security,
IEC programs etc.
Contracting out high technology services like CT scan , MRI
Contracting out maintenance of equipment and facilities
45
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Precautions to be taken for a Successful PPP's
6.33
Before initiating PPP's the Government should come out with explicit policy
document which should be publicly available.
6.34
The implementing agency with in the government need to be decided - whether it
should the Directorate of Health or Urban development authority etc.
6.35
Before attempting a single window clearance, the committee in charge need to get
all the clearances from departments concerned like (Department of Health and
Family Welfare, Finance, Industry, Revenue etc.) to avoid delays and litigation after
the process is initiated. Some of the clearances required may be
♦
♦
♦
Amendments in Land Revenue Act
Exemption orders for offering Sales tax exemption etc
Other clearances from urban development authority etc.
6.36
A detailed brochure containing information and guidelines on selection process,
eligibility requirements, proposed form of participation etc need to be clearly stated
and provided to all prospective bidders.
6.37
All the incentives and conditions need to be clearly stated to the prospective bidders
for e.g., Incentives like subsidized rates at which land would be offered, the location
need to identified, any fiscal exemptions and incentives etc. also need to be clearly
finalized before the process is initiated and provided to all prospective bidders. Also,
Conditions like making the facility operational in a specified time-frame, free care to
poor, any price specifications need to be carefully detailed and finalized before the
process is initiated.
6.38
Finally, public support for the process needs to be ensured to avoid any sort of
litigation after the process is initiated.
6.39
MAPPING of the private sector is of utmost importance since there is no reliable
data on the same.
»
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Policy issues and policy measures for public private partnerships
Issues/ Concern
Expanding hightech super
speciality services
Unintended
implications
Cost
Quality
*
Demand Inducement
Unethical practices
policy measures
•
•
•
•
•
Geographic Distribution of
Facilities
Equity' Access to
facilities
•
•
•
•
•
•
Financing of New
Investments
Cost
Quality
•
Utilization Patterns
Equity:
Access in terms of
ability to meet cost
•
AFF-MCS
•
Protecting poor from
catastrophic financial burden
Protecting and increasing
government budgetary allocation
to public sector
Development of monitoring
mechanism and appropriate
regulations
Rate regulation (change provider
payment system)
Continuing medical education
programmes
_____________
Regulatory interventions such as
Licensing
Creating health map
Various types of incentives
Drawing definite plan where
money should be spent
Remote area subsidy programs
to allocate
Creating specialised financial
channels within the existing set
up of financial institutions to
provide funds to private health
care sector for financing their
new investments in appropriate
technologies after examining its
cost effectiveness_____________
Developing appropriate financial
mechanisms
Protecting poor
47
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7. Conclusions and Recommendations
Quality of Service
7.1
This study has focused on review of level of care and quality in the private sector
through exit patient perception of quality. This was conducted through a detailed
patient survey, wherein around 102 exit proformas were administered to patients
visiting Hospitals, Private clinics etc. In addition, around 10 patients from an
alternate system of medicine namely Ayurvedic Medicine were covered.
7.2
The quality of service offered by the private sector has been reviewed on the
following parameters :
♦
♦
♦
♦
♦
♦
♦
Patient Expectation
Repeat Visit / Recommendations
Doctor - Patient communication
Nursing care
Ward Staff Support
Support Services
Administrative Support
7.3
Only 54% of Inpatients & 48% of outpatients were of the view that their
expectations of service were fully met.
7.4
The above is reinforced with the fact that 54% of patients mentioned that they
would surely revisit at the same hospital and only 42% mentioned they would
recommend to others.
7.5
14% of the respondents were of the view that there is a need to improve behavior
of Doctors.
7.6
The quality of Nursing care in private sector needs to improve although it is
satisfactory in urban areas as compared to rural areas.
»
AFF-MCS
48
u
Confidential
Ro/e of Private Se-o'm Hojltn Can ■: OjnhtY t
•7
7.7
Many private nursing homes both in urban & rural areas, employed oni. 'non
qualified nurses" mainly ayahas given on the job Gaining. Majority of the Nursing
Homes especially did not have qualified trained Registered Nursing staff and
followed staffing norms as per Nursing council norms.
7.8
Majority of the hospitals and nursing homes especially did not have administrative /
nursing / standing orders , procedures manuals at all.
7.9
Majority felt that drugs were expensive (both allopathic or Ayurvedic) but were
easily available.
7.10
Around 38% of respondents felt that the quality of meals provided needs to
improve.
7.11
Only 54% felt that the house-keeping facilities (hygiene of hospital, clean toilets
clean linen etc.) were adequate. Majority of the nursing homes did not provide
clean linen and patients had to use their own linen.
7.12
57% of respondents were of the view that the reception staff needs to imorove
their attitude.
7.13
The average length of stay was in the range of 7-10 days.
Level of Care
Services Availability
3.67
There is wide disparity in terms of services availability within same category of
hospitals and among different categories of hospitals.
3.68
The various services available in the private sector can be summarised as under:
♦
♦
♦
3.69
Super speciality services are generally available in Corporate / Teachinq
hospitals
The Trust and Missionary hospitals generally provide secondary level of care
i.e. internal medicine, paediatrics, general surgery etc.
Most of the nursing homes have only minimal services for emergency care.
With regard to investigation facilities the following observations Tiave been made:
♦
♦
♦
Corporate / Teaching hospitals usually have facilities for all investigations
Missionary / Trust hospitals offer secondary level of investigations
Most nursing homes have only basic investigation services.
3.70
Facilities in terms of adequate water and power supply and the drainage facilities
were found in all the hospitals covered. However, water purifier facilities were not
available in the nursing homes.
7.14
While the private hospitals had adequate number of ambulances, the nursing homes
did not have any. In terms of ward facilities, the nursing homes had only general
wards and no ICU facilities while all the private hospitals covered had Emergency
AFF-MCS
u
Strictly Confcientidl
Role yf Private
m Health C&re' Quality S Acces.
wards, general wards and ICU facilities. The nursing homes do not seem to follow
any kind of standard protocols regimes.
7.15
Most private Nursing homes have only basic investigation service facilities.
7.16
Majority of the private hospitals and nursing homes Laboratories are not
standardized and none of them are participating in standardisation programme or
accreditated to the "National Board of Accreditation of Laboratories".
7.17
The nursing homes do not have ambulances. Quick referral of serious cases is a
major handicap.
7.18
Majority of the Nursing Homes does not have proper emergency wards/ ICU or
equipment or manpower. At best they are suited to give 'first aid '. But they
somehow manage to retain the patients in "ill equipped and ill planned" emergency
rooms and ICU's.
7.19
The Nursing Homes are very poorly planned in terms of space planning and some of
them are also located in remodeled residential houses and also located in residential
areas.
7.20
There are no physical standards currently available for private hospitals. There is no
proper space utilization since there are no norms.
7.21
There is a urgent need to set up minimum standards for hospitals of varying bed
capacity and classified as primary, secondary and tertiary.
7.22
No permission is required to start a Nursing Home from any statutory body. As a
result, there has been a proliferation of poorly planned ill-equipped nursing homes.
Patients Perception on Services Availability
3.71
The patient perception on services availability was reviewed in terms of the
following :
i
♦
♦
♦
♦
AFF-MCS
Extent of investigations conducted
OPD facilities such as
♦ Physical Space
♦ Drinking water
♦ Seating arrangements
♦ Fan & Ventilation
♦ Toilet
In-patient facilities such as water, power and security
Equipment Availability
50
Ii
5ir/ctiY Confidential
fQle ot Private Cecto- m Health Care: Quality & Access
7.23
m9ade°f
7.24
The most common investigation done for the in-patients was Blood (70%) and
Radiological -X-Ray (62%), C.T Scan (12%) etc.
7.25
The facilities in the OPD were found to 'Fairly Sufficient' by majority of patients.
However, in Ayurvedic Hospital the majority (80%) found OPD facilities to be 'less
than satisfactory'.
7.26
Majority of the patients felt that in-patient facility such as water, power and security
were adequate.
7.27
Most the patients could not comment on the adequacy of the equipment availability
in hospitals.
7.28
Majority of the patients visited the private sector as they were either satisfied with
the service or they distinctly preferred a private hospital over the government
hospital for promptness of service, reliability, quality of care or better services.
7.29
The Ayurvedic hospital, in general, was overall rated by patients as 'average or
poor'.
Pati6ntS WSre °f the V'ew that more than SLjfficient' investigations were
Physical Access
4.38
Physical Access has been assessed by the following
♦
♦
♦
♦
Availability of Hospitals
Availability of beds in the districts
Distribution of treatment of Out-patients and In-patients over source of
treatment
Physical distance traveled to reach hospital
Means of transportation used to reach hospital
7.30
There existed in 1995-96, 2624 public hospitals and 1709 private hospitals (STEM,
1996) and 43, 868 public hospital beds as compared to 40,900 private hospital
beds. Thus, there are 1.89 beds per 1000 population
7.31
Only 27% of the OPD patients in urban areas of Karnataka get their treatment at
Public Hospital Centre. Majority of them (43.19%) gets their treatment from private
doctors and 22% of them from private hospital in urban areas and similar trends
are seen in rural areas.
7.32
There is almost equal distribution of In-patients treatment in public and Private
sector in Karnataka Urban areas and whereas, in rural areas 60% get their
treatment in public hospital and primary health centre and the balance 40% in
private sector.
7.33
The primary survey reveals that more f
than 70% of—
OPD patients across categories
use hospital within 10 kilometres of distance from their home.
------ A very noticeable
AFF-MCS
51
u
Strictly Confidential
Ry/e cf Private Sector m Health Care.- Quality f( Access
difference is that in Urban Government hospital as much as 60% of the patients
come from a distance of more than 10 kms.
7.34
There is no particular noticeable difference in accessibility in urban and rural areas
in private hospitals. This is because many patients in rural hospitals are also from
neighboring villages.
7.35
More than 75% of the patients visiting General Physicians are from the radius of
less than 3 kms from clinic and another 20-25% from 3 to 10 kms radius. In case of
specialists the percentage of patients who came from the radius of 3 kms from clinic
were in the range of 30-60% (with an average of 42%) and those from a radius of
3 to 10 kms was about 30-45%.
7.36
Except in case of Corporate Hospitals, Majority (50-80%) of the patients visiting
other hospitals reaches by walking or public transport. Use of public buses to reach
hospitals is greatest in Government hospitals and teaching hospitals. Whereas in
Missionary and teaching (in that order) hospitals patients walking to reach hospitals
is also common.
Social Access
4.39
The Social Access was examined from the view point of
♦
♦
♦
♦
♦
♦
Sex-wise distribution of patients across hospitals
Age-wise distribution of patients across hospitals
Income group profile of patients
Payments Category
Treatment of Low income group patients at Hospitals
Cost of treatment as perceived by patients
i
AFF-MCS
52
u
Str!2tKi Confidential
fo/e of
Sector /<■ dealtf Care: Quality £ Access
7.37
No significant difference in treatment of male or female patients is noticed across
categories of hospitals.
7.38
About 50% to 80% of the patients across categories of private hospitals are from
the age group 12 years to 50 years. But there is no significant noticeable difference
in access of patients of different age groups in rural or urban areas to treatment
facilities in private sector vis-a-vis public sector
7.39
Corporate Hospitals cater mainly to the upper middle and high-income group of
people.
7.40
In Trust/ Missionary hospitals majority of the patients belong to the middle and
lower income group. These hospitals give maximum concession to the poorer
section.
7.41
Teaching hospitals had the maximum number of poor patients (probably due to MCI
regulations)
7.42
Nursing Homes mainly cater to the middle income and upper group of people
7.43
Over 60% of the ayurvedic hospital are from the lower middle income and lower
income group.
Payment Category
7.44
Most of the patients in the corporate hospital are fully charged for consultancy,
diagnostic tests and treatment. A very minimal percentage of them are provided
concessions, usually in the range of 10 to 30%.
7.45
In hospitals run by trusts there was a mixed trend. A few of them, those run by
religious communities, provided free treatment to about 20% of patients and about
50 to 60% of patients were provided treatment at concessional costs.
7.46
Teaching hospitals also provide free and concessional treatment to about 50% of
the patients but the purpose of treating free/at concessional rates poor patients is
to use them as clinical teaching cases for medical students.
7.47
Missionary Hospitals get substantial amount of their funding in the form of grants
and donations from India and abroad for treating the poor patients. They are thus
able to provide free and concessional treatment to majority (70%) of their patients.
7.48
Nursing homes usually run by individuals cater to mainly middle class and upper
middle class and usually charge in full for treatment. A very few of them are
provided any form of free or concessional treatment.
7.49
83% of the private hospitals and nursing homes charged low-income groups
(income less than 600 p.m.). However, 75% of hospitals and nursing homes
provided concessions in fees in treating these patients. The concessions ranged
from 15% to near about 100%. 92% of the hospitals made referrals to other
hospitals. Referrals were usually made for patients requiring super-speciality care.
AFF-MCS
53
u
Stnct!Confidential
foie of
Secrcr /r ^eelth Cere: Ouelitv S Access
25 percent of the hospitals always ordered investigations for patients and also
charged interpretation fees. None of the hospitals had any follow-up procedure.
25% of them (both the corporate hospitals and a nursing home) considered it as a
sole responsibility of Government to provide free treatment to the low-income group
patients.
7.50
There appears to be a widespread nexus between the various hospitals, nursing
homes, diagnostic centres, specialists and family physicians in ordering unnecessary
admissions, investigations, treatment in order to share the fees among themselves.
7.51
Majority of the OPD patients (~58%) were of the view that the charges were
reasonable while around 30 % felt that they were a bit high. Similarly around 76 %
of the in-patients felt that the charges were reasonable while around 19% felt that
they were high.
7.52
Almost all the patients met the treatment charges on their own. A few of them
borrowed funds from friends and relatives. A cross section of patients were queried
on their affordability of these expenses and a majority of them (62%) felt that the
medical care expenses constituted upto 5% of their income. However, a sizable
number (31%) also were of the view that the said expenses constituted more than
20% of their income.
7.53
The Ayurvedic hospital patients availed of free in-patient treatment at the hospital
covered. Hence, while the in-patient charges were considered reasonable, most
patients were of the view that external procurement of drugs is as expensive as the
allopathic medicines.
7.54
Presently there exists not adequate certification and standards
(structure/Process/ outcome) in private health sector in Karnataka.
7.55
There is an urgent need to set up standards, ensure that standards are met and
maintained. This information should be transparent and on website also. The
public should be able to judge themselves the quality of care provided.
7.56
Some private hospitals do carry out Medical Audit internally occasionally but do not
share this information to the public or to the peer group. The performance data on
these hospitals are termed "Confidential documents" by the. concerned hospital
management.
7.57
The nursing homes do not maintain any medical records nor do they have any
medical audit. Data for the hospitals under study was not available and also not
forthcoming especially on the number of re-admissions, repeat operations, hospital
acquired infection, blood utilisation, tissues removed etc.
7.58
All the respondents suggested group insurance. 7% of the respondents also
suggested individual insurance policy. By group insurance here it is meant that
insurance policy should be such that it provides for insurance cover for all the
members of family. However, none of them were clear as to nature of the policy
and its functionality.
AFF-MCS
of care
54
Strictly Confidential
Role of Private Sec:: ' '•
: . arc; Quality & Access
References
1.
Ramesh Bhat, 1998. Public-Private Partnerships in Health Sector in India: Issues
and Prospects. August 1998.
2.
C.David Naylor, et al, 1999. A Fine Balance: Some Options for Private and Public
Health Care in India. Human Development Network
3.
Centre for Social Services, Administrative Staff College of India. Beneficiary Social
Assessment for Karnataka, Secondary health Systems Expansion. Hyderabad.
4.
Rama V Baru, 1998. Private Health Care in India: Social Characteristics and trends.
Sage Publications
5.
Lipika Nanda. Designing an Accreditation System for the Health Care Organizations
in Andhra Pradesh. Hospital Administration, Volume XXXVII, March/June 2000,
Official Journal of Indian Hospital Association.
6.
Suresh Balakrishnan and Anjana Iyer. Bangalore Hospitals and the Urban Poor: A
Report Card. Public Affairs Centre, Bangalore
7.
V.R. Muraleedharan, 1999. Characteristics and Structure of the Private Hospital
Sector in Urban India: A study of Madras City. Partnerships for Health Reforms
8.
Prof. A.K.Roy, Patient Satisfaction Survey: A Tool for Total Quality Improvement.
9.
Others as specified.
i
AFF-MCS
55
11. Are there areas of overlap / duplication with other projects9
a) HMIS
b) [EC
c) Training
d) Staffing
e) Others
12. Are projects creating islands of excellence in an otherwise under funded sector?
13. Who drives the project?
a) State Health Directorate
b) Funding partners
c) External consultants
d) Others
14. Are there problems of :
i)
Ownership
ii)
Leadership
iii)
Intersectorality
iv)
Implerrfentation
v)
Monitoring and Evaluation
vi)
Any other areas
i
15. How do the projects perform in the context of some policy imperatives:
a) Equity
b) Gender sensitivity
c) Regional disparties
d) Partnerships
i.
NGOs
ii.
Private sector
iii.
Academics-Research
iv.
Others
e) Accountability including corruption and political interference
f) Community involvement and partnership
g) Decentralization and Panchayatiraj
16. Do multiple_projects make it difficult for the government to develop and implement a
coherent health policy for the health sector as a whole?
17. What has the project done in the context of sustainability?
18. Any other cross cutting themes that emerge in the discussion between researchers and
the project leaderships.
VI
Integration of EAP’s in Health Service Delivery
Karnataka
CONCEPTUAL FRAME WORK (2)
Objectives ?
Focus ?
Regions ?
I
Complementarity,
Processes
4
or
programmes
Supplementarity,
Overlap,
Ownership /
Leadership
Duplication
Budgets
Partnerships /
Linkages
VII
Evaluating /
Monitoring
CT
integration of EAP's in Health Service Delivery
Karnataka
CONCEPTUAL FRAMEWORK (4)
Whose Agenda ?
Who Drives?
a) State need
b) Funding partners
c) External Consultants
Sustainabili
a) System
b) Financial
I
r
Some
i
Issues
for Integration
. ■-•S’l
Duplication
a) HMIS
b) IEC
c) Training / CME
Financial Issues
a) Budgets
b) Financial System
Accountabili
a) Corruption
b) Political
Interference
IL
Integration of EAP's in Health Service Delivery
Karnataka
CONCEPTUAL FRAMEWORK (3)
1
i
I
Add
Quantity
Add Quality
"T
Add Value
(Improve /
Diversity)
I
!
Innovations
Relationship
to Existing
Health Care
System
- ve
Distort
■ ve
Undermine
!
T
+
System
Development
■ ve
Confuse or
complicate^
-
CONTENTS
VOLUME-I
I.
Research studies conducted by the Task Force on Health and Family Welfare
1.
Proposal for Review of Organisation Structure and Design of Job Responsibilities for
Health and Family Welfare Department.
2,n
Review of Externally Aided Projects in the context of their integration into the Health
Services Delivery in Karnataka.
3.
Training Programmes for Health Personnel in Government Service in Karnataka.
4.
Public Health Care Services under Panchayat Raj System in Karnataka.
S.x/Disparities in Health and Health care Services.
6.
Review of Role of Private Sector in Health Services (Access and Quality).
VOLUME - II
II.
7.
Health Expenditures in the State Budget.
8.
Peoples Perceptions of Public Health Care Services in Karnataka.
9.
Research Study on the Feasibility and Modalities of application of principles of Health
Promotion and its integration with Health Education.
Does Karnataka State need more Medical Colleges?
HL Indian Systems of Medicine and Homoeopathy.
IV. Rational Use of Drugs.
V.
Alcohol Use and Misuse in Karnataka.
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REVIEW OF ORGANISATION STRUCTURE AND DESIGN OF JOB
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Review of Organisation Structure
-Vol I
Confidential
1. ACKNOWLEDGEMENTS
1.1
This study is funded by World Bank aided Karnataka Health Systems
Development Project (KHSDP) for the Task Force on Health - Government of Karnataka.
We would like to express our sincere thanks and appreciation for the support and
constant guidance provided at various stages of the study.
1.2
In particular, we would like to thank Dr. H. Sudarshan, Mr. P.Padmanabha IAS
(Retd) and Dr. C.M.Francis for their valuable guidance, comments and suggestions
during the study.
1.3
We are grateful to Mr. Arvind Risbud, IAS, Project Director- KHSDP & his staff for
giving us an opportunity to carry out this study for the Task force on Health by funding
and providing us with valuable data.
’
1.4
We are indebted to Dr. G.V.Nagaraj - Director of Health Services and his entire
s>.aff at the Directorate, at the District level both urban and rural for providing us all the
support in completing the study through their inputs, suggestions, data etc.
1.5
We would like to express our appreciation to the following who have spared their
valuable time to give their suggestions for the study especially the office bearers of
KGMOA.
Members, Task Force on Health - Dr. Ramesh Bilimagga Dr. Maiya
Dr. Latha Jagannathan, Dr. Thelma Narayan & Others
Prinicpal Secretary (Health) - Mr.Abhijit Sengupta, IAS
Commissioner of Health - Mr. Sanjay Kaul, IAS
Project Director, IPP-IX - Mr. G.V.K.Rau, IAS
Deputy Secretary - Mr. Mohan Chakravarthy, KAS
Director of Medical Education - Dr. Seethalaxmi
Project Administrator, IPP-VIII - Dr. Jayachandra Rao
Directorate Staff- Additional Directors, Joint Directors, Deputy Directors,
Chief Administration Officer, Administration Officer & Others.
Divisional Joint Directors - Bangalore, Mysore & Gulbarga
Office bearers - Karnataka Government Medical Officers Association
Staff of IPP-VIII, IPP-IX, KHSDP & AIDS Society
i
Review of Organisation Structure
-Vol!
Confidential
District Health Officers & District Surgeons of Gulbarga, Mysore, Kolar,
Belgaum, Bangalore - Urban & Rural Districts
Medical Superintendent & Staff - Jayanagar General Hospital
Director & Staff - State Institute of Health & Family Welfare
CEO - Zilla Panchayat - Mysore - Mr. Sundar Naik, IAS
Medical Superintendent & staff - K R Hospital, Mysore
Deputy Director, Indian System of Medicine & Health, Bangalore.
Dr. David Peters - Public Health Specialist, World Bank, India Office, Delhi
Staff at Office of Task Force especially Dr. Deepak & Lakshmi
Administrative Medical Officers and Staff at PHCs/CHCs/Taluk Hospitals
and District Hospitals in Gulbarga and Bangalore Rural Districts.
i
2
Review of Organisation Structure
-Vol I
Confidential
2. EXECUTIVE SUMMARY
2.1
This study is instituted by The Task Force on Health, Government of Karnataka,
to study if any anomalies in the organization structure and present reporting system in
the hierarchy of the Dept, of Health & Family Welfare Exist and the possible ways of
addressing them and improve system to face the challenges posed by the external
environment of the day to deliver quality health services with equity.
2.2
M/S. A.F. Ferguson & Co. (AFF) has been assigned the task to study the above
mentioned tasks and also the possible work areas or the essential job descriptions of the
unique positions in the organization. This part of the report forms the Volume I (Review
of Organization Structure) of the report.
2.3
The methodology has been a qualitative approach of data collection and
discussions with various people involved ig the system. The key issues addressed in the
process of study are:
•
Increase focus on Promotive and Preventive Health (Public Health)
•
Equal promotional avenues for Clinical staff
•
Increase the morale of the people working in the system
•
Increase the accountability of the personnel on the performance of the
system
•
Bring all round development in the state in the area of Health care to remove
regional disparities
•
Identify the key training areas required
required for
for keeping
keeping the
the technical
technical personnel
personnel
abreast with contemporary knowledge and thus contribute for the success of
the department
2.4 The key issues observed during the study are :
•
Very wide span of control for DHS / commissioner, to the extent of handling
the national and state health programs directly
•
More importance to the stream of Public Health personnel during certain
period, thus providing more promotional avenues for personnel with DPH
qualification
•
Improper division of functions to Public Health specialization people and the
clinical people has lead to skewed promotional avenues.
Review of Organisation Structure
-Vol I
Confidential
•
Subsequently, after having brought both Public Health (both preventive &
promotive) and Medical (curative / clinical) into the same stream, the
importance for public health has diminished.
•
Tne reliance on clinical personnel on carrying out the public health programs
leading to dilution of both clinical and public health activities
•
Improper coordination among the main Health & FW department and the
Externally Aided Projects (EAPs), leading to duplication of certain activities.
•
Dual reporting at which the administrative reporting has taken more
importance
•
Reporting to peer groups for lack of promotional posts at certain levels in the
hierarchy leading to lack of authority in such posts.
•
Neglected North Karnataka region
•
Redundant DJD position
•
Lack of Health directed leadership from ZP
•
Imperative need for clearly defined job roles at all levels
•
Poor health management and programme management skills among senior
health staff at all levels
•
Multiple training programmes leading to duplicity without clear objectives and
outcomes
All the above issues are looked at primarily from the structure point of view and
are addressed accordingly. The key recommendations are given as below:
•
Bifurcate the Directorate of Health Services of the Department of Health &
Family Welfare into two basic functions of Clinical & Curative health (Medical)
and Preventive & Promotive health (Public Health) and merge all the activities
accordingly to these functions.
•
Have a common entry point at PHC level for all cadres and divide into Medical
and Public Health from Taluka level hospital onwards or from the Primary
Health Centre itself as suggested by Jungalwalla Committee report in mid
seventies
•
Personnel to be sent to specialisation- courses depending on the requirement
of the department
•
Have lateral entry for the specialist cadre if found imminent. However, the
option of hiring external doctors on contractual basis can also be considered.
4
Review of Organisation Structure
-Vol I
Confidential
•
Enhance the capabilities of the planning wing to work on the issues of short
term and long-term avenues / strategies for the organization
•
All the future External aided Projects under the control of
Commissioner/DGHS, with a Director as head of EAP and thus converting the
projects into programmes mode to be executed by the relevant functionaries
in the department itself
•
Emphasis for the NGO participation in the activities of the health Dept. esp.
related to Promotion and Preventive Health. To have a Nodal Officer/
Consultant on Advisor in the NGO Partnership Cell in DHS who will coordinate
all the enquiry's, execution and monitoring of NGO activities through a single
window at the DHS.
•
A separate cell for all procurement, maintenance and construction activities as
part of the Directorate of Health which follows the World Bank Aided KHSDP
norms ’
•
Create an autonomous institute in form of State Institute of health & Family
Welfare (SIHFW) and provide all inputs to manage it independently.
•
To create mechanisms to improve capacity building by induction training,
retraining in clinical skills at periodic intervals, management training for all
Administrative posts, create incentive mechanisms, increase pay scales,
motivational programs at regular intervals, reward outstanding workers and
provide proper infrastructure both at the health institution and official
residence.
5
Review of Organisation Structure
-Vol I
Confidential
3. INTRODUCTION
3.1
A.F.Ferguson & Co. - MCS division (AFF) have been retained by Karnataka Health
Systems Development Project (KHSDP) to review the structure and functions of the
Health & Family Welfare Department and to design of job responsibilities for
offices/posts in the said Department.
Background to the Study
3.2
Karnataka State has had an impressive record of development and has indeed
been a pioneer in public health development. The present basic structure which has
evolved from the system in vogue in the Princely state of Mysore, has been remarkable
for its approach to primary health care.
3.3
The planned focus of the health department has eroded over the years leading to
the following key concerns of the department as mentioned by the Task Force on Health:
•
Neglect of public health
•
Distortion in Primary Health care implementation
Poor Governance
•
Human Resources Development Inadequately addressed
•
Lack of integration of Externally Aided projects with the mainstream
3.4
A need was felt to bring about higher emphasis in public health care and resolve
the key issues outlined for effective implementation of National Health programmes.
Health care and public health thus being one of the thrust areas for development and
improvement, the Government of Karnataka has considered the need for review of the
current state of Health System so as to ensure 'Health for all' with equity and quality.
3.5
In order to propose measures to improve the public health care systems in the
State of Karnataka, the Department of Health Services and Family Welfare (DHS) has set
up a Task Force, consisting of eminent persons in various fields, which will examine the
issues involved and propose measures which could be adopted by the Government.
3.6
In this regard, the Task Force has conducted a preliminary study and presented
an interim report dealing mainly with short-term recommendations, which can be
implemented within a period of 6 months. It has also identified areas of concern, which
can be accomplished in the medium and long term. The Task Force invited AFF for
consultation in review of structure and functions and design of job responsibilities for
offices/posts in the Health & Family Welfare Department.
Terms of Reference
3.7
The Terms of Reference (ToR) for the study is as follows :
•
To collate the available job descriptions and related information from various
offices visited and submit the same to the task force
6
Review of Organisation Structure
-Vol I
Confidential
•
To review the present structure and functions of offices in the Health &
Family Welfare Department
•
To determine improvements/changes and to design job responsibilities for
various posts of Health & Family Welfare Services
Scope of Work
3.8
The scope of work for the study covered :
•
Collation of Information
Collection & submission of existing job descriptions and related
information from the various offices visited. These will subsequently be
collated and submitted to the Task Force.
Review of Structure
•
-
Understanding existing organisation structure and reporting relationshios
of the directorate
I
-
Reviewing the authority-financial and administrative powers for the
various posts and suggesting changes to facilitate transaction processing.
Review of existing cadres and identification of new cadres/levels such as
vigilance cell, selection posts etc and redundant positions
-
Re-organisation of staffing pattern to facilitate equitable distribution of
work in line with seniority, span of control, job responsibilities.
-
Redefining Job Roles wherever applicable
Determining the need for review of procedures
•
Defining Job Responsibilities
Identifying the key qualifications and experience required for various
posts defined in the structure recommended
-
Determining the key result areas of these posts
Defining the job roles and activities to be performed by the personnel
manning the post
-
Determining the training requirements in line with the job roles envisaged
the requisite qualifications for training, whether they should be cadre
options (clinical/public health) etc.
-
Identification of working hours, stay in quarters and volume of work (if
applicable)
v
Approach & Methdoloqy
3.9
21!5?_dLC?,mnlenSed in first_w?ek of October, 2000 and the AFF's team visited
the Directorate of Health Services (DHS) and had discussions
- -------------- > with the Commissioner,
7
Review of Organisation Structure
-Vol I
Confidential
Director, various Additional Directors (ADs), Divisional Joint Director, District Health
Officers, District Surgeons Joint Directors (JDs), covering their responsibilities, reporting
relationships, operational constraints etc. In addition we met various officers of the
Primary Health Centre (PHC), Community Health Centre (CHC), Sub-Centres, Taluk
Hospital, District hospitals for both rural and urban areas. Table 1.1 provides list of
officers/offices visited.
Table 1.1
Area
Bangalore Rural
Gulbarga Rural
Category^
"Xj Shanmangla
Bidadi____________
Magadi_________
Ramanagara /
Taluk Hosp
__ Channapatna
District Hosp
Mysore (ED hospital)
General Hospital,
Jayanagar, Bangalore
PHO__________
Bangalore Rural
Teaching Hospital KRHospital, Mysore
Sub-Centre
PHC
CHC
Kadacharala
Malkhed
Mudhol
Sedam
Gulbarga, Raichur
Gulbarga, Mysore^Raichur
3.10 The study involved detailed discussions with the above members and the Task
Force members covering various aspects of the study. Focused group discussions were
held with the Task Force and DHS and also representatives of KGMO for confirmation of
observations. Our observations and recommendations are provided in two volumes
covering :
Volume I
:
Volume II :
3.11
Review of Organization Structure
Detailed Job Responsibilities
This report (Volume I) covers the following :
AFF -MC
Section 3 :
Introduction
Section 4 :
Review of Organisation Structure and Job roles
Section 5 :
Proposed Organisation Structure
Section 6 :
Review of Cadre rules
Section 7 :
Re-alignment of staffing patterns
Section 8 :
Observations on Need for Procedure Review
Section 9
Recommendations and Conclusion
8
Review of Organisation Structure
-Vol I
Confidential
4. REVIEW OF ORGANISATION STRUCTURE AND JOB ROLES
4.1
This chapter covers briefly the existing and proposed activities of the Department
of Health, Government of Karnataka (GoK) followed by a review of the organisation
structure and job roles of key functions. This chapter will conclude with the
recommended top organisation structure for the DHS, GoK and its salient features.
4.2
The Department of Health is responsible for providing health care services in
Karnataka. The major programmes undertaken and services provided by the department
are:
4.3
•
Primary Health Care
•
RCH programmes (family welfare and related programmes)
•
Various National programmes for prevention and control of Vector Borne
diseases such as Malaria, Filariat etc, Leprosy, Tuberculosis (TB) and Blindness
•
Prevention and control of communicable and diarrheas diseases
•
Clinical services (Curative Services)
•
Immunization programmes - Universal programs of Immunization
•
Nutrition programmes - Nutrition education and demonstration
•
Health education and training programmes
•
School health programmes and educational and environmental sanitation
•
Laboratory services
The above health services are provided through a network of
•
Sub - Centres
8143
•
Primary health centres (PHCs)
1670
•
Primary Health Units
583
•
Community Health Centres (CHCs)
249
•
Taluk, Teaching, Specialised,
General/Maternity and District Hospitals
177
* Source Annua! report of Department of Health & Family Welfare, 1999-2000
9
Review of Organisation Structure
-Vol I
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4.4
The above institutions are determined by the facilities provided in terms of
number of beds.
4.5
With the objective of direct involvement of people in health care, the 'Panchayat
Raj', introduced in Karnataka in 1983, a number of schemes were transferred from the
state level to the district level under the Zilla Parishad(ZP), effective from April 18, 1987.
Thus the responsibility of management of Taluk Hospitals downwards is under the ZP.
4.6
The Department of Health and family welfare is headed by the Principal Secretary
(PS) - Health who reports to the Minister of Health and Family Welfare. The PS - Health
covers the following areas :
Autonomous Institutes
•
Indian Systems of Medicine
•
Directorate of Health and Family Welfare Services(DHFWS)
•
Drug controller
•
Externally Aided Projects
•
Deputy Secretaries (Secretariat)
i
4.7
The present top structure of the Department of Health and Family Welfare is
provided in Exhibit 4.5
4.8
The DHFW activities and the organisation structure review is presented under the
following categorization:
•
Externally Aided Projects (EAP)
•
Indian Systems of Medicine
•
Directorate of Health and Family Welfare Services (DHFWS)
Divisional Level
•
District Level
t
Externally Aided Projects (EAP)
4.9
The Department of Health has created independent, separate cells for the
externally aided projects with each Project Director reporting to the Principal Secretary Health. The ongoing EAPs under the Department of Health (DHFW) are :
IPP IX - This is being implemented in the state of Karnataka since 1994 with the
assistance from Government of India and World Bank. The specific objective of the
project is to implement a programme sustainable at village level to reduce crude
birth rate, infant mortality rate and maternal mortality rate and increase couple
10
Review of Organisation Structure
-Vol I
Confidential
protection rate to reach the national targets. IPP-IX carries out following functions
for achieving the set objectives of the project.
-
To involve the community in promoting and delivery of family welfare
services.
To strengthen the delivery of services by providing
-
Equipment kit and supplies to TBAs, subcentres and PHCs
Make ANMs at subcentre mobile by providing loans for purchase of
two wheelers.
Building of subcentres with provision of residential accommodation for
ANMs
-
Building for Primary Health Centres
-
Residential quarters for Medical Officers.
Improve the quality of servfces by providing training to personnel, official
and non-official at various levels including TBAs, Community leaders and
voluntary agencies.
Strengthen monitoring and evaluation by developing and installing MIES
from District to State level.
"
-
The IPP-IX has implemented Civil components in 17 districts of the state
and IEC and Training components in all the districts.
The organization structure of IPP IX is showed in exhibit 4.1
IPP VIII - This was launched during 1994-95 to cover the Bangalore
Metropolitan Area with financial aid from the World Bank under Family
Welfare (Urban Slums) Project. The main objectives of this project are:
-
Deliver family welfare, maternal and child healthcare services to the urban
poor and to promote safe motherhood and child survival
Reduce fertility rate among eligible couples, promote consciousness
against early marriage of the daughters
Promote male participation in family planning with a view to reduce the
burden on women
Create awareness of personal hygiene and to maintain a better
environment for prevention of diseases
Non-formal education and vocational training for women to help them in
self-employment
Promote female education
11
Organization Structure - IPP - IX
Exhibit 4.1
I
Project Director
r
Deputy Director
IEC
I
__ rzzz
Joint Director
Projects
I
Superindent Engr
PWD
I
I
Chief Accounts Officer
I
Additional Director
SIHFW
I______
Under Secretary
I______
Procurement Officer
Deputy Director
MIES
Joint Director
Deputy Director
PHM
Deputy Director
OBG
Deputy Director
PHN
Deputy Director
Communication
Deputy Director
Poulation
studies
Deputy Director
Communication
Organization Structure - IPP VIII
Exhibit 4.2
Commissioner
BMP
Project
Coordinator
I
I
I
Demographer
Director
IEC
Director
Training
Programme Offer
Accounts
I
Programme Offer
Civil Works
I
~
I
Programme Offer
Health
I
Women Devpt.
Officer
Review of Organisation Structure
-Vol I
Confidential
This project completes its life period by June, 2001 and all of its present activities
were planned to be shifted to the Bangalore Mahanagar Palike which manages
the hygienic conditions in the slums in the capital.
The organization structure of IPP VIII is showed in exhibit 4.2
•
AIDS Society of Karnataka - This is a 100% centre sponsored scheme .
under the guidelines of national AIDS Control Organization, Ministry of Health
and Family Welfare, Government of India, as the national AIDS Control
Programme in Karnataka. The Present Phase - II of the AIDS Control Project
is officially launched during December - 1999, for a period of five yeas (from
1999 to 2004). The objectives of Phase - II of AIDS Control Project are:
Reduce the spread of HIV infection in Karnataka State
-
Strengthen Karnataka State's capacity to respond to HIV/AIDS on long
term basis.
This project has many officers deputed from the Department of Health &
Family Welfare and a hand-in-hand working is required among all the relevant
functionaries for effectively combating the AIDS. The organization structure
of Karnataka AIDS society is showed in exhibit 4.3
•
Karnataka Health Systems Development Project (KHSDP): The
Karnataka Health Systems Development Project (KHSDP) is a World Bank
aided project setup in 1996 with a project base of Rs. 546 Crores spread over
a period of 6 years to improve the secondary level of health care in
Karnataka. KHSDP has been setup with the following objectives:
-
Improvement in the performance and quality of health care services at
the district and sub-district and sub-district level of the health care system
Narrowing the current coverage gaps by facilitating access to health care
delivery, and
-
Achievement of better efficiency in the allocation and use of health
resources
The project components and sub-components are :
•
Management Development and Institutional Strengthening:
Improving the institutional framework for policy Development
•
-
Strengthening management and implementation capacity; and
-
Developing surveillance capacity for major communicable diseases.
Improving Service Qualit?/, Access and Effectiveness
Extending/ renovating Community, Taluka and District hospitals
Upgrading their clinical effectiveness
Karnataka AIDS Prevention Society
Exhibit 4.3
Project Director
AIDS
I
Joint Director
Surveillance &
Trng (Medical)
Statastical
Officer
___ I
Procurement
Officer
I
Deputy Director
Blood Safety
I
Additional
Project Director
Medical
I
I
I
I
Finance
Controller
Finance Officer
Deputy Director
STD
-
Joint Director
_____ I"
Deputy Director
Blood Safety
I______
Deputy Director
STD
'
I
NGO
Advisory Cell
Organization Structure - KHSDP
Exhibit 4.4
Project Administrator
________I
-dd'ticnal Director
'
Medical
1
I
I
Additional Director
CMD
Additional Director
SPC
Cheif Engineer
Cr.il
I
CAO
~
I
]
Joint Director
Equipment
Cheif Finance
Officer
ZZZETZ
Tl
Consult mt<
KFW
Financial
I
Review of Organisation Structure
-Vol I
Confidential
Improving referral mechanism and linkage with primary and tertiary level;
and
Improving access and equity to disadvantaged sections
The following functions are being carried out for achieving the objectives of
the project:
-
Civil Works: The project is working for renovation and expansion of 74
Community Hospitals, 104 Sub- Divisional Hospitals and 21 District
Hospitals
-
Procurement: The project undertaking procurement of Medical and other
equipment, Vehicles and Medicines.
-
Training: Project is also working towards the training of doctors in
different specialties, Pharmacists, Technicians and Nurses.
The organization structure of KHSDP is showed in exhibit 4.4
i
The Reproductive & Child Health Programme (RCH) funded by World Bank is being
carried out by the Department itself and so also the Blindness Control programmes
funded by Danida.
Indian Systems of Medicine and Homeopathy (ISMH)
4.10 ISMH is rendering medical relief to the public in Ayurveda, Unani, Naturopathy,
Siddha and Homeopathy systems of Medicine and regulates Medical Education, Drugs
manufacture and practice of medicine in these systems.
4.11 The Director of ISMH is independent of Directorate of Health Services. The
current study being focused on the working and reorganization of Directorate of Health
Services, the details of the ISMH are not covered in this report.
Directorate of Health and Family Welfare Services (DHFWS)
4.12
The key activities performed at the Directorate summarized below are :
•
Planning :
Scrutiny of planned proposals at pre-budget stage before submission to
Secretariate
•
Budgeting :
Scrutiny of budget proposals
schemes/institutions under DHS
•
and
release
of
budget
to
all
Accounting and Finance:
13
Review of Organisation Structure
Consolidation
institutions
-Vol I
Confidential
of statement of Expenditure
received
from various
Reconciliation with Accountant General's records
Countersignature of DC and NDC bills drawn by Government Medical
Stores (GMS) and Public health institutions
•
Payroll and Personnel
•
Programme Monitoring and Implementation'.
Monitoring of National and state level health programs
-
Assessing community needs regularly and ensuring their addressal
through different hospitals.
Curative preventive and promotive
health programmes through its
network of PHC's, CHC's, Taluk, subdivision & District hospitals
-
Purchases and Stocks:
-
Procurement of all drugs and equipment (except that for TB, Malaria and
Leprosy) by GMS
Requisition and obtain
Government of India
drugs for TB,
Malaria and
Leprosy from
Participating in finalisation of rate contracts
-
Supply and distribution of drugs, instruments and surgical equipment to
institutions under its control and contraceptives and Family Welfare drugs
throughout the state.
4.13 The DHFW is headed by the Commissioner who reports to the Principal Secretary
(Health). The present top organization structure of DHFW is given in Exhibit 4.5
4.14 The post of Commissioner, Department of Health & Family Welfare Services (held
by an IAS officer) was created during 1997-98 for effective delivery of health services
both preventive_and curative to the people of the state. All the functions related to DHS
apart from the ones managed by different projects are routed through Commissioner.
Divisional Level
4.15 The health care service delivery network for the state of Karnataka is grouped
under four divisions namely,
•
Bangalore
•
Mysore
•
Belgaum
•
Gulbarga
14
Review of Oiganisation Structure
-Vol I
Confidential
4.16 The Divisional Joint Director (DJD) is the officer in-charge for Health and Family
Welfare Services for each of the above divisions. The key activities of the DJD are :
4.17
•
Technical guidance to district level authorities in implementation of Health
and Family Welfare programmes
•
Monitor the performance of hospitals of more than 100 beds, which are not
being managed by any District Surgeon or not a teaching hospital
•
Inspection of various schemes in Health and Family Welfare sectors being
implemented by the district authorities
.
Countersignature of DC Bills and NDC bills of district hospitals and other
specialised hospitals
The organisation structure at the divisional level is given in Exhibit 4.6
District Level
4.18 The District Health and Family Welfare Officer (DHO) is the head of the
department at the district level and functions at the Zilla Parishad as posted by the State
Government. He is responsible for the implementation of the health programs of the
district both to the Zilla Parishad and the Directorate.
4.19
The key activities at the District level are :
•
Implementation of national programmes at the primary and secondary level
of healthcare delivery system
•
Health education to the public on the various health programmes conducted
by the DHFW
•
Planning and implementation of various health programmes (preventive and
promotive) through community needs assessment approach and also based
on guidelines issued by Government of India and State Department of Health
& Family Welfare
•
Provision of curative services at the various health centres and hospitals
under the DHFW
The present-organisation structure at the district level is provided in Exhibit
4.7
~
---------------------- —
The present staff structure from the village level onwards is shown below :
Village
:
VHF - Anganwadi - Dai
Sub Centre : JHA ( F ) / ( M ) , Dai / Ayah
PHC
: MO / LMO, Staff Nurse, Pharmacist, Lab.Tech, SHA ( F / M ), FDC, D Group
CHC
: Physician, Surgeon, OBG, Paed, Anaesthetist,Dentist ( Specialists ), GDMO,
Staff Nurses, Pharmacist
15
Grg anizalion structure at Divisional lev el (Gulbar■ga) - current
Exhibit 4.6
i\ Hal uniform in n!l divisions
77//v
Di.isional
Joint Director
__ IIZZZ
Deputy
Director
u'iMEP)
J
r
Medical
lecturer cum
demonstrator
Health.
Education
f
Instructor
I
Public Health
Nursing
Instructor
___ J___
Social
Welfare
Instructor
Deputy
J
Director-CMD
Inv & Trg
Deputy
Director
»liMEPP-nej
i.leoicai Cffcr
Optna &
Pental
____ 1____
Entcmasgist
I
Statastical
Officer
Heaitn
Super-, isor
I)
Deputy
DitcCtcr
1. __ _
Gazzenea
-ss.sstant
1
Deputy
Surgezr, ac Prdn ur.it
StatasLoai
Officer
i
I
Medical
Lecturer
Senior
Training
Officer
Senior
Trng offer
(nursing)
I
Superindent
District
surgeon
I
Deputy
Surgeon
__1__
Medical
Officer
I
. J.__
Health Offer
cum
- sst Surgeon
Uursmg
Superindent
I
ZZi__
Lay
Secretary
LFf:r-; FD
Divisional DHFW - Current
Exhibit 4.7
Divisional
Jt.Director (4)
I
Dy Director
HQ (4)
I
Dy Director
(NMEP) (4)
I
District Surgeons
(26)
I
Superilendents ol
100 bedded
Hospitals (5)
Superintendents cf
TB Hospitals (6)
I
Health Officer
(SSP UNIT) (4)
Surgeons of
women & Childrer
Hospital (3)
I
Surgeons of
PPG (3)
Superintendents c
major Hospitals (3
Primary Health Centre
Organisation Structure - Current
Exhibit 4.7
Structure varies from PHC to PHC - District wise
I
[
DJD
CEO - ZP
[
JD Prog.officers
(HQ)
]
I District Health Officer]^-^
I
| Taluk Health Officer |
|
FDA & Other Staff
Driver
BHE
Refractionist
1
PHC- MOH
Lab Technician
'
|
I
Sr. HA (M)
— 1
Sr.HA(F)
J-
| Jr.HAM/F |
Pharmacist
PHU
[
~T
MOH
~T
I Pharmacist |
SDA
I
Jr.HA(F)&
Other staff
Taluk Health Office
Org. Structure - Current
Exhibit 4.7
DJD
CEO - ZP
| District Health Officer~|
JD Prog.officers
(HQ)
Taluk Health Officer/
AMO
I
FDA
Sr. H. A. (M)/(F)
I
SDA/Drivers
I
PHC-MOH
FDA 4 Other Staff
Driver
BHE
Refraction ist
Lab Technician
” Sr. HA (M)
Sr.HA (F)
PHU
Pharmacist
T~
ZE
Jr.FA (FD)
MOH
r~
Dy. CMC
I
Specialists
4 Other Staff
I
[ Pharmacist |
SDA
ZZEZ
Jr.HA (F) 4
Other staff
I
District Health & Family Welfare Office
Administration Control Chart - Current
Exhibit 4.7
i
CEO-ZP
District
HFW Offer
______ I
Prog.Offers
DHO office
Field supervision
r
"LI
RCH
Family welf.
Offer (1)
Offer
I
Mental Health
Offer
I
District
Program level
officers
I
District
Nursing
I
-
I
Administration
&
Finance
I
DHEO
(Mass Edn)
Offer
ASO
DyHEO
ASO
I
Technical
Service Engr
District Health & Family Welfare Office
Administration Control Chart - Current
Exhibit 4.7
CEO - ZP
I
Prog.Offers
DHO office
Field supervision
District
HFW Offer
I
I
Admnistration
&
Finance
I
District
Program level
officers
Technical
Service Engr
G.A
.... r~
Administration
Superindent
E
~T~
FDA
SDA
|.
Accts
I
Accounts
superindent
I
Mechanic
Electrician
I
Cold Chain
Engineer
~
I
Typist
]
Group D
i
Drivers
Asst.Engr
Department of Health & Family Welfare - Govt of Karnataka
Organization Structure - Current
Exhibit 4.7
Commissioner
~ I
DHS
I
CAO-Admin 1
~
I
I
AD-PD
(RCH)
AD-HET
JD - RCH
pD HET |
I CAO-Admin 2
CAO-Fin
CAO-Vig
--- 1
AD-PHC
_ L_
~~ I
DJD(4)
JD-TB
I
JD-LEP
I
JD-H&P
__ 1
JD-MED
JD-GMS
JOOPTH
~r~
ZIP"
JD-Vac
JD-LABS
JD-CMD
Department of Health & Family Welfare - Govt of Karnataka
Organization Structure - Current
Exhibit 4.7
MHFW
_JZ
L
SME
PS
I
I
Secr-ME
Commissioner
X
___ I
DME
I Govt/Pvt Med Coll I
Dy Seer
I
Autonomous
Institutes
H.
H
4
—I
Director
ISM
Drug Controller
DHS
I
I
IPPIX PD
IPPVIII PD
1
I
I
AD(D»rector-SHFW)
AD-PHC
I
CAO-Admin
CAO-Fin
CAO-Vig
][
]
]
|
AD-PD(RCH)
I
DJD(4)
|
AD-HET
I
JD-TB
I
] | JD-LEP
]
I
I
I
JD-H&P
JD-MED I
JD-GMS
I
l
JD-OPTH | f JD-Val
I
1 _
I
AIDS PD
KHSDP PD
CAO
I
JD-LABS | F JD-CMD I
4
CFO
1
AD-SPC
AD-MED
■{
AD CMD
AD-KFW
□
□
Review of Organisation Structure
Vol I
Confidential
The basic primary healthcare concept consists of one CHC with 3-4 PHC's. The staff of
CMC will have the dual role of executing both clinical as well as public health care to the
community through the Taluk Health Officer.
Observations in Current Organisation Structure
4.20 The notable observations arrived at after detailed discussions with key personnel
of Department of health and members of Task Force and analysis of the organisation
structure are given below :
Span of Control
4.21 The DHFW is a complex Health service set-up with key activities of
administration, public health care and clinical health care having high differentiation and
specialization
,
4.22 . Such set-ups require limited span of control especially at the top for optimum
supervision and functioning. However, the Director of Health and Family Welfare has 18
functional personnel including 3 Additional Directors and 10 Joint Directors directly
reporting to him, thereby having a wide span of control.
Curative Vs Preventive
4.23 The role of public health programmes is designed to be primarily focussed on the
preventive and promotive aspects wherein a need has been determined for improving
the basic health of the society and prevention of illness. However, it has been observed
that there is more emphasis on the curative aspects of health vis-a-vis preventive /
promotive health by the Department of Health (GoK). As observed most of District
Health Officers are clinicians without any training in public health. There is severe
mismatch of specialists to their place of posting. Senior specialists are still serving at
PHC's.
4.24 Further the public health staff at the Taluk hospitals and District hospitals do not
have separate infrastructure for conducting their activities. There is a lot of reliance on
the medical wing personnel for implementation of public health programs. This results to
overload of activities/responsibilities on the medical wing personnel further leading to
dilution of role either on Public health or on clinical due to lack of time. There is also
lack of managerial and administrative capabilities of Senior Personnel of the Dept from
Taluk level onwards
In-equality in Promotion Opportunities between Public Health & Clinical
4.25. Around 1976, during the emergence of public health in the DHFW, the promotion
opportunities for the Public Health qualified personnel rose tremendously with the result
of clinical personnel higher on the seniority list positioned way below in the organisation
structure. This was mainly due to the mandatory requirement of Public Health
AFF-MC
~~~
io
Review of Organisation Structure
-Vol I
Confidential
qualification from the post of DHO onwards, i.e. role of DPH qualification as criterion for
promotion to DHO/JD/AD/DHS created imbalance. This being rectified in 1992, the
growth opportunities became equal for both Public Health and clinical personnel.
4.26 Thus, in the district level the career opportunities are equal for both Public Health
personnel as well as Clinical Personnel. However, going by the need of specialisation at
the senior levels, the promotional path for a District Surgeon (DS) is limited to 3-4 posts
at the JD level as against around 12 JDs posts for the DHO.
Multiple authority for certain functions
4.27 It has been observed that the same function is assigned to more than one JD/AD
leading to non-optimum utilization of resources and duplication of efforts. Especially
while planning Externally Aided Projects (EAP), number of imbalances occurs in staff
positioning, training, etc as the activity is in project mode and constraints in terms of
availability of time exist. Certain examples are given below :
•
AD (HET) handles health training for the public while training for public as
well as personnel of DHFW is also conducted by the RCH cell, IPP, KHSDP and
SIHFW.
•
Research/Studies are organized by PRC, KHSDP, IPP VIII, and IPP IX
Improper Positioning of Functions
4.28 It has been observed that there is no streamlining of functions in terms of
reporting hierarchy and departmental responsibility in the organisation structure of the
DHFW. Thus while the planning, funding and review is done by certain section of
personnel, another conducts the actual implementation with no reporting relationship
defined between both sections. This will result in in-effective implementation of the
various programs. Certain examples of the same are given below :
•
KHSDP as an EAP, created a position of AD (CMD) who is to cover all public
health activities for the state relating to communicable diseases. This AD post
reports to the Project Director (KHSDP) and is expected to work with the staff
of the Department of Health. In the DHFW structure, there is a JD (CMD) who
reports to the DHS and has no reporting defined to the AD (CMD), till
recently. Only recently a government order has been issued asking three Joint
Directors (CMD, Lab and M& F) to report to AD - CMD. Moreover there seems
to a lack of co-ordination between the AD(CMD) and DHS office.
•
Similar to the above, there is a AD (Medical) reporting to the Project Director
(KHSDP) while the JD Medical reports to the DHS office. Nearly all new posts
created in the EAP (project mode of functioning) work in isolation from main
DHS, thereby creating duplication and confusion in the roles and
responsibilities.
Af-F -MC
17
•^4', mv ?r Organisation Structure
-Vol I
Confidential
Dual Reporting
4.29 Discussions with a cross-section of personnel of DHFW revealed that there is an
overlapping of authority and lack of clarity in responsibility. E.g. the DHO being under
the District cadre, reports administratively to the CEO, Zilla Parishad, while functionally
he reports to the DJD. Many were of the view that in this context of multiple line of
command, the one through which the inputs for Confidential Report are taken is the
most responsive one. Thus, the DJD, a department functionary, couldn't contribute to
the development of the respective district.
Peer Reporting
4.30 As per cadre policies, in certain cases, the post of administrative head is held by
the senior most person in that office. E.g. the senior most Sr. Specialist holds the post of
the District Surgeon (DS). As these posts are not promotion posts, the personnel holding
these offices find it difficult to effectively discharge their duties due to non-reporting by
other peer personnel.
Disparity of Health care development in Northern Karnataka vis-a-vis other
regions
4.31 Field
r......................
' "
visits to thejGulbarga
district health centres revealed a very low health care
reach and infrastructure for services. It was found that the situation was very grim when
compared with national health standards
4.32 The regional disparity between Northern Karnataka and
other regions are
outlined below:
•
High number of vacancies due to non reporting of personnel deployed/posted
•
Abysmally low health care awareness amongst the public
•
Distance from directorate leading to ineffective governance
•
Low .Morale amongst staff
Poor health infrastructure including poor maintenance of existing infrastructure
(building. Equipment etc.)
Externally Aided Projects
4.33 The externally aided projects function distinctly from the DHS office despite
having the same objectives and operating mechanisms. E.g. the KHSDP was initiated to
design and implement various health programmes in co-ordination with the DHS office
to improve secondary level health care. However, the KHSDP is considered to be a
separate entity with minimal/no co-ordination with the DHS office, thereby resulting in
similar activities being conducted parallely by the DHFW and under utilization of various
funds at the disposal of KHSDP.
18
Review of Organisation Structure
-Vol I
Confidential
4.34 According to the planning of different Externally Aided Projects, majority of EAPs
come to a end of their stipulated period of working while creating a number of new
additional posts as dictated by the project modalities. This gives a challenge of
repositioning of the personnel at appropriate levels/positions in the hierarchy at the end
of the project.
Role of Divisional Joint Director
4.35 The DJD is the overall in-charge of the divisions under him and have the
functions of technical guidance and inspection of implementation of various national
programme schemes. However, it has been observed that the DJD functions mainly as a
co-ordinator between the district and the headquarters and performs the functions of
collating information from the various offices under him and submitting the same to the
DHS. The DJD does not exercise any administrative or functional powers leading to the
redundancy of the post in the overall functioning of the DHFW
Sanctity of certain posts
4.36 The original organisation structure* has been modified by creation of new posts
based on requirements for a specific activity. However, due to lack of clearly defined
roles and reporting relationships, lack of proper authorities and non-cooperation from
other members in the system, these personnel holding these posts cannot function
effectively, leading to their redundancy e.g. Director - Training. In addition, posts such
as Officer on Special Duty (OSD) are created from time to time for specific
projects/activities.
Lack of integration of functions
4.37 Currently, the various duties of the staff in the lower level of hierarchy, are
defined at a program level. E.g. Lab Technician-Malaria, Lab Technician- TB etc. This
lack of integration of functions often leads to under-utilisation of personnel as given
below :
•
Overload on a certain function while under utilisation of the other personnel
•
Lab technicians not interested in doing duties assigned to them, due to higher
learning opportunities in other functions. E.g. Lab Technician of TB prefer to
do malaria related activities
Similarly the ANM's are overloaded and the male health worker underutilized.
Role of ZP in Public Health Care
4.38 ZP being the administrative authority at the district level has a vital role to play in
delivery of health care in the district. Various personnel in the DHFWS were of the view
that there exists a misuse of financial and administrative powers by the ZP. This has led
to a de-motivation in the department. The various forms of abuse of power indicated by
the personnel are :
19
Review of Organisation Structure
-Vol l
Confidential
•
Use of Public Health Care facilities for other purposes or for personal work
•
Use of Force/pressure tactics to achieve their needs. E.g.:
-
In the event vehicles reserved for public health are not provided to ZP for
other use, the personnel are threatened with cuts on vehicle allowance.
-
Delay in payment of salaries
•
The ZP has powers to post personnel of the 'C' and 'D' category staff at the
district level. However, quite often, such personnel have been posted by the
ZP against non-sanctioned posts into the health department.
•
Procedural delays such as pending
pending electricity
electricity bills,
bills, delay
delay in
in maintenance
maintenance of
of
equipment and buildings etc.
4.39 Further to the above, the personnel of the DHFWS feel that health programmes
are not a priority Tor the ZP as the ZP personnel do not appreciate the criticality of
successful implementation of proposed national/state health programmes. The ZP
regularly insists on the DHO and other stafr of the DHFWS to be present for all meetings
being conducted by them, irrespective of the connection of these meetings to health.
These meetings are often of the nature of absenteeism, administration etc., This results
in lack of time for personnel of DHFWS to conduct their basic duties of health care
thereby providing scope for productivity reduction.
4.40 There is a lack of morale amongst the personnel of DHFWS at the district level
due to the authoritative attitude of ZP and the misuse of power. It has been brought to
our notice that very often the interference of ZP in the day-day functioning of the DHO
and their support to the lower cadres of personnel, result in ineffective use of such staff
by the DHO for implementation of health related programs.
Need for Re-defining of Job Roles
4.41 Discussions with various personnel in the DHFWS have brought out a need for
clear definition of Job roles at each level. Certain lacunae identified in the current system
.are z
—
•
The role demarcation of Strategic Planning Cell (SRC) vis-a-vis JD (H&P) in
DHS needs to be clearly reviewed in depth and outlined
•
The present SPC at KHSDP has not been able to deliver the objectives for
which it was set up through KHSDP
•
Lack of program orientation in officers
•
Specialists of District Hospitals attached with medical icolleges are given
minimal / no responsibility or authority such as :
No additional units/beds provided for their clinical work
Only MLC cases and casualty are given to specialists
20
Review of Organisation Structure
•
-Vol I
Confidential
Despite senior DHFW doctors in premises, casualty is referred to the
Orthopedic units , PG and Junior residents
Senior personnel are not involved in strategy and planning. E.g. :
DHO/DS not involved in technical micro planning of District Health
programs or hospitals, current role being administration driven
Role of senior personnel currently reduced to transfer of correspondence
or provision of data
-
No analysis of information conducted even at certain JD levels on data
collated
Specific demerits of the structure
4.42
Key demerits observed in the existing structure are summarized below:
•
Very wide span of control for DHS / commissioner, to the extent of handling
the national and state health prpgrams directly
•
More importance to the stream of Public Health personnel during certain
period, thus providing more promotional avenues for personnel with DPH
qualification
•
Improper division of functions to Public Health specialisation people and the
clinical people has lead to skewed promotional avenues.
•
Subsequently, after having brought both Public Health (both preventive &
promotive) and Medical (curative / clinical) into the same stream, the
importance for public health has taken a back seat.
•
The reliance on clinical personnel on carrying out the public health programs
leading to dilution of both clinical and public health activities
•
Improper coordination among the main department and the EAPs, leading to
duplication of certain activities.
•
Dual reporting at which the administrative reporting has taken more
importance
•
Reporting to peer groups for lack of promotional posts at certain levels in the
hierarchy leading to lack of authority in such posts.
•
Neglected North Karnataka region
•
Redundant DJD position
•
Lack of Health directed leadership from ZP
•
Imperative need for clearly defined job roles at all levels
r -.V/S
21
Review of Organisation Structure
-Vol I
Confidential
5. Recommendations on Organisation Structure
Principles Behind Proposed Organisation Structure
5.1
The proposed organisation structure has been designed in line with the following
principles :
•
Equal emphasis for both Public Health as well as Clinical from the District level
onwards
•
Optimum utilization of all resources across the DHFW
•
High priority on Rural health development
•
Health MIS and Planning is significant for the functioning of the department
•
Role clarity and well defined Job Responsibilities/Key Result Areas
•
A Bureaucratic structure
i
•
A Professional Domination
•
Accountability to public
•
Equity of treatment
VISION STATEMENT
| QUALITY HEALTH CARE DELIVERY SYSTEM WITH EQUITY
The Department of Health and Family Welfare is committed to act as a catalvst for
progress that will result in healthier people in a healthful environment.
The department will incorporate strategic management to implement a core set of values
that are integral to public health. We will translate science and technology into action to
safeguard the public's health. We will apply innovative, sound, and reasonable solutions
to traditional public health challenges and emerging issues. At the same time we will
retain that, which is good with public health in the state. We will expand knowledge
through epidemiology and applied research on health and environmental issues.
The department recognizes its tie with other health and human service agencies to
respond to global, national, state, and local public health concerns. We
will forge
We will
forge
alliances with public and private sectors to ensure that timely, cost-effective, public
health interventions are planned and implemented. We will strengthen our commitment
to collaborate with other departments.
.wc
22
Review of Organisation Structure
-Vol I
Confidential
Our employees are out most valuable resources. We will provide an environment in
which our employees strive for excellence, display initiative, and demonstrate
achievement. Our employees will continue to promote health; work to prevent diseases,
disability, and premature death; and help to assure access to health care for all
populations.
This vision of the future is one in which the Department of Health & Family Welfare,
communities, local health agencies, Special Institutions, and the private sector across the
state cooperate to develop plans, programs, and resources. It guides our work to
increase the span of healthy life, to reduce health disparities among different
populations, and to assure access to preventive services for all.
MISSION STATEMENT
The Department of Health & Family Welfare is dedicated to promoting health and
wellness among people in Karnataka through planning, prevention, service, and
education. DH&FW serves to help people attain the highest level of health possible. The
DH&FW is a proactive leader and collaborator in assessment, policy development, and
assurance, based on science, innovation, and efficiency.
DH&FW affirms that health includes physical, mental, and social well-being, and is
dependent on economic and environmental factors, access to health care, and individual
responsibility and choice.
Although the DH&FW primarily serves people within
Karnataka's geographic boundaries, we recognize our interdependence with the larger
world.
To achieve our mission, the DH&FW supports :
•
Training and technical assistance
•
Disease prevention and health education programs
•
Epidemiology for surveillance and analysis of health data for intervention and
program evaluation
•
Development of policies and regulations to optimize health
•
Planning and evaluation
•
Staff recruitment and development to accomplish our mission, and
•
Collaboration with the public, local health departments, other governmental
agencies, the scientific community, and special populations.
The DH&FW is dedicated to quality service, innovation, respect for every individual,
affirmative action, personal integrity, trust, and high ethical standards.
23
of Organisation Structure
-Vol I
Confidential
Quality care for all
Equity in health
* the St0"e “ Pr°9rKS
the state
a"
Treatment of the whole person
the whole person-his mental and emotional welfare as well as his deep - seated spiritual
I ILLUOt
i
Emphasis in the Best
5.5
The maximum advantages of modern medicine are possible only through
comprehensive healthcare encompassing the best medical staffs, working in close
harmony with its hospitals; the most highly trained personnel, the most advanced life
saving equipment, the most up-to -date facilities and the widest possible range of
services.
a
Consideration for Employees
5‘6
P1.6 Ioya|ty and enthusiasm of its employees are among its most valuable assets
and realising this, the Government seeks to provide fair compensation, excellent benefits
and working conditions and a chance to advance in accordance with skills and ability.
Stress on Training and Continuing Medical Education
5.7
Training and Continuing Medical Educational programmes must be perpetuated
and expanded to train health personnel for today and for the future, servinq tho beet
interests both of hospitals and the community
’
Interest in research
5.8
Research is essential for life and health in support of this belief, the Society
maintains and furthers major research projects and constantly explores additional areas
of interest in which to establish activities for the eventual betterment of others.
Concern with Costs
5.9
The patient comes above all and must receive the finest care at the lowest cost
consistent with quality and equity.
I
AFF -MC
24
Exhibit 5.1
Clinical/Medical
Public Health
Family Physician
Gyna
1 aieral entry (one
\ear probationary
[K*noJ) Field
c\pci iciicc at PI 1C
Ortho
Opthal
mo
AMO
>------------------------------------
Need based on numbers
GDMC
FP <
MBBS
Insenice
In sen ice
PG
PG
PHC(MO) <
▲
MBBS
◄Taluk
MDBS + PG
Lateral entry
need based
District level - Department of Health & Family welfare
Organization structure - Proposed : Exhibit 5.2
______ Medical______
Public Health
District Maint.Unit
DMO (DS)
DHO
District Laboratory
State cadre
PG in Clinical Discipline District Medical Store
PG in Public Health
PG qual. compulsory
I
District HMIS
<
........................... . ......... i
! Dy DMO/RMO
A
Merit cum seniority
I
i
i
i
i
i
i
i
i
....... 7................................
Prog.Offer
J
AMO (CHC/THC/
Specialists
O
i
i
Tajuk
________ I_______
CHC
P
THO
ex
o
N
*0
GDMO
Q-
MOH - PHC
MDBS mip.qualificati|on
PGs can also enter y
>
Review of Organisation Structure
-Vol I
Confidential
CHC/Taluk Hospital
5.24 As discussed in the earlier paragraphs, the distinction between Public Health and
Medical is initiated at the Taluk level. Each of the two streams will have their own
infrastructure and will draw upon the other's resources in terms of consultation and
expertise. Thus, the medical specialists will primarily be responsible for providing clinical
care to the patients of the hospital and the public health specialists will be involved in
implementation of the various health programs initiated by the DHFW. The common
seniority list of PHC entry level will have to be reworked with 2 independent seniority
lists of Medical Public health.
5.25 In the medical wing, the specialists will look after curative work. A THC/CHC will
be headed by the Administrative Medical Officer-CHC (AMO). The post of the AMO will
be a promotional post from the Specialists post. Among the seniors of the AMO's of the
Taluk, there will be a Taluk Medical Officer (promotional post) who will monitor and
evaluate all the CHC's and Taluk Hospital.
5.26 The Taluk Public Health Officer (TFJHO) will head the public health wing of Taluk
and will have Public Health officers and program officers, assisting him to carry out
various national and state national programmes. These are monitored by district
programme officers who in turn report to Zilla Parishad (administratively) and DPHOs &
concerned JDs (functionally). TPHO must have a public health PG qualification ( atleast
DPH ) . He will be assisted by Taluk Health assistants ( promoted Jr/Sr HA's from the
PHC level ), Block Health Educators, Assistant Statistical Officers for HMIS, Refractionist
and clerical staff.
District Hospitai/DPHO office
5.27 The District hospital will conduct the functions of clinical service. The district
hospital is headed by the District Hospital Medical Superintendent and is supported by
the RMO, specialists and other , staff. The district office will also have a post of the
District Medical Officer (DMO) who will look after all medical hospitals ( CHC's and
TLH,DH ) in the district other than the district hospital. The DMO is a promotional post
and he will be the senior-most specialist with managerial/ administrative qualifications
and experiences. This cadre is above the District Surgeon & necessary C & R rules will
have to be framed. Similarly the DHO post will also be upgraded. The senior most
programme Officer becomes the DHO.PG qualifications in public health is must for this
post. He must have additional managerial/ Admininistrative Qualifications & experience,
necessary C & R rules to be framed.
5.28
A detailed work motion study may be carried out for the DHO and indepth
analysis to be carried out about his time utilisation. Based on this report a necessary GO
in Consultation with the ZP authorities to be framed permitting the DHO to attend only
the most important meetings. Programme Officers at District level to be given more
autonomy (financial and administrative) with technical directions from the DHO. These
officers should be accountable financially also for their respective programmes to the ZP.
Presently only DHO operates all the financial matters. Suggest a joint account of
Programme Officer with another ZP official to use the programme funds effectively.
Details need to be worked out on the monitoring of these issues.
29
d
Review of Organisation Structure
-Vol I
Confidential
5.29 The DHO which is upgraded as a promotional selection post will be assisted by a
ADHO who will be the senior most programme Officer. ADHO will represent the DHO at
the ZP meetings and also his major responsibilities will include health planning ( micro
planning at District level ) with implementation / monitoring of HMIS. The Gulbarga and
Belgaum Districts will have 2 DHO's each in view of the large size of the District and
number of PHC's.
5.30 The following Programme Officers will report to the ADHO for smooth functioning
at the District level : a) DLO with STD/HIV b) Health Promotion with 2 Officers ( one for
nutrition - new post and other for health education - DHEO ) c) RCH d) Vector Borne e)
TB Officer . Programme Officers for urban health and STD/HIV can be added later as
and when these programmes are launched.
5.31 The District Surveillance Officer with his staff of the District Lab etc the District
Pharmacist - warehouse incharge , District Maintainance Unit for vehicles, equipment
and civil will report directly to the DHO for efficient and smooth functioning and
monitoring.
Both the DHO and DMO will be responsible for an efficient surveillance system of
communicable diseases and referral systems respectively in their areas of operations
The DHO and DMO will be trained in applying epidemiological skills for microlevel
planning to the dynamic and changing health scenario both at the public health &
hospital lelvel.
5.32 Though the District Public Health Officer and District Medical Officer / District
Surgeon are made to belong to state cadre, it is observed that they cannot escape the
influence of Zilla Parishad for having to work in the same territory and for obvious
reasons to work closely for common mandate. But, in the present reporting standard
the DHO represents the DHFW in all the meetings of Zilla Parishad, including the ones
not about health programs. It is proposed that the DHO may not attend such programs
and the authority levels of district programme levels have to be enhanced to be
accountable to Zilla Parishad directly.
5.33 The DMO will be a promotional selection post. His office will be located within the
District Hospital. The Medical Suptd. ( earlier DS) of the District hospital
all the
Administrative Medical Officers of the CHC / Taluk and other hospitals in the district will
report to the DMO.The DMO will monitor the quality of care in all the hospitals in the
district. The Program Officers for Ophthalmology and NCD will also report to the DMO.
Presently there will be a separate program officer for Ophthalmology and a combined
Program Officer for CVS / Diabetes/ Mental Health / Oncology of the rank of senior
specialist till these programs are launched as independent programs with funds
allocation. The physician at the District hospital will monitor the TB Centre in the District
hospital in coordination with the DTO. Training in public health and program
management will be given to all Program Officers. The DMO will also have a
maintainance unit of civil, equipment and vehicles under him.
5.34
The proposed re-organisation of the district level structure is depicted in Exhibit 5
30
Review of Organisation Structure
-Vol I
Confidential
Divisional Structure
5.35 As discussed in the previous chapter, the DJD post has become redundant in light
of transfer of all district level supervision to the ZP and is recommended to be abolished.
It is proposed that the various district level officers under the DJD will report functionally
to the respective Joint Directors and administratively will continue to report to the ZP..
Directorate Structure
5.36 The Directorate of Health will be headed by Commissioner / Directorate General
of Health Services (DGHS), who will report to the Principal Secretary. The proposed
directorate structure is shown in Exhibit 5.5
Commissioner / Director Genera! of Health Services
5.37 The main function of the Commissioner of Health and Family Welfare presently
filled by IAS Cadre Officer) to bring about better internal and inter-sector co-ordination
and to achieve a greater degree of accountability in health services both in financial and
administrative terms. The key activities of this post are :
•
Monitoring, supervising and implementing all National and State health and
family welfare programmes in the State
•
Ensuring co-ordination among the various directorates and divisions within
the Health system and also with related departments
It is proposed to rename the Commissioners Post to Director General of Health Services
- DGHS to be held by a Senior Technical Officer of the Dept who has risen from the
ranks. Also this is a selection post
5.38 The key qualifications for this post ( DGHS ) will be managerial, administrative
and financial skills as well as health systems exposure to carry out their functions
effectively. In the current DHFW, it is observed that there are hardly any health
personnel skilled in managerial/ administration and related areas. Moreover the exposure
to government-functioning is minimal. It is proposed that the senior personnel of the
DHFWS are given opportunities for attaining the requisite skills such that they meet the
qualifications of this post. Till such time, it is proposed that the Commissioner (of IAS
cadre) continue to hold the post till such time a suitable technical person is available to
fill the post of DGHS.
Reporting Structure to Commissioner/DGHS
5.39
him:
The Commissioner/DGHS will have the following functional heads reporting to
Director - Medical
Director - Public Health
•
Director - External Aided Projects
31
I
Organization Structure at District Level - Proposed
Taluk Health Office - Proposed
Taluk Health Officer
I
DPH Qualification Must
.
„ . JZ“___
;
■
T Health Asst
: J1
BHE'S
: M/F (prom from Jr. HA) | •
i
(Shift from PHC
i [ Pattern to Tgiuk Level)
IF
Refractionist
(Shift from PHC
Pattern to Taluk Level) |
ASO
(Statistics person must
for HMIS
Proposed Org.Structure at District Health Office
Exhibit 5.1
Di.iint Heakh aH I 0 Alter
OrtU
Selection Post
ADHO
'Seniormosl Prg Ofker
Dtsl Prgm Co-oiO
Planning HMIS
RCH
Prog
Offcer
Distnci
Mohtenance
Un«
t AEE (Chi)
2 Vehicles
3 Equipmenl
;
I OitUKllab
J Bio-chemsl
i
Pathotogsi
I Microbiologtst
Dntrtl
Pnannacut
Warohoutt
Dielnct
Survelante
0 Nicer
i
EntamolegKl
, Sututical 0 leer
Sector
Borne
Prog
Oflker
Dntnct
TB 0 leer
Prog
Oleer
Heikk Pramotwn
Prog
Oflker
jNulrilMi
|___
4
EC
DHEQ
010
STD
MV
Prag 0fleer
FomiyWeliare
Offctr
L
Note. The District Lab staff - Microbiologist/Bio-chemist/Pathologist will be shared
by the District Surveillance Office and the District Hospital
District Medical Office - Proposed
i District Med'cal Office'1
|____
DMO
Dy DMO/CMO/RMO
Distnct Surgeon
District Hospital
1)110
/
I
District Surveillance Officer
/
r-----Admin
Medical Officer
laluk/CHC/olhets ,
Prog Officer( P O)
Opfhal
(Senior Specialist)
CVS/ Diabetology
Senior Specialist
PO
I
Mental Health
Senior Specialist
PO
ONCOLOGY
Senior Specialist
PO
Maintamance
Unit
Equipment
Vehicle/Civil
I
Proposed Org.Structure DHFW
Exhibit 5.5
I
Drug Controller
... Principal Secretary
- Sec-II (ME)
SIHFW
I
CAO
Finance
DME
Commissioner/DGHS x-......
ISMH
I
CAO
Vigilance
I
Director
Public Health
i
Director
Medical
AD -SPC
Planning and
Monitoring
JD
Special Groups
Director
EAP
I
~
Directoe
Procurement/
Maintainance
AD
N. Karnataka
I
NGO Cell
Consultant
Proposed Health Org. structure at HQ
1
Director
i
Public Health ■
r TT
I
ad/^d
AO
AI OS
Rf.M
T'q—1
Primary
Heath Care
J.
JD
AIDS
□ 1
JD
RCH
JD '
Primary
| Heath I
! Care I .
__E
JD
I EC
J.
□JD
1
I
NUT
• S'ate SuvE’ii'ancr j
|
Offrrr
j ;
j
jF I I JD
Vector
Borne I
|
TB
jd“|
Leptcsv .
[
JD
j Vacr.ine
Deputy Director 1
Disease Sun eillance
ZL
JD
Lab
Proposed Medical Org. Structure at HQ
I
: DIRECTOR
Medical
.
I.
"ZTr
JD
Medical
JD
Pharma
Zl__
r.“
AD
Medical
JD
Hospital
North
J
JD
Hospital
South
JD
Trauma
Emergency
Medicine
][
JD
Opthal
JD
CVS & Diab
AD
NCD
CAO
2
JD
Dental Health
JD
Mental Health
JD
Oncology
Proposed HQ Org. Structur
Director
EAP
I___________
Secy PWD
DIRECTOR
Procurement & Maintenance
____ EZZZ
JD
Procurement
I /
JD
Bio-Medical
Equipment
Maintenance
Superintendent
Engineer
Civil
7
Civil Engg.Staff
as in
KHSDP
i^eview of Organise.
Director
-Vol I
Confidential
it and Maintenance
NGO Partn h hip Ce
AD - Planning
AD - Nortn <anata
•
CAOs (Administrate
I & II, Finance and Surveillance)
5.40 This division of work ai mg the key functions of Commissioner / DGHS keeping
in view the dynamic nature 01 he work and effective monitoring of the activities. The
structure and functions of the
ice of each Director's office are discussed below:
Public Health Vs Medical
5.41 Continuing the proposa or two main cadres namely Public Health and Medical at
the District level, it is propose., to have a similar structure at the Directorate. Thus, he
key preventive, promotive and irative furfetions of the Directorate of Health are divided
split among two directors, i.e. irector - Medical (for curative and clinical services) and
Director - Public Health (Prove .ve and promotive services).
mmitment from the Directorate to the District for both
5.42 This will ensure equal
Public Health as well as Medic . Further, it will provide focused supervision in each of
the areas. It will also addres the promotional opportunity to each cadre to be their
respective Directors
Director - Medical
5.43 This functionar/ heads
Health. The Director - Medical
- NCD.
the clinical and curative services of the Directorate of
reported to by two ADs, namely, AD - Medical and AD
5.44 AD-Medica/ : The ADintegration between externally
Director - Medicai. The AD
management aspects in the
mechanism is in place in the
hospital care. This post will be
edical currently exists in the KHSDP and due to need for
ded projects and the DHFWS, it has been brought under
- Medical will look after the Hospital and Hospital
Directorate.
He will ensure that a proper referral
ztate to ensure speedy treatment at various levels of
ssisted by the following JDs:
JD - Medical
JD - Hospital
JD - Pharma
5.45 The JD - Hosoital is
under the DHFWS. The JD (Gi
distribution of drugs and pharn
and responsibilities of the aoo\
new post created for focused supervision of hospitals
) has been re-named to JD (Pharma) with emphasis on
zeuticais. The detailed reporting relationships and duties
me provided in Volume II of this report.
32
.^cwevv ;r Organisation S;/
Confidential
5.46 AD-NCD: To bring a:
□nd treatment of Non- comr
would look after non-commun
In addition, it is proposed to r.
’ ’i* emphasis and co-ordination in identification
diseases, it is proposed to have an AD post who
rases likes Cancer, Opthalmology, Diabetes, etc.
’Slowing JD posts reporting to the AD-NCD :
Joint Director - Or
Joint Director - NC
ascular and Diabetology)
Joint Director - Em
c
Joint Director - Mer
1031 th
Jedicine / Traumatology
Joint Director - On<
;gy
Joint Director - Der
Health
5.47 Recent studies Murray
NCAER etc) have shown the r
Dept of Health have senior or
monitor the identification,cure-
Lopez: WHO and other reports - Nimhans, AIIMS,
g :nciden<te of NCD cases. This will necessiate that the
?rs of the rank of JD's in each of these specialiities to
preventive and promotive aspects of the NCD's.
5.48 Taking into considerat.
proposed to have focussed a:
responsible for the curative w
reporting relationships and c
Volume II of this report.
h'} future requirements of Health care delivery, it is
on m these areas. The various JDs will primarily be
.search aspects of these specialisations. The detailed
: and responsibilities of the above are provided in
Director - Public Health:
5.49 The Director -Puolic
development in the State oi
implementation of the various
be assisted by the following AL
AD - RCH / Priman
: will be overall in-charge of the Public Health
rmataka. He will utilize his resources for effective
s :i and State level public health programmes. He will
:3itn
AD - Health Promo:
AD - CMD
AD - AIDS
5.50 AD -RCH is an exist
functions. He will be assisted
Care which is essentially a part
.ost and will continue to perform the current key
_'e JD - RCH. He will also look after Primary Health
and assisted by JD - PHC.
JJ
:r Organisation Stmonr
5.51 AD - Health Promot
Promotion and will handle the
(IEC) along with other health :
JD:
■Vol I
Confidential
n: The current AD (HE~' is renamed as AD - Health
-nctions of Information, Education and Communication
motional activities. He miil be assisted by the following
JD - IEC
•
JD - Nutrition ( nev.
5.52 JD (IEC) currently is un
to communication of health rek
post to be under AD - Hea;
activities under a single head
utilization of resources.
;-.t )
- AD (RCH). As the main -unction of the JD (IEC) relate
d programs to the public :t is proposed to re-locate this
omotion. Thus, bringing all health communication
h. facilitate higher level of integration and maximum
5.53 AD - CMD is re-locatec ?m the KHSDP and will supervise the activities of
relating to vector borne diseases, TB, Leprosy as
various national and state prog
:he
Laboratory . Each of the above functions are
well as the Vaccine Institute an
managed by the Joint Directors
mill be‘nodal officer for the State surveillance Unit,
the detailed job description is ir
. II of the report. The JDs reporting to AD- CMD are :
JD -Vector Borne
JD-TB
JD - Leprosy
JD - Vaccine Institir
JD - Labs
The JD (Vector Borne) p ;t s renamed from JD - Malaria & Filaria with the scope
e diseases.
to incorporate additional vector
5.54
AD - North Karnataka
5.55 In view of the existing
medical & public health standa
the development of this regie
Karnataka, held by a senior p
management) as well clinical, r
jckwardness in the distncts specified in terms of the
. ’.here is a need in the DHFW for focused attention on
is proposed to have a post namely AD - North
with exposure to bcm public health (programme
. ung directly to the Commissioner/DGHS).
5.56 The key role of this pos
activities at Bijapur, Raichur, G
districts. His office acts as a nc
Welfare. He acts as a coordinaalso liaison with the director'
description is given in Vol II of
/ill be to monitor the Dec:. Of Health & Family Welfare
■ma, Belgaum, Bidar, Bagalkot, Bellary, Koppal ,Gadag
Tee for all the activities of Dept. Of Health & Family
tween different functionaries in the department and
: behalf of the distrms mentioned, (detailed job
port)
34
of Orgari:
Confidential
AD - Planning
5.57 The need
\ .jcratio
of AD - Planning
/ring di
existing Strategic a a'mng Ce!
and perspective plam 'g for th
international agerc. a- 2-; w
functionary of the ::ecartment.
burden of disease, mccmmenc
resources. Also cam. jut stuc
initiate policy initiates mr re
year plans and MMP.. Till edit
by the following personnel :
anning at the Directorate Level necessitates a post
to Commissioner / DGHS). This post replaces the
i
■■/‘I take up the activities of long-term ,short-term
.nr m-ant, with the inputs from different national and
'ne Management Information Systems (MIS)
■ >vill monitor the changing epidemiological profile, the
t effective measures to achieve best use of limited
a continuos basis and interpret , analyse trends
.nd change. Will also review the annual plans, five
u:al report of the department. He will be assisted
JD -MIS
JD -Planr:rc
5.58 The JD -MIS .vill be the
will collate information from a;
department and interprets for
intelligence, demography cell
under the JD ( MIS \
point for all information relating to the DHFWS. He
cal, hospital and public health functionaries in the
I
erences or corrective actions. The bureau of health
r' all statistical units in some divisions will function
5.59 The JD ( Planning ) will
year plans and annual report
report.
? nodal Officer for preparation of annual plans, five
department. Detailed JD's are in volume II of the
Director - Exterr
Aided P
5.60 The various operation^
conducted in the main stream
functionary reporting to the Cc
projects and to handle any co
EAP will have the following key
•
n
s
n
the Externally Aided Projects is proposed to be
DHFWS. However, a need was felt to introduce a
ner/DGHFW to oversee the management of these
t: n with external agencies, if any. The Director ans :
Monitor ail :ne exist
reporting authority
financial accountabi
xternal Aided Projects, if needed by having different
ich. He stands the overall responsibility for the
he Projects
Identify new areas
reality.
.'oration with other agencies and bring them to
Work in 'Pose assc
objectives of all Extrather than a projec
with mainline department in carrying forward the
ced Projects with a programme mode of approach
35
Confidential
Review of Organisation Structure
. <;/1
Director — Procurement anc
i tenanee
5.61 In the current structure
and civil works are distribute
centralize these activities
Commissioner/DGHS. It is pro
since this is administratively ar
will be assisted by the following
"ocurement and maintenance of various equipment
ss the various departments. It is proposed to
.. eating a separate cell reporting to the
to place an IAS person to head this department
inically the key functionary for the department. He
c
JD - Procurement
•
JD - Equipment & M
•
Chief Engineer - Civ
ice (Bio-Medical)
5.62 JD - Procurement's ke\
from all respective functionar
tenders for acquiring those eqi.
bidder. The person to hold
background since it involves a
supplying to the destined loca
procedures of World Bank and
ons include receiving the indent for any equipment
the department about their requirement, placing
■ and finally acquiring them from the most feasible
osition can be one with engineering/logistics
ng of tender documents, acquiring equipment and
He should be well versed in all the procurement
unding agencies.
5.63 JD - Equipment and M
and equipment including the
assisted by
nee (Bio-Medical) takes care of all the machinery
of Directorate of Health Services. He will be
DD - Equipment
•
DD - Equipment (tr<
•
DD-Transport
These posts are alread*.
Directorate of Healt:
l. under KHSDP and same to be transferred to the
-amily Welfare.
5.64 Chief Engineer - Civil
administrative relationship to
incharge of all the civil related
Health services. He appraises
eligible persons. He is assisted
notional reporting to the Secretary - PWD and
nmissioner through Director - Procurement. He is
otion and maintenance work of the Directorate of
!ers for construction and allots the work to the
Superindent Engine.
Dy. Cheif Architect
36
Review of Organic, ;•
Confidential
Director -SIHF'r,
5.65 Currently, he is a fur
proposed that henceforth he
SIHFW which will be a Autom
Health. The hierarchy of the pi
nan/
I he
is a
sed
'porting to Project Director - IPP - IX. It is
rhe training function of the department and
raport functionally to the Principal Secretary of
ucture of the office of Director SIHFW includes:
JD
DD
•
District i raining Of
•
Other training per
throughout the stat
lel i: /oived in training in Health & Family Welfare
NGO Partnership Ce/I
NGO participation in F
Health Care and first referral,
focus esp. in the backward ..
registered with the Health DeIt is important that all NGO's
Health Department. It will
activities of the various NGO:
suggested to have a NGO Par
by preferably by a Advisor/ C
Commissioner/ DGHS to simpl
n Cc
• has become very essential at levels of Public
ise r ?d to be supported and encouraged with special
remr 2 region of the State. A number of NGO are
nent .nder various schemes and various programmes,
e a
gle source of interaction, coordination with the
ena _■ the Government to monitor and evaluate the
licip ing with the Health Department,
Hence it is
hip
I as a single window in the department headed
Jltan io coordinate the activities of this cell with the
roce' res for grant in Aids avoiding delays.
Joint Director ( Special Gr
A new post needs to be crea:
, Triba/s, Elderly and :he Disc
with other departments and s
o ca
H
s.
* to the problems of women ( gender sensitivity
d!! report directly to the DGHS and coordinate
posr
structure are outlined below :
The structure is Pr
programme c:‘ _er
Yin
ased thereby leading to more accountability for
<a level itself
The split of DHF\
monitoring and ex
scope for accounta
jnct
into Public health and medical for better
duties and responsibilities, thus increasing the
' stage
Benefits of proposed struct
5.66
The key benefits of the
•
on -
37
Q'jJins.!
Reviw
•
Confidential
Equal prc^otional avenu--'
■.' medical professionals in the department
Scope to ■'ave seniority cut
■ r during promotions
Removal r divisional str .-, :rleading to concentrating the activities at
district le. e
•
Direct mentoring of ail * ::: crai and‘ state programs from the directorate
itself, thus saving way for jetter coordination among districts and with the
directorate
38
H
• • i'.c.'? Structure
Confidential
5. Review of Existing Cadre
f/.. . / '.
involved determining .:' ? various cadre-related concerns as expressed
J7 ■“j'.Q1'1 " i?e mei ^ur,'n9 detailed discussions and offering suggestions for the same.
Ln
he cadre and recruitment rules were reviewed in brief to determine
conrormanc:- to the proposed strucun. This cadre review is presented under the
rollowing :
'oduction of sub-cadres
•
Promotion, Postings and related Policies
•
Qualification and Training
•
Private Practice
•
Adherence to working hours
Introduction of Sub-Cadres within Specialist cadre
IT-,thS preV'0US Chapter' the DHFW has
distinct cadres namely
ublic healtn and Medical. One or the considerations taken into account was the
.traduction of sub-cadres for the various specialists under the medical cadre The
drawbacks or such a consideration are :
•
Complex cadre management
•
Blocking of levels based on growth
*
Skewed requirement across specializations
5.3 i(.cThed 'S thtsua,.need t0 determine senioritis and growth path for each sub-cadre
anr1
d its implementabihty and acceptance prior to introduction. In the interim it is
instead of m-rri
de.termin- the number of posts under each specialization
nsteao or introducing sub-cadres. Identify the need for specialists in the state and
■ recy send doctors to acquire postgraduate qualification in those specializations only
i ms will avoid mismatch of specialists to number of posts in the department.
Y'
InLi i TTcDHFWt t35 a'ready identified the posts of [>/ Chief Medical Officers/Senior
peciahstS/Senior Medical Officers/Specialists and General Duty Medical Officers in April
9^ and documented the same in an official memorandum (No 378). This can be used
as a reference for determining the number of posts at each specialist post
Subsequently, it was reworked recently. And known as Dr. Halagi report which is yet to
be accepted by the Government for implementation.
Promotion, Postings and Related Policies
t5
7he existlri9 Policies on promotion, postings and related areas have been
nrntSS-T :!g.,t with the current ssues faced by tre various personnel and our
proposed organisation structure.
39
u
- •. .• 7 jr Organisat
^ol i
Confidential
Postings
5.6
It is the viev. st
though accepted by t.
•
; section of personnel in the DHFW that very often postings
cite, are subsequently not filled up mainly due to :
State cacre
women can; :
ment leading to selection of urban candidates (specifically
who are unwilling to take up postings in rural areas
Unwillingness
their choice
irhdraw from offer as they are sure of getting a posting of
5.7
This leads to a or " :costs
■ •being
■
vacant for long duration's thereby defeating the
ven/ objective of DHr A
wntinuous health care especially for the ruralI areas.
5.8
Suggestions to tne same were offered in terms of introduction of criteria of native
piace/permanent resic-v
of candidate in the merit determination specifically for
postings for rural-areas - .vever, this may lead to the higher merit candidates not
getting opportunities in re place of their choice. It is suggested that a counseling form
of posting the Candida as similar to the CET counseling) be introduced with the
following measures :
•
Mandator/ rura costing for a minimum defined period in the initial years of
service (e.g co .ears)
•
Posting once accepted cannot be revoked except under extra-ordinary
circumstances s^cn as on medical or humanitarian grounds (which need to be
clearly stated c': sroved)- any attempt to do the same to result in expulsion
from service
5.9
A move towards ::
recruitment for the district cadre was considered and the
view was that this wouic a w :o certain issues such as imbalance of posts required vis-avis available candidates r :he district and lesser opportunities for merit candidates
resulting in the decision
ntral recruitment policy with counseling. DHFW will need
to review the legal impiic
3 “or implementation of counseling mode of posting
Specialty based Post: ' .:
5.10 The postings at
done taking into consice
requirements.
a ious CHC/Taluk Hospital and District hospital should be
on the various specialties at these centres and their
5.11
rSpecialisations or
5.12
' i he posting po!icec :''culd also incorporate specialization based requirements at
.arious candidates need to be considered during postings.
Currently for example Otthccedic specialists are posted at. PHCs where therea are no
facilities to provide then : ?::alists service in addition to the routine PHC activity,
Further, additional quaiirc w attained by the candidates between application to service
and joining DHFW is reco ' r<ded to be considered while posting.
each health
------ centre.
-------- E.c. _"ently there are surgeons posted in hospitals without
40
u
Review of Organisation Structure
-Vol I
Confidential
anesthetist, three ENT specialists in a one centre while there are no surgeons etc leading
to mis-match between requirements and postings.
Promotion/Transfers
5.13 Currently transfers are mostly promotion based, which is on the basis of seniority
It has been observed that very often the promotion/transfer mechanism is not effective
due to the following factors :
•
Lack of rotational transfers
•
Non-conformance to transfer order
•
Consideration of pending service period prior to transfer
Promotions Table
Village
SC
Trained.Dai
ANM
JHA-F/M
J HA F/M
PHC
*
CHC
SHA F/M
TLH
District
THA
i F/M
DHA F/M
State
Staff Nurse
Junior
SN
Staff Nurse
Senior
SN
DNO
DD
Nursing
Pharmacist
Junior
Pharmacist
Senior
District
Chief/DD
BHE
DHEO
DD
Senior
Senior
BHE
I______
Lab.Tech.
Lab.Tech
Junior
Rotational Transfers
- re_V?:W Of: Cadre p0licy. has brou9ht t0 H9ht that verY often Personnel are
Tl_.
based in the same health centre for long periods extending upto
T
,
- .
— ---------- □ -r-J around 20-23 years.
Introduction of rotational transfers will facilitate spread of experience across different
regions. Rotational transfers can be done through counseling with the support of
manpower planning details.
5.14
41
u
- ^-i/zevv ct Organisation Structure
Confidential
Non-Conformance to Transfer Orders
5.15 Transfer orders are not necessarily followed by the personnel. The personnel is
given a choice to refuse transfer in lieu cf losing his promotion. However it has indicated
chat personnel use references to get transfers of their choice. This leads to non-favored
locations not being posted for long duration of time.
5.16 It has been suggested by a cross section of personnel that specific measures
need to be undertaken to control in-disc:pline regarding transfer orders. These measures
include :
•
Recording use of any reference for transfer of choice, in the service book,
which will be reflected in the future career growth of the personnel
•
Delay in PG admission etc
Consideration of Pending Service Period
5.17 The current policy of minimum period at a post is in the range of 6-7 years
leading to a personnel to have at least 17 years of experience prior to the post of Deputy
Director. This policy has led to various personnel being promoted (especially at senior
levels such as JD, AD etc) having around 6 months to one year of pending service
period. The roles of the senior posts being mainly in the form of strategy and planning,
this period is not sufficient for effective implementation of plans.
5.18 Considering the importance of prior field experience for the directorate posts, it is
recommended that the promotion policy In terms of minimum period of service be re
looked to facilitate Senior Personnel being promoted to a post having at least two years
of pending service. Alternatively,, the personnel can be given the option of in-service
oromotion with requisite compensation benefits whereby he will continue to remain in his
previous post.
Qualifications and Training
5.19 This section covers observations and suggestions on matters relating to
qualification of personnel and the need for training.
Qualification Related
5.20 The qualification related matters discussed in the ensuing paragraphs are
primarily of :
•
Post-Specific Qualifications
•
PG Course Selection
Post-Specific Qualification
5.21 The proposed structure pre-requs.tes the need for post - specific qualifications
rcr the various personnel manning these posts. The division of the department into
u
.-c-7/evv of Oi\j.h
-Vol I
Confidential
Public Health and Medical wings necessitates the need for respective qualification.
Further, for the function based posts such as JD (Optha) under the medical wing,
specific specialization e.g. MD /MS (Optha) will need to be mandatory.
PG Course Selection
The medical ^^-^onnel of the DHFW are provided sponsorship for post graduate
qualification after completion of three years of service. They are selected into the course
on the basis of their seniority. The key concerns brought to our notice were :
Postgraduate subject selection is driven by the candidate preference instead
of the DHFW ;equirements leading to mismatch of specialists' vis-a-vis state
needs.
Certain percentage of candidates do not complete the course in the specified
duration leading to on one hand blocking of seat of a more deserving
candidate and on the other under-utilization of DHFW expenditure.
5.23 In order to maximize the benefits of postgraduate course
_ sponsorship,
’
it is
suggested that the DHFW consider a merit based selection intTthe program,1,-,
j programme as
compared to a seniority based selection. The proposed selection procedure
‘ can
incorporate the following standards,
•
Introduction of PG course selection examination similar to that held for the
non-government students. However, it must be noted that the seats reserved
for the government students will still remain the same.
•
The merit selection should also incorporate field and academic experience
including the performance evaluation conducted through the Confidential
Report (CR) procedure.
•
The subject selection should be on the basis of expected vacancies under
each specialization in the DHFW. Candidates to be permitted to indicate
preference, however admissions to PG programme to be done through the
counseling process. Further, on non-acceptance by the candidate of the
subject offered, the candidate will lose his chance of DHFW sponsorship
unless he re-visits the selection procedure in any future period. Can opt for
only one clinical speciality with option for Management training if required.
5.24 In addition the DHFW may consider charging the candidates
an appropriate
penal fine (in lieu of expenditure incurred by the DHFW) on non-completion of course in
the specified period due to in-discipline or failure in the examinations.
Training
5'25 -U Majna9ement / Administration training and induction programme for new entrants
into the department is currently not a thrust area in the DHFW leading to lack of
motivation and uncertainty of the various procedural issues. The average personnel has
limited / poor programme management abilities of national health programs especially
43
H
?'/ ew <?.• Ci<;nr
■ '/? Structure
that of public health and also poor admini
been observed across all categories of staff.
Confidential
management of hospitals. This has
5.26 As discussed in the previous chapt :
specific thrust for training of DHFW
personnel is one of the key features in th proposed organisation structure. It is
recommended that the training emphasis mav vein with the following initiatives :
•
Administration training to be prove: ?c to all personnel holding administrative
posts such as head of PHC, TPHO,DPHO JMO,DMO etc
•
Short-term and extensive training programs to be conducted for awareness of
all national health programs
•
Clinical training in areas of specialization / job role requirements for
familiarizing with latest technology and clinical skills
•
i he minimal knowledge of public 'c-jith amongst the staff requisites training
in public health to be at least of 6 - 10 weeks duration.
A beginning in this direction has been made by KHSDP but these programmes need to
be thoroughly evaluated and renewed.
Private Practice
5.27 The private practice being conducted bv the staff after duty hours is a routine
matter for most or the doctor personnel of the DHFW. This issue has been much debated
upon and a decision is yet to be arrived at on the same. Some of the suggestions given
by members - Task Force on Health is given below :
•
Though private practice is banned, certain medical personnel carry on private
practice to the detriment of their official responsibilities
•
Factors affecting decision on permitting private practice are :
Need to ensure availability of medical services at all hours
Essentiality of such services at the !ocal level specifically in rural areas
•
Recommendations on private pract:: j :
MCs at the PHC level to be given rural allowances in lieu of private
practice
Specify duty hours, publicly announce them and attendance during these
hours to be strictly followed and monitored by the community
-
Ban private practice at all levels
Prohibition of association of doctors as consultants to private nursing
homes
Public health cadre and Administrative Officers to be given special
allowances
44
u
Review of Organisation Structure
-Vol I
Confidential
5.28 Few of the reasons offered by the various doctors on the private practice is that
the non-practicing allowance offered as part of compensation is in no way close to what
the doctor would earn in private practice. Banning private practice at senior levels
without adequate compensation, would result in movement of highly skilled practitioners
to private service. An appropriate mechanism should be designed by the DHFW whereby
public sen/ice and doctor motivation will be at the acceptable level.
5.29 While private practice after duty hours may seem acceptable taking into
consideration factors outlined above, it has been observed that private practice is
conducted even during duty hours. This may be in the form of accepting consultation
fees from the patients visiting the DHFW's health centres or conducting external private
practice during official duty hours
5.30 Control measures need to be adopted by the DHFW with regard to private
practice, especially during duty hours through stringent disciplinary actions.
Adherence to Working Hours
5.31
The working hours for the different; health centres are given below :
•
•
PHC/CHC/Taluka
-
8.00 a.m. to 12.00 p.m.
-
2.00 p.m. to 5.00 p.m.
-
At Taluk level Duty Doctor has night shift of 5.00 pm to 8.00 am
District Hospital
-
9.00 a.m. to 1.00 p.m.
-
2.00 p.m. to 5.00 p.m.
Directorate
-
10.00 a.m. to 5.30 p.m. (General Shift)
-
Lunch break: 1.30 p.m. to 2.00 p.m.
5.32 It has been brought to our notice that as certain medical staff do not stay in the
quarters, they may not be available during emergencies. Moreover, in health centres
situated around urban centres, the working hours are not necessarily adhered to as the
staff spend a lot of time on travelling to work.
45
11C 'i J
PH
Re'j1
■ ;j/' sjM':' Sirncture
Confidential
-Vol I
6. Re-aiignment of Staffing Pattern
6.1
hhe study of review of organisation structure involved identifying any concerns
addressed by personnel on the staffing pattern and any re-alignment of the same arising
out or :he proposeo organisation structure. A detailed study is being conducted by
CESCON
wherein the terms of reference are to determine Manpower Planning
requirements .
6.2
As the above study is a detailed manpower planning exercise, it was suggested to
us that we limit the staffing pattern to the top management structure.
Observations
6.3
Key concerns addressed by various personnel on the staffing pattern are given in
the ensuing paragraphs.
Manpower shortage
i
6.4
Sanctioned manpower is defined for each section/function within the department.
However, it has been brought to our notice that in most departments, quite a few of the
sanctioned posts are vacant. These could be due to various reasons such as transfer
posts not taken up by the personnel etc.,
Shortage of Staff Nurses
6.5
There is an indicated shortage of staff nurses at the District Hospital visited.
Nurses forming a critical part of para-medical staff, shortage of the same will lead to
lesser assistance to medical staff in their functioning.
Shortage of ANM (Female Health Assistant)
6.6
The training for future batches for the ANM post has been stopped leading to an
expected shortage of ANMs at a later point of time.
Mismatch of requirements vis-a-vis personnel
6.7
As covered in the previous chapters, the staff assigned to various health centres
do not necessarily meet the professional/specialization requirements at these centres.
There is a need to implement facilities based posting.
Unequal distribution of Staff
6.8
It has been observed that there is an unequal distribution of staff especially in
the group D categon/ across the health centres. It has been observed that contracting
out ser/ices for non-clinical work of hospital, especially hospital hygiene and cleanliness
has been successful under KHSDP. This will definitely reduce the burden of the state of
maintaining these hospitals through Group D.
46
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Confidential
- '/O/
6.9
Further, as indicated earlier, in a single hospital there are 3 ENT specialists while
none at another.
Skewed utilization of staff
6.10
i h.e current utilization of staff is found to be skewed or under-utilized. E.g.
Over utilization of Female Health Assistant
Under utilization of Male Health Assistant
Lab assistants posted at PHC, etc without requisite material to conduct their work
Non-availability of Allocated Staff
6.11
In certain situations, the allocated staff for a department is assigned other duties
leading to non-availabilitv of the staff for the concerned department's activities. E.g. In
the HET ceil, certain staff are utilized by the CAO as a result of which HET activities are
under staffed.
«
Proposed Senior level Staffing Pattern
6.12 On the basis of the proposed organisation structure, the Senior Level Staffing
pattern is given below :
DGHS/Commissioner
1 no.
Director
4 nos
Additional Directors
10
Joint Directors
20
47
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Review of Organ saticn Structure
Confidential
-Vol I
7. Need of Procedure Review
7.1
As a part of the organisation structure review, detailed discussions were held with
a cross section of personnel across various categories of health centres (PHC, CHC etc)
covering both rural and urban areas and the directorate. From these discussions, certain
areas where identified wherein there is a need to conduct a detailed procedure review
for improving the functioning of the department. The key areas identified are :
•
Planning and Budgeting
•
Drug Procurement and Disbursal process
•
Register/Record maintenance
•
Management Information Systems
i
Planning and Budgeting
7.2
Planning for the various national and state level health programs and their
distribution across the entire network of the DHFW is one of the key activities of the
DHFW. Planning and budgeting are critical to the overall success of implementation due
to the vastness and complexity of these programs. However, it has been observed that
the planning and budgeting exercise is conducted in a mundane manner as highlighted
below :
•
There is no scientific need based process e.g. Epidemiological basis, morbidity
pattern etc., utilized for planning and budgeting
•
The budgeting exercise is conducted in the form of re-allotment of figures
based on expenditure pattern
•
Further, budgeting for programs are ad-hoc with no consultation from
program officers. More often, the budgeting is seen as a directive from a
department rather than a consultative form.
7.3
As reiterated in the previous paragraphs, planning and budgeting being critical
functions, for efficient implementation of various programs a scientific based approach to
planning needs to be considered. Thereby, it is imperative that a detailed study be
conducted to suggest an effective planning and budgeting mechanisms and procedures.
Drug Procurement and Distribution
7.4
Drugs at the health centres of DHFW are received from the following sources :
DHO
60 %
GMS
40 %
48
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• v Oiqar <
Structure
-Vol I
Confidential
7.5
The various concerns raised by the DHFW personnel with regard to Drug
procurement and Disbursal are :
•
Planning and processing of drugs are inot need based leading to shortage of
certain supplies in case of emergencies
•
Thougn funds are provided for ASV for procurement of emergency drugs,
these runds are unavailable for utilization
•
Complaints have been received regarding high pilferage of drugs through the
entire supply chain i.e. from the GMS store to the PHC via the DHS
•
Delays in supply or non-supply of essential drugs have led to the various
centres to claim the cost from the patients. Normally the drugs received on
the annual quota are sufficient only for one month. This in effect defeats the
very objective of Public Care.
7.6
A detailed procedure review on the drug procurement and disbursal cycle will
determine the gaps in the process that subsequently lead to delay in receipt of supplies,
procedures Ure reV'eW Wl11 als° provide recommendations on internal control policies and
Register / Record Maintenance
77
Detailed registers have been prescribed for recording implementation details of
the National Health Programmes. However, it has been observed that there exists a
certain delay in register updation and information flow. More often there is a short
supply of registers especially at the PHCs leading to the ANMs procuring them at their
cost. Though the cost incurred is subsequently reimbursable, the entire procedure
causes delay and inconvenience to the ANMs.
Management Information Systems (MIS)
7.8
The MIS exists to the extent of collating information from all sub-ordinate levels
and the submission
------ of the
..... same to the superior. Currently, no analysis is conducted on
ataT !evel in the DHFW with the exception of the senior-most levels.
It has been observed
— — that
---- even at the DJD and JD levels, the role of the personnel is
restricted to collation of data.
7.9
Strategic planning being a thrust area for decisions on National
National Health
Programs
Health Programs,
it is imperative to have an effective MIS system that will provide information support for
decision making. I here is thus a need to conduct a detailed process review to determine
information needs at each level.
49
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Review of Organisation Structure
Confidential
-Vol I
8. Recommendations &
& Conclusion
8.1
This section provides a summary of the issues discussed about in the previous
chapters. The recommendations are provided keeping in view the following points:
•
Increase the efforts on preventive and promotive health
•
Increase the promotional avenues for the personnel (preferably doctors) in
the department and thus increase their morale
•
Making the personnel accountable for the success of the department by
enlisting the key accountability areas
•
Better implementation of the projects planned and in the future
•
More thrust for training the personnel and
contemporary technical and managerial skills
thus equip
them
with
8.2
The recommendations (possible solutions) for the above issues are devised after
thorough discussions with the members of task force, office bearers of the Karnataka
Medical Officers Association, doctors in the department and others, directly involved in
the department. The key recommendations and conclusions about the reorganization of
the Department of Health & Family Welfare are enlisted below:
Top structures
8.3
Commissioner/Director General of Health Services (DGHS): He reports to
the Principal Secretary. Three options were considered with relation to this position in
the department: they are:
•
Continue the occupancy of a senior IAS officer in this position for the present
till an alternative is achieved.
•
Place a doctor who rises from the ranks in the department and has the
functional knowledge of Public Health and Medical along with good project
management and administrative management skills. Then, this post may be
renamed as Director General of Health Services. Until a person with utmost
caliber within the department is identified, an IAS functionary may only
continue as Commissioner, Directorate of Health Services. But once a DGHS is
instituted, it must be the regular exercise of the government to groom his/her
successor to occupy the senior most position next. The continual change from
DGHS to the IAS officer may only effect the morale of the department people
and thus the functioning of the department.
•
Create a contractual position at the too rr.o can be called the Chief Executive
(Health) and specify the qualifications oackground and experience for the
person.
He should have extraordinar/ leadership abilities, managerial
capabilities, capacity for strategic thirn-ing and planning, skills for change
management and enhanced communication. The key result accountability
areas can be specified. The profile m me person to occupy this position
50
Confidential
should -eaily be of great - ■
size anc the acceptabili
difficult.
•
Creation of an advisor/ I
professionals who will
department and also acr
the department. The
inter/als.
mndards since the operations include mammoth
“he person from outside the system is also
: c consisting of eminent health and administrative
me monitoring and evaluation body for the
strategic planning with future perspectives for
will report to this advisory Board at regular
Directorate structure:
8.4
The activities of the director e .- are basically divided into two streams of Medical
and Public Health.
8.5
Medical functionary looks afer the hospital administration in the state, which
includes even the Non Communicable Diseases. All the specialist cadre personnel report
to the head of this functionary (Director - Medical)
8.6
1Public Health functionary looks alter the preventive and promotive health of the
people of the state. This includes the Primary Health Centres, the RCH Communicable
Diseases, the IEC and the Urban Health components.
8.7
It was thought to give more emphasis to the programs and other activities in the
N. Karnataka region for all the existing state of affairs of health in that region. A set of
seven districts are identified in that mgion to give more emphasis on and a position has
been proposed (Additional Director' to coordinate and monitor the activities in that
region.
8.8
Emphasis was also proposec :; be given to the present nascent area of future
planning and research activities. An Additional Director post is proposed to head the
functions of Planning, Research and MIS activities
8.9
It was obser/ed that there vas lack of coordination between different External
Aided Projects and different functionaries in the department. For this reason, it is being
proposed to introduce a directoral y/e! person to head and monitor all the External
Aided Projects in the state (Director - EAP).
8.10 For better coordination between the numerous NGOs working hand-in-hand with
various functionaries of Department of Health and Family Welfare, a special cell for NGO
participation and coordination is prooosed to be head by a directoral level oerson
(Director - NGO participation).
8.11 It is also proposed that a social wing be created to form the procurement and
maintenance cell to manage the act: 'ties of equipment, machinery and civil works of the
department.
8.12 The DHO and DMO snould ; - out monitoring visits regularly on a continous
basis with a check list and enforce disciplinary action wherever required.
51
cction
Review a
Confidential
-Vol I
8.13 More i nancial and functional autonomy be given to programme officers so that
they are also, ^sponsible for the programme as much as the DHO / DMO.
8.14 Great ? leave reserve Doctors posted at the District HQ to replace staff posted for
training or on ong leave.
State Instc-a of Family We < fare and Training (SIHFW):
8.15 This institute founded under the project IPP - IX for training the required
personnel in .re department is proposed to play a larger role in their development.
Keeping in view the dynamic nature of the circumstances the personnel of the
department are required to work and the pace of decision making, it is proposed to have
an autonomous institute as SIHFW.
8.16 The new organization set-up of SIHFW will be head by Director who reports
functionally to Principal Secretar/ - Health will be assisted by:
•
JD
i
DD
•
District Training Officer
•
Other training personnel involved in training in Health & Family Welfare
throughout the state
8.17 It is proposed that hitherto training function of Health Education and Training
(HET) functionary of the Department be shifted to SIHFW. All the personnel involved in
training would be a functionary of SIHFW.
8.18 It is proposed that all the functionary heads in the department and the office of
AD - Planning submit the training areas required for the personnel working in their
section to SIHFW. SIHFW in turn prepares the modules of training to be conducted for
different personnel in the department. The structure of SIHFW may be designed such
that the following processes can be handled smoothly:
Receive requisition for training areas from different functional and sectional
heads (efforts should be made towards self-appraisal of the people in the
department and the areas identified during that process too can be forwarded
to SIHFW). Most of the times, clarifications are sought from the reporting
authority about the training area specified. The individuals may also be
counseled to fill any gaps during the training need identification process
within each functionan/. Directions should also be taken from the office of DD
i raining, reporting to JD - Planning since he is responsible to identify the
process of linking the organization's long-term and short-term goals to the
individuals development, identify career planning processes for the
department people, recommend the format and module for orientation
programme for new-recruits and any refresher courses for doctors and others
from time to time.
52
Review of Orc;.
.:-i;cture
-Vol I
Confidential
Analyse u,'e inputs from different sources and cluster them so as to offer the
programme in easy modules at different places easily
Tram the eternal training staff (TOT) to enable them to conduct programs
more effectively
•
Prepare tee external trainers' list and their competencies in different areas
related :o Health Management, Hospital management, programme
management, logistics management, etc.
•
Inform the respective persons and their respective reporting authority about
the training programme identified for them and the planned period (including
the dates;. This should happen to enable the proposed trainee and the
relieving authority to plan better so that the general public is not at loss anv
time
'
Coordinate the training programme at the place determined. Other
administrative matters like providing the accommodation for outstation
candidates, providing good facilities if a residential programme is planned etc
should also be taken care of.
•
Inform the trainers about the expectations from them should also be done
much prior to the programme.
•
Have a feedback mechanism on fthe quality of inputs provided, for effective
monitoring and plan for any improvements.
8.19 Apart from the above, the new organization set-up should also take care of three
tier training system for better reach to the people in the department. This includes:
•
State level
•
Regional level
District level
8.20 The district level system should reach to the taluka level and the PHC level
including the doctors, nurses, pharmacists, health workers and the ANMs.
8.21 The changing systems impel the SIHFW to conduct courses in the areas
of Medical audit and Internal audit too apart from other courses. These areas
provide inputs in the accountability of the people in the system and thus its
sustenance.
8.22
The financial sustenance of the department can be derived by different means:
•
Allot specific budget for this autonomous institution depending on the number
of training orograms to be conducted and the number of people to be
covered in the department, the number of trainers required, the infrastructure
to be acquired, etc
53
e •.
O/gj'T/saf/on Structure
-Vol I
Confidential
•
Training fees can be charged for the training programs even for the
Department of Health and Family Welfare, Government of Karnataka and
raise the bill for each programme planned/announced/concluded
•
Open the facilities of SIHFW for other institutions as well to train their
personnel as well
8.23 Whatever maybe the structure and status of SIHFW, more coordination is
envisaged from different sections/functionaries in the department for effective utilization
of its resources and realize its basic purpose of existence as a single nodal agency for
training.
8.24
i he morale of the department needs to be uplifted through impartial promotions
postings, transrers, selection for PG Courses incentives etd. As mentioned earlier the
SIHFW should be the nodal training centre in capacity building of the health personnel at
all levels.
i
54
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GOVERNMENT OF KARNATAKA
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TASK FORCE ON HEALTH AND FAMILY WELFARE
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A Commissioned Research Study
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REVIEW OF ORGANISATION STRUCTURE AND DESIGN OF JOB
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RESPONSIBILITIES FOR HEALTH AND FAMILY WELFARE
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Rfi vie w ■ ?f Oz qa /1/.s a Ik ■ ■' ■ -Jti uon ire
-Vo! II. (Job Desc^oiioos
Introduction
The following pages form the Volume II of the organization restructuring study report.
This volume contains the job descriptions of the unique and identified positions at the
Directorate and different hospitals and other offices of Department of Health & RCH,
Government of Karnataka.
Methodology
•
Collating information available in different documents about the basic functions and
the responsibilities and duties of different personnel in the department
•
Discussions with different functionaries in the department about their basic functions
and duties along with any modifications required in the existing set-up to meet any
future requirements.
•
The salient features of the proposed structure are also discussed with people at
different functions and representatives of Medial Officers Association and certain key
functions were evolved
•
The gaps in the existing manuals and other departmental orders were identified and
utmost care is taken to address them.
Terminology: Job description for each identified position was explained under different
headings. They are:
Job Title:
The position / designation for which the job description relates to.
Reporting to:
This position for which a person is responsible to and it is at most of the
occasions, the appraiser of the person handling the above referred position /
designation. At certain instances, dual and multi relationship was reported. To have
better monitoring of the envisaged procedures and policies, these were imminent. Also
to have functional inputs and proper care to follow the authority schedules, dual
reporting was envisaged.
Immediate Level Subordinates:
This explains the reach of work of the incumbent and the basic logic of division
of work among the subordinates. However, only the medical profession designations are
only given as part of the subordinates' list. This doesn't include the staff reporting at the
office of the incumbent
Basic Function:
This explains in brief the function of the person handling the position and the
relationship with other functionaries in the department.
-MJ
2
Re v. vv of Ora a > /; ~ ‘: •
Duties, Responsibilities and Authorities:
These are the expected deliverables and the guidelines for the incumbent in
performing to the expectation of his/her senior (superior). These form the basis in his
one's approach in taking up a job or division of work in the department. The
responsibilities are split among the functionaries in the department, with the overall
responsibility lying with the head of the department.
The Financial, administrative and disciplinary powers are enclosed as
annexures and these are as per the KSCR rules and regulations.
This list may just guide the head of department in dividing the work
(delegating the work) among his subordinates.
Main accountabiiities/Key Result Areas/Performance Areas:
These are the reference points for the performance evaluation of the incumbent.
The duties, responsibilities and authority were considered to decide the accountabilities
Training Areas:
With reference to the duties and job responsibilities of the incumbent, and to
raise to the expectations of the concerned authorities and people at large, a set of
generic areas for training and possible methods of training for overall development of
the incumbent. This does not refer to any training needs assessment done but the
essential skill set of the incumbent.
Disclaimer: proformas submitted thro ugh the DHS to all personnel - have
still not been received but however we have still compiled the job
descriptions based on discussions with the senior staff of the Directorate .A
limited number of job descriptions are presently available with the
department.
3
Job Title:
COMMISSIONER/DIRECTOR GENERAL OF HEALTH
SERVICES
Reporting To:
Principal Secretary - Health & Family Welfare
Government of Karnataka
Immediate Level Subordinates:
• Director - Medical
Director - Public Health
•
Director - External Aided Projects
•
Director - Procurement & Maintenance
•
Additional Director - Planning
•
Additional Director - N.Karnataka
CAO - Finance
•
CAO - Vigilance
Basic Function:
Responsible for effective functioning of the Health Systems in the state to deliver
quality health care. Responsible for integrating the entire Medical health function
throughout the state and provide appropriate professional leadership for continual
improvement and upgradation of medical health services in the state including Hospitals,
health Units, preventive Health, etc. Also responsible for the management and
functioning of Medical and Health infrastructure of the state and ensuring their optimal
utilisation. Develop necessary strategies as well as policies, procedures and systems for
curative and preventive health throughout the state. Overall responsibility for the
Preventive and Curative Health of the people of the state and the best use and
development of available infrastructure.
Duties, Responsibilities and Authorities:
•
Develop a comprehensive strategic plan for the department which includes vision,
mission, objectives, goals of the department
•
Ensure that quality curative health care services are available to the target
population , Ensure adequate population/bed ratio, physician/bed ratio as per norms
is maintained (Government of India / WHO / state government
•
Handle all the policies relating to the administration and implementation of Various
National Health programmes in the state such as RCH, Leprosy eradication and
control of TB, Malaria and Blindness.
•
The DGHS office will maintain a functional relationship with Directorate of Medical
Education and Directorate of Indian System of Medicine regarding their activities.
4
•
Co-ordinate with the Commissioner of Public Education, Director for Development of
Handicapped and the Heads of Municipalities and Corporations on all the matters
relating to Public Health.
•
Co-ordinate with the Project Administrators of the various externally aided projects
with various departments of Directorate of Health & Family Welfare to ensure
smooth functioning of these projects.
•
Ensure efficient administration and implementation of policy issues for
computerisation and Management Information Systems at Department of Health &
Family Welfare
•
Responsible for submission of various policy and project proposals to the
government. Commissioner of Health to receive the reports from Additional Director
- Planning and after review submit the same to the Principal Secretary - Health &
Family Welfare Department.
•
Administer the matters relating to service and transfers of Group "A" officers of the
department and also responsible for taking disciplinary action against them.
•
Responsible for constitution of various committees from time to time and frame
policies for nominations.
•
To function as a member on all the programme implementation committees of the
Department of Health & Family Welfare.
•
To collect the documents pertaining to the Assets and Liabilities and implementation
reports from the Joint Directors.
•
Approve capital expenditure proposals within the powers delegated to him, put up
other proposals for approvals by the respective authorities, periodically review the
capital expenditure projects and ensure that the original plans are being adhered to
•
Responsible for administration of the vigilance cell in the state.
•
Provide the professional leadership, guidance and support to his immediate
subordinates as well as other senior officers who work with them and enable the
building up of a cohesive team that works in the overall interests of the state
Main Accountabilities:
• Overall quality of health care in the state
• Balanced and equitable availability of basic health facilities
•
•
•
•
Proactive measures for epidemic control
Controlling cost of services of providing health
Development of norms / standards for service quality
Professional delivery of medical and public health services
•
•
•
Budget performance of the department
Achievement of state health goals such as IMR.MMR.CPR etc
Number of problems resolved effectively
•
Functioning and timely completion of externally aided projects
-A/-C
5
•
Timely address to the natural calamities and effective gearing up to meet any
untoward incidents
Training Areas:
• Attend Management Development Programmes at International Institutes such as
Harvard, John Hopkins, etc in areas of Public Health, health policies, New business
models and management techniques in Health care.
•
Study Health care facilities and delivery system in both developed and developing
countries and also attend national and international seminars and conferences and
to share the experiences of Karnataka and get a feedback.
Job Title:
DIRECTOR - MEDICAL
Reporting To:
Commissioner
Immediate Level Subordinates:
• Additional Director - Medical
•
Additional Director - NCD
Basic Function:
Overall responsibility for establishing, managing and development of hospital
infrastructure in the state. Is responsible for the curative services delivered at hospitals
in the state. He is also responsible for developing and implementation of rational drug
policy including the essential drug list for the state. Monitor distribution of drugs
throughout the state in the hospitals.
Duties, Responsibilities and Authorities:
• Develop a comprehensive strategic plan for the medical wing of the department
which includes vision, mission, objectives, goals of the department
•
•
•
Ensure that quality curative health care services are available to the target
population
Ensure adequate population/bed ratio, physician/bed ratio as per norms is
maintained (Government of India / WHO / state government)
Ensure that the hospitals, dispensaries, Maternal homes and referral hospitals are
easily accessible to the population, review need for rationalisation and relocation of
some health units as well as setting up new health units in order to improve
accessibility and service coverage.
•
Review and evaluate the existing policies and procedures and work methods by
means of periodic and special studies
•
Review the MIS reports generated by AD - Medical / Planning and take corrective
actions
•
Review and recommend the upgradation of health infrastructure in the state
6
R--vie
•
Work out improved methods and procedures to achieve the objectives of the hospital
•
Develop standards, methods and measurements of the hospital activities
•
Monitor the utilisation of hospital resources throughout the state and adopt means of
bringing optimum utilisation
•
Ensure periodic health promotion activities (quantifiable) are carried out in the
hospital
•
Be a member of the accreditation board to certify standards in hospitals, both in
private and government hospitals
Ensure that all hospitals have a disaster management plan of action
Visit all district and major hospitals in the state, atleast once a year
•
•
•
Ensure that medical audit and internal audit has been carried out in all hospitals at
periodic intervals
•
Submit all relevant material which can be hosted on the department website
•
Ensure that full economy and expenditure control is observed in all clinical (curative)
related operations and activities of hospitals in the state.
Recommend transfer and postings of District surgeons and
Superintendents of Major Hospitals.
•
Main Accountabilities:
• Ensure quality of care in all government hospitals through periodic medical audit and
patient satisfaction surveys
•
Ensure optimum capacity utilisation of hospital infrastructure through periodic review
of MIS reports (hospital efficiency indicators) of all hospitals
•
Increase of health infrastructure (need / technology based) in the state in
coordination with planning cell
•
Ensure that there is no mis-match of specialists and all posts are identified in
hospitals as per norms of the bed capacity of the particular hospitals and also ensure
full complement of staff
•
Visit all District hospitals atleast once in a year to monitor their functioning and
utilsation of resources
Training Areas:
• Attend Management Development Programmes at international institutes such as
Harvard, John Hopkins, etc in areas of Public Health Policies, health policies, New
business models in Health care.
•
Study Health care facilities and delivery system in both developed and developing
countries and also attend national and international and to share the experiences of
Karnataka and get a feedback.
7
Job Title:
ADDITIONAL DIRECTOR - MEDICAL
Reporting To:
•
Director - Medical
Immediate Level Subordinates:
• Joint Director - Medical
•
Joint Director - Pharma (GMS)
• Joint Director - Hospital
Basic Function:
Overall responsibility for effective medical care at different hospitals in the state, looking
after the transfer policy of the state cadre doctors including the specialists. Monitor the
effective utilisation of hospital and medical facilities throughout the state and following
the drug policy guidelines throughout the state.
Duties, Responsibilities and Authorities:
• Upgradation of facilities at district level institutions and other institutions having bed
strength of 200 and above other than those institutions coming under the control of
the Directorate of Medical Education.
•
Adhering to wherever statutory obligations
up/maintaining of hospitals in the state
•
District hospitals attached to medical colleges will also be under the perview of office
of Director - Medical Services
•
Planning, implementation, Monitoring, reviewing evaluation and all matters relating
to upgradation, sanction of additional beds, sanction of additional staff etc.
•
Policy matters related to establishment of hospital pharmacy Units, Govt. Medical
stores, Health equipment, Drugs & matter relating to Department rate contracts on
drugs and equipment.
•
Assists the government in the implementation of medical staff by laws.
•
Matters connected with non-communicable diseases such as Cancer control, Hospital
psychiatric clinics, diabetes control programme and other similar diseases.
•
Responsible for coordination in all areas of operation in the hospital
•
Monitor effective implementation of hospital infection control
•
Policy matters relating to medical reimbursement constitution of medical
boards etc.
•
Monitor medical care facilities to VIPs {as organised by JD)., visiting the State
and arranging medical facilities in the various special functions (Sports/
congregations of Spl. Festivals/ Melas etc.,).
•
Work in coordination with Additional Director - Planning to identify the number of
specialist posts for the next five years at regular intervals in different hospitals of the
applicable
regarding
setting
8
Review of
Stnuonre
-Vol II (Job uescnpt
state and take steps to groom the existing doctors by recommending for Post
Graduate Course or any refresher course.
•
Ensure optimum utilisation of the manpower resources attached to him, organize
and / or arrange to organize training programmes to augment skills and attitudes,
appraise performance of employees, counsel employees and contribute to overall
growth and development of the staff directly attached to him, recommend
increments, promotions, transfers, etc.
•
Continuous monitoring of the performance of the personnel at different hospitals and
recommend for any training required.
•
Monitor the utilisation of hospital resources (space planning, physical infrastructure,
capacity utilisation of beds, etc) and equipment.
•
Study the MIS reports and decide on any corrective actions.
•
Responsible for conducting medical audit by appropriate personnel
•
Hold periodical quality assurance meetings for effective review
•
Aware of all legislative provisions which affect his work area. Ensure that the
reporting staff is also doing this. Also ensure that all tasks and operations of his
departments are carried out within the framework of the laws, statues, rules, orders
and procedures as may be stipulated from time to time.
•
Monitoring the policy matters relating to organ transplantation, and matters relating
to Corpus fund
Main Accountabilities:
• Pay visit to all District hospitals and other major hospitals atleast once in a year to
check the proper usage of allotted resources and find out reasons for need for
upgradation of resources.
• Complete the record of medical audits conducted on a sample basis in the state and
show the corrective actions taken
•
Conduct internal audit for the processes related to a particular functionary in the
department in a major hospital and suggest means to improve that.
•
Suggest for proper demand estimation for the specialists in different hospitals of the
state
Plan and indent for the equipment required for diagnosing and treatment of different
kinds of NCD cases
•
•
Monitor the working of referral system in the state
•
Coordinate with the office of AD - Planning in identifying the number of specialists
required from time to time
9
Training Areas:
reputed institutes and study tours of well
• MDP in hospital administration from
managed hospitals abroad
Process of conducting internal and medical audit
•
Job Title:
JOINT DIRECTOR - MEDICAL
Reporting To:
Additional Director - Medical
Immediate Level Subordinates:
• Deputy Director - Medical
Basic Function:
Oversee the treatment and availability of doctors for all kinds of human ailments and
their effectiveness in delivering the best medical care
Duties, Responsibilities and Authorities:
• Recommendation for establishment of hospital pharmacy Units, procuring health
equipment, Drugs and other matters relating to Department rate contracts on drugs
and equipment in coordination and consultation with Joint Director - Pharma, Joint
Director - Procurement, Joint Director - Hospital and Joint Director - Equipment &
Maintenance as and when the need arises
Arrange infrastructure for non-communicable diseases such as Cancer control.
Hospital psychiatric clinics, diabetes control programme and other similar ailments
and of mental health, de-addiction programme, old age programme, anti-smoking,
de-addiction, hypertension, etc, in coordination with Procurement division of the
.
department.
•
Matters relating to medical reimbursement, constitution of medical boards etc.,
.
Constituting medical boards for first appointment of all appointments in the state.
.
Constituting medical board for unauthorised absence or long leave certification,
change of cadre, etc
.
Medical audit and quality assurance of hospitals
•
Monitor effective implementation of hospital infection control
.
Inspection of hospitals to monitor their physical / equipment / staff for
transplant, etc. (special acts as
implementation of special programmes such as organ
<
member of the appropriate authority)
•
Inspection regarding customs duty exemption
10
Monitor the flow of information regarding toe availing of
.
*
^nZngTinfoLdon aTesing It ArX for aociai science research and any
interpretations for better service
Study the MIS reports and decide on any corrective actions.
Monitor the process of handling the medico-legal cases in different hospitals.
•
•
Providing medical care facilities to VIPs., visiting the
the State
State and arranging medical
facilities in the various special functions (Sports/ congregations of Special
.
Melas etc.,).
Monitor all matters relating to Corpus fund (Chief Minister's fund)
•
Main Accountabilities:
. t
. Proper deployment of doctors during special festivals and melas. To see that no
disease spreads due to the lapses from the doctors.
•
Effective utilization of Corpus fund
•
a year and report
Visit all district Hospitals and atleast -■ CHC/TH (quantifiable) in
the existing facilities there to AD Medical
Training Areas:
• Conducting medial audit and internal audit
. Hospital Personnel management (emphasis on Organizational Behavior/motivation)
Job Title:
DEPUTY DIRECTOR - MEDICAL
Reporting To:
Joint Director - Medical
Immediate Level Subordinates:
•
District surgeon
•
Superindent of major hospital
Basic Function:
government sponsored schemes for the poor and needy in the state.
Duties, Responsibilities and Authorities:
• Reaularlv review the quality of healthi care provided at various health units in the
state su^ as dlnlcs. Maternal
hosptals by
Maternal homes,
homes, dispensaries
dispensaries and
a.- referral
----undertaking regular visits to them along with the heads of those units.
.
Ensure the flow of information regarding the availing of medica!
different hospitals to the office of Additional Director - Planning s office for
11
MG
generating MIS information and using it further for social science research and any
interpretations for better service.
•
Review the working of different schemes of government for the poor to avail good
treatment at the government hospitals
•
Ensure proper maintenance of all medical records, documents and files in his
department.
•
Ensure proper up-keeping and maintenance of assets assigned to the department
situated at all locations
•
Support any activity related to medical audit initiated anywhere in the department
•
Recommend medical audit for the cases involving any irregularity specifically found
out on routine inspection
•
Monitor effective implementation of hospital infection control
•
Monitor the cleanliness of hospital programme to maintain the hygienic conditions
•
Monitor all matters relating to Corpus fund (Chief Minister's fund)
Main Accountabilities:
•
Visit all district hospitals and major hospitals atleast once in a year and conduct
enquiries about availability of specialists at the required time
•
Suggest ways and means of availing the specialists' services at remote places in the
state (by means of transfers which can be worked out)
Training Areas:
•
Conducting medical audit
•
Administration of personnel
Job Title:
JOINT DIRECTOR - PHARMA
Reporting To:
Additional Director - Medical
Immediate Level Subordinates:
• Deputy Director - Pharma
Basic Function:
Functionally the reference authority in the department for any drugs and
pharmaceuticals related issue. Oversee the functioning of Government Medical Stores
and pharmacies handling different volumes located at different hospitals in the state
including the staffing matters at the respective locations.
12
rv t-' v ,C- >.-V
O/Ucj/
-Vo* 'i
De^c:
Duties, Responsibilities and Authorities:
•
Monitor the process of taking requisitions from different hospitals for replenishing
the stocks of pharmaceuticals and the other related policy matters.
•
Planning, implementation, monitoring and reviewing of various activities connected
with the procurement and disbursement of drugs.
•
Review of Stock position of drugs and equipment in the pharmacies located in the
government hospitals and Government Medical Stores and distribution as per
annual indents.
•
Oversee the mandatory guidelines in employing the pharmacists in hospitals
•
Work in coordination with and directions from Drug Controller regarding the policies
and regulations.
•
Approve setting up of pharmacies in different hospitals
•
Provide information as required to Drug Controller
•
Proper documentation of matters relating to Expert committee and High Power
Committee meetings and finalisation of rate contracts on drugs and equipment and
follow up action.
•
Preparing / updating essential drug lists for use at various levels such as PHC / CHC
/TLH / DH and other hospitals.
Main Accountabilities:
•
Proper logistics in procuring the drugs and vaccines
•
Proper logistics in disbursing the drugs as the requirement is, at different places
•
Conduct inspection visits to all district hospitals and major hospitals in the state to
monitor the working of pharmacies in those respective locations.
•
Effective addressing of any sudden requirement of life-saving drugs or problems
during epidemics/natural calamities
Training Areas:
•
Statutory obligations with the Drug Controller's office
•
Logistics in handling drugs and related materials
13
Review of Orc
Job Title:
JOINT DIRECTOR - HOSPITAL
Reporting To:
Additional Director - Medical
Immediate Level Subordinates:
•
•
Deputy Director - Hospital (N)
Deputy Director - Hospital (S)
Basic Function:
Monitor basic infrastructure facilities in all the hospitals and review the
requirements for any upgradation to meet the specified standards. (Coordinate with
District Medical Officer in taking up this activity). Monitor the working of nursing staff
and address to their requirements and suggestions in upgrading the delivery of health
services to the people of the state.
Duties, Responsibilities and Authorities:
•
Recommendation for establishment of hospital pharmacy Units, procuring health
equipment, Drugs and other matters relating to Department rate contracts on drugs
and equipment in coordination and consultation with Joint Director - Pharma, Joint
Director - Procurement, Joi. J Director - Hospital and Joint Director - Equipment &
Maintenance as and when the need arises
•
Overall incharge of hospital functioning,
throughout the state.
•
Responsible for inter-hospital coordination at all occasions, especially during any
exigencies or outbreak of epidemics in the state.
•
Responsible for nursing activity and any coordination with external agencies like Red
Cross (India) whenever the need arises.
•
Monitor the cleanliness of hospital programme to maintain the hygienic conditions
•
Plan regarding the hospital waste disposal in consultation with the office of AD
Urban health and Commissioner, municipal authorities
•
Up-keeping of district level institutions and other institutions having bed strength of
100 and above other than those institutions coming under the control of the
Directorate of Medical Education.
•
Planning, implementation, monitoring, reviewing evaluation and all matters relating
to upgradation, sanction of additional beds, sanction of additional staff etc.,
•
Monitor the flow of information regarding the availing of medical information at
different hospitals to the office of Additional Director - Planning's office for
generating MIS information and using it further for social science research and any
interpretations for better service.
•
Monitoring of Medical audit and internal audit of all the hospitals
•
Ensuring the patients charter of rights
infrastructure and patient facilities
14
Main Accountabilities:
•
All the infrastructure related requirements within the budgeted framework are met
within 6 months of raising the requirement from any District surgeon / DHO, routed
through DD Hospital
•
Hygenic conditions in the hospital and effective hospital waste disposal norms as
specified by the concerned authorities from time to time
•
Planning, implementation, monitoring, reviewing evaluation and all matters relating
to upgradation, sanction of additional beds, sanction of additional staff etc.,
•
Monitor the flow of information regarding the availing of medical information at
different hospitals to the office of Additional Director - Planning's office for
generating MIS information and using it further for social science research and any
interpretations for better service.
• Monitoring of Medical audit and internal audit of all the hospitals
Training Areas:
• Hospital planning (any designs, apart from functioning)
•
Hospital administration
•
Hospital waste disposal and treatment
Job Title:
DEPUTY DIRECTOR - HOSPITAL
Reporting To:
Joint Director - Hospital
Immediate Level Subordinates:
• Coordination with District Surgeons
•
Lay secretaries of hospitals
Basic Function:
Ensure optimum utilization of hospital facilities and are maintained according to the
standards specified by central and state governments from time to time.
Duties, Responsibilities and Authorities:
• Ensure that the health care services available to the target population is adequate
•
Ensure that the dispensaries, Maternal homes and referral hospitals are easily
accessible to the population as per the directives of central government
•
Review need for rationalization and relocation of some health units as well as setting
up new health units in order to improve accessibility and service coverage.
•
Monitor the cleanliness of hospital programme to maintain the hygienic conditions
.................................................................................
15
•
Ensure the flow of information regarding the availing of medical information at
different hospitals to the office of Additional Director - Planning's office for
generating MIS information and using it further for social science research and any
interpretations for better service.
Continuous monitoring of the performance of the personnel at different hospitals and
recommend for any training required.
Main Accountabilities:
• Proper utilization of hospital resources / infrastructure
•
•
Visit all government hospitals and major hospitals atleast once a year and monitor
the utilization of hospital resources by the concerned people
• Ensure proper hospital waste disposal
Training Areas:
• Hospital administration
•
People Management
•
Monitoring technology improvements in other parts of the world
Job Title:
ADDITIONAL DIRECTOR - NCD
Reporting To:
Director - Medical
Immediate Level Subordinates:
• Joint Director - Opthalmology
•
Joint Director - NCD (Cardiology and Diabetology)
•
Joint Director - Traumotology
•
Joint Director - Mental Health
• Joint Director - Oncology
Basic Function:
Implementation and Monitoring of national programmes of NCD, proper treatment for all
kinds of NCD diseases such as Cancer, diabetes, heart ailments and trauma in different
hospitals in the state.
Duties, Responsibilities and Authorities:
• Suggest for proper demand estimation for the specialists in different hospitals of the
state
•
Identify the magnitude of the problem of NCD cases
•
Plan and indent for the equipment required for diagnosing and treatment of different
kinds of NCD cases
•
Monitor the working of referral system in the state
16
I
•
Coordinate with the office of AD - Planning in identifying the number of specialists
required from time to time
•
Ensure proper storing of radio-active material at different hospitals, used in the
treatment of cancer
•
Inform the target number of posts in the fifth successive year to Director - Medical
and suggest the means of getting such numbers into the system.
•
Review the MIS reports from time to time and suggest corrective actions to the
concerned Surgeons and other officials in the department
•
Study the developments around the world in the treatment of different kinds of
Human ailments and pass on the knowledge to different functionaries in the
department
•
Encourage participation of the doctors in their related national and state health
programmes and work hand-in-hand with the office of District Health officer
•
Identify the potential levels of the doctors in the Medical health department and
suggest for any refresher/continuous learning courses for them from time to time
•
Conduct medical audit on sample basis for some cases and compulsorily for all the
controversial cases.
•
Monitor effective implementation of hospital infection control
•
Coordinate with the office of Additional Director - Planning
•
Ensure implementation of Blindness Control Programme, Mental Health Programme
Main Accountabilities:
• Visit all the district and other major hospitals in the state atleast once a year
•
Ensure implementation of Blindness Control Programme, Mental Health Programme
•
Identify the magnitude of the problem of NCD cases
•
Conduct medical audit on sample basis for some cases and compulsorily for all the
controversial cases
Training Areas:
• Health Management
•
Hospital management
•
Programme management
17
Job Title:
JOINT DIRECTOR - OPHTHALMOLOGY
Reporting To:
Additional Director - NCD
Immediate Level Subordinates:
• District Surgeons
•
Eye specialists in the state
•
Other National Blindness Control Programme officers of the district
• District Health Officer
Basic Function:
Oversee the National Blindness Control Programme in the state and ensure proper
staffing pattern in the ophthalmology department in different hospitals in the state. Also
ensure adequate care for the ophthalmology related patients and high success rate
during any operation. Identify the magnitude of the problem of blindness cases
Duties, Responsibilities and Authorities:
• Planning, implementation and monitoring of programmes connected with National
Programme for control of Blindness.
•
Identify the magnitude of the problem of blindness cases
•
Training of Ophthalmic Assistants.
•
Matters pertaining to calling for tenders for drugs, equipment related to
ophthalmology.
•
Ensure conducting of medical audit for some operations on a sample basis and
compulsorily for critical and controversial operations
•
Coordinate with District Officers in spreading the message of good nutrition for
control of blindness among the people of the state
•
Review of working of Major equipment
•
Continuous monitoring of the performance of the personnel at different hospitals and
recommend for any training required.
•
Monitoring the activities related to District Blindness Societies
•
Monitor the effectiveness of eye-camps conducted
•
Review the hygienic conditions in the eye-operation theaters and eye-wards
•
Monitoring the eye transplantation operations performed in different hospitals
• Coordination with NGO's working in the field of blindness control
Main Accountabilities:
• Medical audit of eye operations conducted either at special camps or hospitals
•
Visit all hospitals which have the facility for eye-operation in the state, atleast once a
year.
18
Ri
•
Be a part of the team conducting eye related operation, atleast on 15 occasions in a
year
• Programme evaluation of blindness control
Training Areas:
• New areas of development in proper eye care
•
Exposure to new equipment related to opthalmology
•
Programme Management
•
Health Management
Job Title:
JOINT DIRECTOR - NCD (Cardiology & Diabetology)
Reporting To:
Additional Director - NCD
Immediate Level Subordinates:
• District Surgeon
•
Superintendents of major hospitals
•
Other specialists in the area of Cardiology and Diabetology
Basic Function:
Overall incharge for the diagnosis and possible treatment of Cardiac and Diabetes
related ailments to the people of the state. Monitor the basic referral system in the state
with reference to the above mentioned ailments and conduct medical audit of the cases
wherever found necessary and asked for.
Duties, Responsibilities and Authorities:
• Conduct different awareness building camps about Cardiology and Diabetes including
prevention factors, risk factors and patient education
•
Monitor proper availability of life saving drugs related to Cardiology and Diabetes
•
Monitor referral system in the state with respect to the above ailments
•
Ensure conducting of medical audit for some operations on a sample basis and
compulsorily for critical and controversial operations
•
Planning, implementation and monitoring of programmes connected with National
Programme for control of cardiac cases and diabetic cases
•
Identify the magnitude of the problem of blindness cases
•
Training of Assistants in the field of cardiology and diabetology.
•
Matters pertaining to calling for tenders for drugs, equipment related to cardiology
and diabetology.
•
Ensure conducting of medical audit for some operations on a sample basis and
compulsorily for critical and controversial operations
19
•
Submit all relevant material which can be hosted on the department website
•
Ensure that full economy and expenditure control is observed in all public health
related operations and activities in the state.
•
Recommend transfer and postings of District Health Officers.
•
Overall responsibility for the prevention of diseases of any kind and promotion of
health throughout the state by training the department cadre
•
Monitor each national and State health programmes and their implementation with
special emphasis to Maternal & Child Health and Primary Health Care
•
Suggest for the continuation or stopping of different national and state health
programmes according to the need of the state.
•
Monitor the training needs identification of the personnel in the department and
nominate for the respective programmes to be conducted by State Institute of
Health and Family Welfare or other institutes from time to time
•
Monitor the Information, Education and Communication department activities in the
state in terms of educating / bringing awareness among the people
•
Monitor the treatment and curbing the spread of vectorborne diseases in the state
with the coordination of corporations and municipal authorities in the state with
emphasis on disease surveillance and epedemiology
•
Monitor the norms of blood safety as specified by concerned authorities/boards from
time to time
•
Monitor the functioning and activities of Vaccine Institute, Belgaum.
•
Monitor and Review the methods of combating the spread of Communicable diseases
in the state
•
Monitor the working of urban health programme and slum improvement programme
•
Receive and review the MIS reports on the status of health in the state and take up
any remedial actions either in terms of interim review of existing programmes or
new programmes.
•
Work for the coordination between all the reporting functionaries
•
Work for the effective coordination with external and autonomous agencies in
implementing the health mandate in the state.
•
Monitor effective implementation of various public health programme
Main Accountabilities:
•
Visit all districts and taluks
which conduct the national/state public Health
programmes in the state atleast once in a year
Address all programme officers in the districts atleast once in a year and appraise
them of the expectations of the government and their deliverables
22
•
Ensure quality of care in all PHC's through periodic medical audit and patient
satisfaction surveys
•
Achievement of Health goals of state
•
Ensure optimum capacity utilisation of hospital infrastructure through periodic review
of MIS reports (hospital efficiency indicators) of all hospitals
•
Increase of health infrastructure (need / technology based) in the state in
coordination with planning cell
Training Areas:
• Attend Management Development Programmes at international institutes such as
Harvard, John Hopkins, etc in areas of Public Health Policies, health policies, New
business models in Health care.
•
Study Health care facilities and delivery system in both developed and developing
countries and also attend national and international and to share the experiences of
Karnataka and get a feedback.
•
Awareness of different kinds of Public Health Programmes in the developed and
developing countries
•
Project execution methodology of international agencies
•
Health Management
Job Title:
ADDITIONAL DIRECTOR - RCH
Reporting To:
Director - Public Health
Immediate Level Subordinates:
• Joint Director - RCH
Basic Function:
Overall responsibility for all Maternal and child health in the state. Ensure proper
implementation of RCH / Family Planning programme in the state
Canalso look after the work of AD - primary health.
Duties, Responsibilities and authorities:
•
He is the overall head of the RCH project office of Directorate of Health & FW
Services.
•
He is responsible for planning of RCH programme
•
He is responsible for effective achievement of the laid down projects under FW &
MCH programme.
•
He is overall supervisory authority for training of various field staff like Dais, Para
Medical staff and Medical personnel.
23
•
Coordinate with municipal and corporation authorities in spreading the message of
Maternal and Child Health
•
He is responsible for acting as liaison between Govt, of India/ Internal agencies like
UNICEF, World Bank and State Government for various projects from preparation to
implementation stage.
•
He is responsible for procuring and equipping the public health institutions and Taluk
institutions, with various types of equipment & apparatus for effective
implementation stage.
•
Ensure the increase in deliveries in PHC or other hospitals to decrease the risk of
infant mortality and maternal mortality
•
He is responsible for monitoring and supervising the activities of the demographic
cell, IEC activities of RCH project office.
•
Recommend construction of subcenters for RCH programme
Main Accountabilities:
• Visit all district Hospitals, some PHC/CHC's (quantifiable number) and specialty
hospitals atleast once a year
•
Ensure the increase in deliveries in PHC or other hospitals to decrease the risk of
infant mortality and maternal mortality
•
He is responsible for monitoring and supervising the activities of the demographic
cell, IEC activities of RCH programme
I
Training Areas:
• Programme management
•
Health management
•
Pediatric care
•
Community Health
•
Issues in Maternal & Child Health, their addressal in different parts of the world
24
-Voi r 'Job Desr
Job Title:
JOINT DIRECTOR - RCH
Reporting To:
Additional Director - RCH
Immediate Level Subordinates:
• Deputy Director - RCH
•
Deputy Director - IUD & PPP
Basic Function:
Responsible for proper Maternal and child health in the state. Ensure proper
implementation of RCH programme in the state
Duties, Responsibilities and authorities:
•
He is the nodal officer of the RCH project office of Directorate of Health & FW
Services.
•
He is responsible for implementation of RCH programme
•
He is responsible for effective achievement of the laid down projects under FW &
MCH programme.
•
He is overall supervisory authority for training of various field staff like Dais, Para
Medical staff and Medical personnel.
•
Coordinate with municipal and corporation authorities in spreading the message of
Maternal and Child Health
•
He is responsible for acting as liaison between Govt, of India/ Internal agencies like
UNICEF, World Bank and State Government for various projects from preparation to
implementation stage.
•
He is responsible for procuring and equipping the public health institutions and Taluk
institutions, with various types of equipment & apparatus for effective
implementation stage.
•
Ensure the increase in deliveries in PHC or other hospitals to decrease the risk of
infant mortality and maternai mortality
• Implement construction of subcenters for RCH programme
Implementation, monitoring and reviewing of all activities connected with RCH
programme, immunization of children against vaccine preventable diseases and other
MCH activities.
•
Procurement of UIP vaccines, distribution and follow-up of the vaccines &
maintenance of Cold chain equipment/ articles.
•
Monitor the timely administration of vaccines to pregnant women and infants
throughout the state
•
Ensure the availability of doctors, nurses and ANMs at the respective hospitals to
attend to any kind of medical help regarding Maternal and child health
25
Review of Orqam'.-i
Structure
•
Work in coordination with the IEC functionary in spreading the message of Mother
and Child Health and the precautions to be taken during pregnancy and child birth
•
Submit the reports regularly to the office of AD-planning for developing a
comprehensive MIS reports on the status of Maternal and Child Health in the state.
•
Supply of material to IEC functionaries regarding the material to be prepared about
Maternal and Child Health
•
Recommend for construction of RCH sub-centres, postpartum centres and other
buildings coming under RCH programmes.
•
Payment of Grant-in-aid to the voluntary agencies who are implementing the RCH
programme.
•
Coordinate with the office ofJD - IUD & PPP to spread the message of RCH
•
Monitor the effective implementation of Universal Immunization Programme.
•
Ensure the increase in child deliveries in PHC or other hospitals to decrease the risk
of infant mortality
Main Accountabilities:
•
Increase in deliveries in PHC or other hospitals to decrease the risk of infant
mortality and maternal mortality
•
Visit all district hospitals atleast once in a year and other community health and
primary health centres on a sample basis
•
Conduct atleast one meeting of all the district family planning and RCH officers in a
year
•
He is responsible for monitoring and supervising the activities of the demographic
cell, IEC activities of RCH programme
Training Areas:
•
Programme management
•
Health management
•
Pediatric care
•
Community Health
•
Issues in Maternal & Child Health, their addressal in different parts of the state
26
Job Title:
DEPUTY DIRECTOR - IUD & PPP
Reporting To:
Joint Director - RCH
Immediate Level Subordinates:
• District Health Officer
• District Family Planning Officer
Basic Function:
Overall incharge of family planning operations in the state and implement the
national and state level programs in relation to IUD & PPP. Convey the decisions taken
at the directorate regarding IUD & PPP programs to the district officials
Duties, Responsibilities and Authorities:
•
Responsible for planning, supervision and guidance of IUD programme oral pill
programme and All India Hospitals Post Partum Programme under the supervision
of Joint Director - RCH
•
Provide guidance and supervision to the field operations in relation to Family
Planning Programme in State at various levels especially in the field of IUD & PPP
and oral pill programme.
•
Secure cooperation and assistance of related departments for family planning work
at State level.
•
Review programme operation from time to time, identify problems, provide help in
finding situations and seek assistance of Govt, of India, to solve them when
necessary.
•
Ensure arrangement to follow up of each case of IUD in the region allocated.
•
Maintain administrative liaison with all official and non-official family planning
organisations in the State.
•
Coordinate with the office of JD - RCH and spread the message about Family
planning
•
Conduct special family planning camps to men and women throughout the state
•
Coordinate with IEC functionary in spreading the message of family planning and
misconceptions about different kinds of family planning methods
•
Formulate field instructions and operative manuals.
•
Function as a clearinghouse for up to-date information on achievements and
progress in the State as a whole for IUD & IPPP and oral pill.
•
Attend to such other items of work as may be assigned and the Joint Director - RCH
and other superior authorities.
27
Job Title;
DEPUTY DIRECTOR - RCH
Reporting To:
Joint Director - RCH
Immediate Level Subordinates:
Basic Function:
His office acts as nodal centre for all the districts regarding different national and state
RCH programs. Monitors the RCH and particularly the reproductive and child health
programs in different parts of the state. Conveys different decisions taken at the
directorate regarding the above programs to the district officials.
Duties, Responsibilities and Authorities:
• Work towards integrating maternal & child health and family planning.
•
Work in close liaison with the Deputy Director - IUD & PPP and other officers of
State Family Planning Bureau.
•
Ensure that all maternal and child health staff fulfil their required responsibilities in
family planning and that the MCH clinics are equipped with the necessary supplies
and facilities for family planning work.
•
Assess the in-service training neeos of all MCH personnel and arrange for their
training.
•
Coordinate and guide family planning training in the nurses and ANM training
courses to ensure that proper training in family planning is imparted.
•
Help to supervise the MCH services to ensure that there are adequate physical
facilities, equipment and drugs and to see that proper educational and clinical
procedures are carried-out.
•
Convey the decisions taken regarding RCH activities to the district officials.
•
Ccwi/ey the suggestions and problems of the district level officials to the JD/AD RCH
•
Help to guide and supervise proper follow-up of women who have adopted family
planning methods.
•
Take action to organise the ANM training centres and LHV training centres and see
that the centres function properly.
•
Arrange to see that selection to the ANM and LHV training centres is done in time
and as per rules.
•
Arrange to conduct the training according to prescribed syllabus and arrange for
conducting examinations periodically and to announce the results.
•
Take action to organise the dais training.
•
Supervise work of District Nursing Supervisors, check and review their diaries,
inspect the work of LHVs and ANMs.
28
•
Take action to organise the programme of immunisation of pre-school children and
expectant mothers and prophylaxis against nutritional anemia vitamin A deficiency.
•
Attend to such other items to work as may be assigned to him by the Joint Director
(RCH) and other superior authorities.
Job Title:
ADDITIONAL DIRECTOR - HEALTH PROMOTION
Reporting To:
Director - Public Health
Immediate Level Subordinates:
• Joint Director - Health promotion
•
Joint Director - IEC
Basic Function:
Responsible for educating the different functionaries in the department about national
and state health programmes. Oversee the Information, Education and Communication
activities in the state and their affectivity in reaching to the people of the state with
special emphasis to the rural, slum and school children and liasion with different
agencies of mass media in the state in spreading the message of health to all.
Duties, Responsibilities and Authorities:
•
Liaison with AIDS society in spread ng the message of prevention measures against
AIDS
•
Coordinate with all the functionaries in the Health Department and receive
requisitions regarding any kind of spread of prevention message for the public
regarding public Health and medica! health
•
Emphasis of positive health, school health and use of captive audience in hospitals
•
Oversee the activities of the publication division of the department
•
Review the process of sending requisition of publication from IEC cell to the
publisher.
•
Set standards and monitor the quality assurance in the publications of the
department
•
Guide the respective Joint Directors in setting targets to the Health Promotion and
IEC cells of the department and attain the goals
•
Coordinate with the office AD - planning in generating reports about the status of
health in the state and planning for the future in attaining good health standards
•
Suggest methods of using the special occasions of melas and exhibitions to spread
the message of Public Health
•
Monitor the activities involving bringing awareness among the general public and
children about the public health.
29
•
Identify the areas of development among the department functionary about public
Health and appraise the State Institute of Health and RCH about them and ensure
nominating eligible persons as and when such programmes are announced by any
institute
•
Liasion with All India Radio, Doordarshan and other authorities in spreading the
message of Public Health
•
Intersectoral coordination with information and broadcasting, labour education,
women and child department
•
Emphasis on patients charter of rights
•
Head of State health Education Bureau
Main Accountabilities:
Visit all major exhibitions where the department participates with its stall in it
Public perception of IEC activities
Post programme evaluation
Training Areas:
Mass media education
30
Job Title:
JOINT DIRECTOR - I.E.C.
Reporting To:
Additional Director - Health Promotion
Immediate Level Subordinates:
• Deputy Director - Information
Basic Function:
Overall responsibility for spreading the message of preventive health to the
people of the state through different platforms. Use all such opportunities wherein which
the message of Public Health can be spread.
Duties, Responsibilities and Authorities:
•
Monitor all matters relating to information, education and communication related to
Health of the people of Karnataka.
•
Responsible for procurement, distribution and utilisation of educational materials
related to RCH and Maternal and Child Health
•
Incharge of the publication of KUTUMBA, every fortnight
•
Conduct the field verification of RCH acceptors and incentives paid to the RCH
beneficiaries.
•
Coordinate with State Institute of Health and RCH in formulating the content of the
course about Public / Preventive Health and its allied areas
•
Post programme evaluation and its impact on the public (quantifiab/e)
•
Conduct in-service training to the RCH staff on I.E.C. activities.
•
Head the department press and its activities
•
Coordinate with different Medical and health departments in the contents related to
the publication and distribution
•
Spread the message of drug addiction / alcohol and educate people for being away
from smoking, drinking and other forms of drug addiction.
Main Accountabilities:
Error free distribution IEC material and other publications from the department
Training Areas:
a)Mass communication b)Conducting exhibitions c)Multi-media
31
Job Title:
DEPUTY DIRECTOR - INFORMATION
Reports To:
Joint Director (Information, Education & Communication)
Immediate Level Subordinates:
• Field Publicity Officer
Basic Function:
Ensure the spread of the error free desired information among the public of the state,
organise exhibitions at small/big congregations to bring awareness in the areas related
to Health. Liaison with other agencies in production of films related to educational
aspects of health
Duties, Responsibilities and Authorities:
• Responsible for entire Mass Media and Mass education programmes of Family
Planning in the state.
•
Co-ordinate the family planning mass education programme in the state, districts
with the help of all other states and Government of India Publicity units.
•
Plan and design for production and distribution of publicity material for Mass
education, and extension education in the state.
•
Collect information on all districts about the newspapers in circulation, cinema
theatres in operation, audio-visual units of State and Government of India available
and other mass media education items, so as to use them effectively for education.
•
Liaison with the press, radio, field publicity units and mass media to provide
necessary background material to them.
•
Guide and supervise the work of District Mass Education and Information officers
and District Health educators.
•
Bring out success stories of individuals adopting family planning methods by visiting
services, camps, wherever held in the districts.
•
Prepare digests of critical newspaper comments and bring such comments to the
notice of the administrative head of the department and technical officers of the
State Family planning Bureau and also arrange for issue of any clarification to
remove the mis-apprehension or doubts in the minds of the people.
•
Plan for the production of sufficient printing matters for running the offset press.
•
To stimulate and coordinate the effective use of all types of educational material by
all categories of Family Planning field workers as well as others.
•
Monitor the out door publicity programmes.
32
Training Areas:
•
Conducting exhibitions
•
Effectiveness of theatre arts
Multi-media
•
Effective use of print media
•
An internship with DAVP, GOI
Job Title:
FIELD PUBLICITY OFFICERS
Reporting To:
Deputy Director - Information
Immediate Level Subordinates:
• Programme Assistant
•
Health Education Officer
Basic Function:
Incharge of all the publicity material procured by the IEC functionary of the Directorate
of Health Services. Plan and implement the ways to take the message even to the rural
areas in the state.
Duties, Responsibilities and Authorities:
• Encourage production of family planning films in the state with the help of available
official and or private agencies.
•
Arrange production and distribution of family planning filmstrip, slides, recordings
and distribution thereof.
•
Supervise the functioning of audio-visual units in the districts.
•
Maintain effective liaison with the media units
•
Assist in the organisation of Family Planning campaign at the State/District level
•
Initiate and supervise design and fabrication of all exhibits for the exhibition
•
Direct and supervise the activities of Exhibition in the Districts/Rural centres
•
Guide and help the district MEIO's Extension Educators
•
Supervise effective use of display publicity, hoardings, bus-boards, wall paints and
metallic tablets etc. in the state
•
Such other allied duties as may be assigned by the AD (RCH)
Main Accountabilities:
• Number of exhibitions conducted
33
Training Areas:
•
Conducting exhibitions
Communication in mass media
Job Title:
HEALTH EDUCATION OFFICER
Reporting To:
Field Publicity Officer (Functionally)
District Health Officer (Administratively)
Immediate Level Subordinates:
Basic Function:
Primary responsibility to establish working relationship with NGOs and local bodies in
spreading the message of Health, taking stock of the available material and plan for
procurement and distribution of the same.
Duties, Responsibilities and Authorities:
•
Develop and maintain a close working relationship with the State Health Education
Bureau in order to utilise fully the technical and physical resources of the bureau for
the family planning programme.
•
Develop and maintain close working relationship with different agencies that can
contribute to the educational programme like the education department, information
department, All India Radio, Development and Panchayat Raj Department etc. and
utilise their resources.
•
Promote the educational activities of the voluntary agencies and local bodies
•
Co-ordinate the efforts of honorary, education leaders and assist them in their work.
•
Assess the educational needs and recommend educational programmes for district
and state Training institutes.
•
Responsible for planning and operating a statewide information programme utilising
all available channels and media of mass communication.
•
Provide technical guidance to the District Family Planning Bureau.
•
Assess the needs of educational material and equipment and arrange for their
procurement and distribution.
•
Assist the AD - RCH in assessing training needs in health education and develop a
plan for detaining personnel for training.
•
Organise seminars, workshops, conferences and periodical staff meetings.
•
Attend to such other functions as may be assigned from time to time.
34
Training Areas:
• Conducting health campaigns
•
Conducting exhibitions
•
Effective use of theatre arts
Job Title:
PROGRAMME ASSISTANT
Reporting To:
Field Publicity Officer
Immediate Level Subordinates:
Basic Function:
Duties, Responsibilities and Authorities:
• Assist Field Publicity Officer in compiling organising and production of field
programmes, exhibitions songs and drama programmes, traditional media
programme and other cultural activities to communicate Family planning programme
to the people.
•
Assess the programmes sponsored and consolidate them.
•
Assist in selection of artists and types of programmes which the audience prefer.
•
Assist in selection of movie films on Family planning, exhibits for exhibition purposes,
production of family planning films to be produced by State Family Planning Bureau.
35
Job Title:
DEPUTY DIRECTOR - SCHOOL HEALTH
Reporting To:
Joint Director - Health Promotion
Immediate Level Subordinates:
Basic Function:
Spread the message of good health among school children and arrange to
conduct periodic health check-ups to school children. Also monitor the hygienic
conditions around the schools and suggest corrective actions to the municipality
authorities and heads of respective schools/institutions
Duties, Responsibilities and Authorities:
• Coordinate with the District Education Officers and organise for periodical health
check-up for the students in different schools
•
Coordinate with District Health Officers in spreading the message of Public Health
among the students of different schools in the state
•
Ensure proper hygenic conditions around the premises of schools in the state and
suggest corrective actions to the heads of institutions
•
Encourage literary activities among the students of different schools
•
Spread the message of special days (world health day, AIDS day, day for the
physically handicapped, etc) among the students of different schools and educate
the pupils about them.
•
Send reports to the MIS functionary for any interpretation regarding the health of
school going children in the state.
Main Accountabilities:
Number of school health programmes
Evaluation of the programme
36
Review
Job Title:
-Vol I! (Job Descni.
ADDITIONAL DIRECTOR - PRIMARY HEALTH
Reporting To:
Director - Public Health
Immediate Level Subordinates:
• Joint Director - Primary Health
Basic Function:
Effective Implementation of all national and state public health programmes. Preparation
of a primary health care policy for the State. Overall responsibility for establishing,
managing and development of health infrastructure at the primary level in the state. Is
responsible for the public health services delivered at the primary level in the state.
Monitor and evaluate the basic programs at all the Primary Health Centres in the state,
availability of basic infrastructure facilities offered to all the Primary health centres and
effective patient care at PHCs. Also monitor the referral system .
Duties, Responsibilities and Authorities:
• Ensure that quality public health care services are available to the target population
•
Ensure that the primary health centers and referral hospitals are easily accessible to
the population, review need for rationalisation and relocation of some health units as
well as setting up new health units in order to improve accessibility and service
coverage
•
Review and evaluate the existing policies and procedures and work methods by
means of periodic and special studies
•
Review the MIS reports generated and take corrective actions
•
Review and recommend the upgradation of primary health infrastructure in the state
•
Work out improved methods and procedures to achieve the objectives and Develop
standards, methods and measurements of the PHC activities
•
Monitor the utilisation of public health
means of bringing optimum utilisation
•
Coordinatr periodic health promotion activities that are carried out in the community
•
Visit all districts esp PHC's at random and review the Public health programmes in
the state, atleast once a year
•
Ensure that medical audit and internal audit has been carried out in as many PHC's
as possible at periodic intervals
•
Submit all relevant material which can be hosted on the department website
•
Ensure that full economy and expenditure control is observed in all public health
related operations and activities in the state at the PHC's level.
Ensure that full complement staff are available at all the PHC's
•
•
resources throughout the state and adopt
Monitor the training needs identification of the PHC personnel in the department
and nominate for the respective programmes to be conducted by State Institute of
Health and Family Welfare or other institutes from time to time
37
•
Monitor effective implementation of various public health programme
•
Coordinate with AD-planning on the budgeting activities
Main Accountabilities:
• Visit all districts and taluks which conduct the national/state public Health
programmes in the state atleast once in a year
Address all PHC officers in the districts atleast once in a year and appraise them of
the expectations of the government and their deliverables
•
Ensure quality of care in all PHC's through periodic medical audit and patient
satisfaction surveys
•
Achievement of Health goals of state
•
Ensure optimum capacity utilisation of hospital infrastructure through periodic review
of MIS reports (hospital efficiency indicators) of all hospitals
•
Increase of health infrastructure (need / technology based) in the state in
coordination with planning cell
raining Areas:
• Attend Management Development Programmes at international institutes such as
Harvard, John Hopkins, etc in areas of Public Health Policies, health policies, New
business models in Health care.
•
Study Health care facilities and delivery system in both developed and developing
countries and also attend national and international and to share the experiences of
Karnataka and get a feedback.
•
Awareness of different kinds of Public Health Programmes in the developed and
developing countries
•
Project execution methodology of international agencies
•
Health Management
38
Job Title:
ADDITIONAL DIRECTOR - CMD
Reporting To:
Director - Public Health
Immediate Level Subordinates:
• Joint Director - Vector Borne
• Joint Director - Leprosy
• Joint Director - TB
• Joint Director - Vaccine
• Joint Director - Lab
Basic Function:
Nodal Officer for the State Surveillance unit. Ensure proper implementation of
various national and state programmes related to Leprosy, Vector borne diseases and
TB. Ensure proper maintenance of laboratories in the state.
Duties, Responsibilities and Authorities:
•
Evolve strategies for Surveillance
•
Set up procedures for collection, analysis and reporting of morbidity and mortality
data.
•
Monitor the functioning of the District Surveillance Units
•
Co-ordinate with other related Departments at the State level, Indian Medical
Association, Programme Officers, Voluntary Organisations, etc.
•
Conduct surveys, compile morbidity and mortality data, by disease, for planning and
working out priorities and strategies.
•
Evaluate the effectiveness of interventions instituted to control epidemics.
•
Carry out research studies and suggest innovative and the effective methods of
intervention
•
Act as the nodal Surveillance unit at the district level and provide the missing link
between the primary and secondary level sub-systems
•
Provide early warning of outbreak of epidemics of all the major communicable
diseases through continuos Zilla Panchayat, PWD, Fisheries, Irrigation, Agriculture,
Rural Development, Indian Medical Association, Programme Officers, Voluntary
Organisations, etc.
•
Planning, implementation, reviewing and monitoring of communicable diseases such
as Diarroheal diseases, Kyasnoor Forest Disease, Guinea Worm etc.
•
Monitor the running of Diagnostic Laboratory, Shimoga, Vaccine Institute, Belgaum,
communicable diseases investigation and Training Centre, Mandya.
-F -/V/C-
39
•
Monitor all activities relating to manufacture (at Vaccine Institute), supply and
distribution of vaccines
•
Monitor the precautionary measures and preparedness of state machinery in tackling
with any natural calamities
•
All matters relating to Air, Water and Environmental pollution, and Slum Clearance
board
•
Monitor the National Leprosy Eradication programme implementation throughout the
state
•
Monitor the overall performance of National TB Control Programme and Lady
Wellington TB Demonstration & Training Centre, Bangalore
Work in coordination with the office of Additional Director - Urban Health in control
of Malaria & Filaria and such other diseases.
Main Accountabilities:
•
Conduct surveys, compile morbidity and mortality data, by disease, for planning and
working out priorities and strategies.
•
Evaluate the effectiveness of interventions instituted to control epidemics.
•
Carry out research studies and suggest innovative and the effective methods of
intervention
•
Set up procedures for collection, analysis and reporting of morbidity and mortality
data.
•
Monitor the functioning of the District Surveillance Units
•
Co-ordinate with other related Departments at the State level, Indian Medical
Association, Programme Officers, Voluntary Organisations, etc.
Training Areas:
Health management
Epidemiological methodology
Programm management
40
Job Title:
JOINT DIRECTOR - VECTOR BORNE
Reporting To:
Additional Director - CMD
Immediate Level Subordinates:
• District Malaria Officer
•
District Filaria officer
•
District Health Officer
Basic Function:
Ensure proper planning and implementation of national and state programmes related to
all Vector Borne diseases and proper utilisation of funds allotted for each unit/district.
Liaison with the municipal authorities in ensuring hygenic living conditions for the people
in the state and appraise them of better methods of sanitation and the importance of
that.
Duties, Responsibilities and Authorities:
•
Planning, implementation, reviewing and monitoring of communicable diseases such
as Diarroheal diseases, Kyasnoor Forest Disease, Guinea Worm etc.
•
Planning, implementation, monitoring of all matters connected with the Ecology,
Malaria, Filaria and other mosquito borne diseases.
•
Process the reports generated through to Central Malaria Laboratory and take
preventive measures to curb the spread of the disease.
•
Planning the activities like budget allocation and key sustenance factors related to
various Diagnostic Laboratory, Shimoga, Vaccine Institute, Belgaum, Communicable
Diseases Investigation and Training Centre, Mandya.
•
All matters relating to manufacture, supply and distribution of vaccines
•
Work in coordination with various civic bodies relating to natural calamities.
•
All matters relating to Air, Water and Environmental pollution, and Slum Clearance
board
•
Overall incharge of curing and arresting the spread of Malaria & Filarial diseases in
the state
•
Work in coordination with the office of Additional Director - Urban Health in control
of Malaria & Filaria and such other diseases.
41
OiStructure
Main Accountabilities:
•
Planning, implementation, reviewing and monitoring of communicable diseases such
as Diarroheal diseases, Kyasnoor Forest Disease, Guinea Worm etc.
•
Planning, implementation, monitoring of all matters connected with the Ecology,
Malaria, Filaria and other mosquito borne diseases.
•
Process the reports generated through to Central Malaria Laboratory and take
preventive measures to curb the spread of the disease.
Training Areas:
Health management
Epidemiological methodology
Programm management
42
Job Title:
JOINT DIRECTOR - TB
Reporting To:
Additional Director — CMD
Immediate Level Subordinates:
• District Health Officer
•
District TB and AIDS Programme Officers
Basic Function:
Carry forward the different national and state programs related to Tuberculosis and
AIDS in the state, treatment of the respective patients and monitor the processes of
control of TB
Duties, Responsibilities and Authorities:
• Monitor different national and state programs related to Tuberculosis and AIDS in
the state
•
Coordinate with the office of AD - IEC for any material or inputs for the publicity
material to educate the people in the areas of TB and AIDS
•
Monitor the process of treatment for some chronic TB patients in the state
•
Coordinate with AIDS Society in the state to educate the people regarding the
precautions to be taken about AIDS
Main Accountabilities:
• Monitor different national and state programs related to Tuberculosis and AIDS in
the state
Training Areas:
Health management
Epidemiological methodology
Programm management
43
of Orga
So actare
Job Title:
JOINT DIRECTOR, VACCINE INSTITUTE, BELGAUM
Reporting To:
Additional Director - CMD
Immediate Level Subordinates:
• Deputy Director - Epidemiological surveillance Unit
•
DHO
• Deputy Director - Pharma
Basic Function:
Manufacture ARV vaccine and its distribution to the institutions of the State and
ensure proper procurement, storage and distribution of UIP / Vaccines in the districts of
Gulbarga and Belgaum divisions
Duties, Responsibilities and Authorities:
• Manufacture of ARV vaccine and its distribution to the institutions of the State.
•
Coordinate with all NGO's and department agencies
•
All matters relating to the DIP/ Vaccines, procurement, storage and distribution to
the districts of Gulbarga and Belgaum divisions.
Training Areas:
Health management
Epidemiological methodology
Programm management
Job Title:
Reporting To:
JOINT DIRECTOR - LABORATORIES
Additional Director - CMD
Immediate Level Subordinates:
• Deputy Director - Viral Diagnostic Lab, Shimoga
• Deputy Director - Bacteriological lab, PHI, Bangalore
• Chemical Examiner
• Chief Chemist
Duties, Responsibilities and Authorities:
•
Planning, implementation, monitoring and reviewing of various activities of Public
Health Laboratories in the State including district Laboratories, Divisional
laboratories, Divisional Food Laboratories and laboratories at various levels
•
Implement Food Adulteration Act procedures in coordination with the municipal and
corporate functionaries at different locations in the state.
44
Review of
•
Imparting training to Laboratory Technicians and Food Inspectors.
•
Dispense the authority and submit reports pertaining to consumers protection Act.
•
Monitor the activities pertaining to food and water analysis in coordination with
pollution control board and local-self bodies.
•
International certification on Health related matters for issue of passports and Visa
•
Generate and submit analytical reports on various samples of epidemiological
importance including samples received from Lokayukta.
Job Title:
ADDITIONAL DIRECTOR - URBAN HEALTH
Reporting To:
Commissioner / DGHS
Immediate Level Subordinates:
Basic Function:
Coordinate with local self bodies in planning to create hygenic conditions in urban areas
and slums. Work in coordination with pollution control authorities in planning for anti
pollution activities. Passing of stringent norms from time to time regarding the disposal
of hospital waste.
Duties, Responsibilities and Authorities:
• Promote urban sanitation among all the municipalities and corporations in the state
with special emphasis on urban slums
• Be in touch with corporation/municipalities commissioners and Chief Executive of
Zilla Parishad through the department functionary and monitor the sanitation/health
activities throughout the state
• To create awareness of personal hygiene and to maintain a better environment for
prevention of diseases
• Recommend policies in handling the waste generated from different hospitals.
• Create amicable platform for interaction between the department of health and
Public Health Engineering functionary of different corporations and municipalities
• Coordinate with the Project Directors of different national Programmes
Training Areas:
Health management
Programm management
45
.I
Job Title:
DIRECTOR - EXTERNAL AIDED PROJECTS (EAP)
Reporting To:
Commissioner / DGHS
Immediate Level Subordinates:
Basic Function:
Guide the department in securing the national and international projects by concerned
bodies and see thay they are properly executed without any mis-appropriation of funds.
Duties, Responsibilities and Authorities:
• He/She and his team of officers are responsible to implement the project. He is also
designated as ex-officio Additional Secretary to Govt to enable to issue Government
orders on all the related matters.
• Shall carryout such of the functions which are assigned by the steering committee
and Project Governing board
• Coordinate with different functionaries / departments in Central / State government
in meeting the project requirements.
• Monitor the usage of funds released for the purpose of the project
• Monitor the effectiveness of different Externally Aided Projects in the state
• Appraise different project reports which are submitted by state department of health
which are prepared to seek financial/any kind of help from ouL.de the government
functionary
Main Accountabilities:
Effective usage of funds released
Timely completion with desired / planned results
Training Areas:
• Project management
•
Coordination and Administrative skills
Job Title:
DIRECTOR - PROCUREMENT & MAINTENANCE
Reporting To:
Commissioner / DGHS
Immediate Level Subordinates:
• Chief Engineer - Civil
• Joint Director - Procurement
• Joint Director - Equipment & Maintenance (Bio-Medical)
Basic Function:
Being overall incharge of the physical asset base of the department should take utmost
care in procuring as per the requirement and properly maintaining them. Procurement
skills as per the norms of the funding agencies
46
Duties, Responsibilities and Authorities:
• Pass the bill ofpayment for the land accumulated / procured for different
constructions to be taken by the Department of Health & RCH
• Approve the procurement and release payment for hospital equipment which are of
value above the level of authorisation by the Joint Director in the department
• Monitor the effective utilisation of all machinery/ equipment / buildings, etc and
their longevity.
• Provide managerial inputs in selection of any kind of construction or procurement of
equipment
• Work for coordination between all the technical functionaries of the department
• Monitor the procurement procedures and processes from time to time
• Monitor and approve for Procure, install, commission, maintain and service bio
medical and other hospital equipment for diagnosis, monitoring, analysis and
therapy, etc
• Work in coordination with funding agencies and manufacturers of equipment and
follow the conditions agreed upon.
• Oversee the transfer of works from procurement functionary to the maintenance
functionary.
Main Accountabilities:
• Monitor the effective utilisation of all machinery / equipment / buildings, etc and
their longevity.
• Provide managerial inputs in selection of any kind of construction or procurement of
equipment
• Work for coordination between all the technical functionaries of the department
• Monitor the procurement procedures and processes from time to time
• Monitor and approve for Procure, install, commission, maintain and service bio
medical and other hospital equipment for diagnosis, monitoring, analysis and
therapy, etc
• Work in coordination with funding agencies and manufacturers of equipment and
follow the conditions agreed upon.
Training Areas:
• Appraising global tenders
•
Coordination & Administrative skills
Procurement skills as per the norms of the funding agencies
I
I
47
•/- .?f 0/ q?. n s a tio; i Structt if
Job Title:
JOINT DIRECTOR - PROCUREMENT
Reporting To:
Director - Procurement & Maintenance
Immediate Level Subordinates:
Basic Function:
Procure all kinds of equipment other than related to pharmacy and Government medical
stores, after properly studying the reliability of the manufacturer and efficient after-sales
service. Ensure the requirement of the equipment to be procured by suggesting a better
indenting, sanctioning and approving authority to procure them. Procurement skills as
per the norms of the funding agencies
Duties, Responsibilities and Authorities:
1. Understand / study the equipment needs and provide atieast basic utilities wherever
required
2. Select the equipment based on technical evaluation
3. Ensure proper chanellisation of indenting, approving and sanctioning of the
procurement of equipment.
4. Monitor the installation, commissioning and acceptance of the machinery and
equipment for the department
5. Signing the service provider contract for training wherever applicable before
purchase of equipment and inform Deputy Director - Equipment training.
Main Accountabilities:
Procurement skills as per the norms of the funding agencies
Training Areas:
• Apprising of Global Tenders
•
Logistics
48
Review "J
Job Title:
CHIEF ENGINEER - CIVIL
Commissioner / DGHS (Administratively)
Secretary PWD department (Functionally)
Immediate Level Subordinates:
• Superindent Engineer (Bangalore)
• Superindent Engineer (Dharwad)
• Dy.Chief Architect
Reporting To:
Basic Function:
Ensure quality construction and maintenance work for the Department of Health in the
state. Ensure proper appraisal of tender documents for allotment of construction work to
the eligible parties. Work in coordination with appropriate authorites in finalisation of the
design of hospitals
Duties, Responsibilities and Authorities:
• He receives the indent for work from the department of Health and RCH and
executes that with the help of his functionaries in coordination with the concerned
officials in the department
• He is the overall incharge of all the civil works in the state which are related to the
Department of Health and RCH
• Obtaining architectural drawings estimates and sanctioning administrative and
technical approval to execute the works
• Coordinating various departments on land and civil works
• Monitoring construction programme and suggest necessary mid-term corrections and
actions
• Planning for maintenance of existing buildings
Job Title:
DEPUTY CHIEF ARCHITECT
Reporting To:
Chief Engineer - Civil (Administratively)
Chief Architect - Karnataka (Functionally)
Immediate Level Subordinates:
• Executive Engineer - Civil
Basic Function:
Prepare drawings and designs of the department constructions in connivance of the
concerned authorities in the department
Duties, Responsibilities and Authorities:
• Heads the design wing of the Department of Health & RCH, Government of
Karnataka
• Prepares the plan for the structure of buildings as per the felt need and allotted
budget by the department
49
-'
.i (Joi) Des
Main Accountabilities:
• Optimum space utilisation in the civil works of the state Department of Health & RCH
Training Areas:
Hospital architecture
Job Title:
SUPERINDENT ENGINEER - CIVIL
Reporting To:
Chief Engineer - Civil
Immediate Level Subordinates:
• Executive Engineer - Civil
Basic Function:
Monitor the construction work of Department of Health & RCH as per the specifications
given and ensure the quality in construction
Duties, Responsibilities and Authorities:
• Executes the approved civil work from the department of Health and RCH and
executes that with the help of his functionaries in coordination with the concerned
officials in the department
• He is the overall incharge of all the civil works in the region specified which are
related to the Department of Health and RCH
• Obtaining architectural drawings estimates and sanctioning administrative and
technical approval to execute the works
• Suggest for release of payment for satisfactory completion of works according to the
norms of the state PWD department
• Coordinating various departments on land and civil works
• Supervising and Monitoring construction programme and suggest necessary mid
term corrections and actions
• Planning for maintenance of existing buiL.ngs
50
Ch
Job Title:
Reporting To:
- ■
- ■' G es
' :■ ■
JOINT DIRECTOR - EQUIPMENT & MAINTENANCE - BIO
MEDICAL
Director - Procurement & Maintenance
Immediate Level Subordinates:
• Deputy Director - Equipment Training
•
Deputy Director - Equipment (DHS)
•
Deputy Director - Transport
Basic Function:
Organize for periodic schedules of preventive maintenance of the equipment of the
department, monitor the response time in attending the breakdown enquiries and take
marfSp6
Organize for trainin9 the internal technicians to work on the new
machinery and follow-up with OEMs for maintenance and training.
Duties, Responsibilities and Authorities:
i,nLa2klty relat'n9 5° after installation of equipment, like conveying the precautions
to be taken in operating certain equipment, etc to the technicians
•
Organise for training from the service provider or the OEMs regarding the operation
of the equipment by the technicians
upe.duon
•
Monitoring the periodic schedules of preventive maintenance
•
Less response time for breakdown mainl nance
•
Organize for training the internal technicnns itself in tackling the minor breakdowns
•
Plan for alternative equipm-t in case of
major shutdown of one equipment
Release of budget for regular maintenance and any such other activities
Main Accountabilities:
’ haX'a:?Xye“9;nSePment ■anU*‘",m
Less response time in attending to any maintenance / shutdown problem
Training Areas:
• Coordination with external agencies
•
Preparation of maintenance schedules
&FF -M
51
Hevievv of Qigan:
Hire
Job Title:
ADDITIONAL DIRECTOR - N.KARNATAKA REGION
Reporting To:
Commissioner / DGHS
Immediate Level Subordinates:
•
District Health Officers of Bijapur, Raichur Gulbarga, Belgaum, Bidar, Bagalkot,
Bellary, Koppal districts
•
All national and state Programme officers of Bijapur, Raipur, Gulbarga, Belgaum,
Bidar, Bagalkot, Bellary, Koppal districts
•
The Joint Directors handling different national and state health programmes at the
directorate
Basic Function:
The office of Additional Director - North Karnataka Region acts as a nodal officer for
coordinating the efforts of various functionaries in the department in showing the special
emphasis for a faster upliftment of the health conditions in the region. His office also
identifies various special programmes as and when required to bring development in the
area specified
Duties, Responsibilities and Authorities:
• Overall coordinating authority of all the programmes and projects in the districts of
Bijapur, Raipur, Gulbarga, Belgaum, Bidar, Bagalkot, Bellary, Koppal both in the
areas of Medical Health and Public Health
•
Identify the additional budget allocation areas for the region allotted
•
Head the office of the nodal office for the districts specified as a group
•
Coordinate with the offices of all national and state programmes and monitor their
implementation in the districts specified
•
Coordinate with the office of AD - Planning and obtain the MIS reports about the
health standards from time to time to review the progress in the districts specified
•
Frequently visit the District and other speciality hospitals in the state and review the
public health and medical care in the districts specified
•
Coordinate with the municipal and other local bodies and monitor the urban health
activities.
•
Identification of any new projects and programs for speedy upliftment of health
standards in the districts specified
Main Accountabilities:
• Should visit all the district hospitals and other major hospitals in the districts
specified atleast twice in six-months period
•
Speedy implementation of all health programmes
52
Job Title:
ADDITIONAL DIRECTOR - PLANNING
Reporting To:
Commissioner / DGHS
Immediate Level Subordinates:
• Joint Director - Planning
•
Joint Director - Research
• Joint Director - MIS
Basic Function:
Oversee the planning process in the department regarding the different areas of health
and hospital management in the state of Karnantaka. Obtain and review MIS reports
related to different aspects in managing the department like availability of doctors, bed
occupancy, population-bed ratio in a particular region, etc. Plays visionary role to the
department and suggest future plans periodically. Suggest any improvements/corrective
actions in managing the department to the concerned functionaries according to their
job responsibilities
Duties, Responsibilities and Authorities:
• Review the growth pattern in the state and plan the requirements in the health
sector accordingly
•
Develop strategic and perspective plan for the department
•
Develop short-term and long-term budgetary plans for the department
•
Suggest the appropriate authorities about the corrective actions to be taken if any
shortfall is observed in their functioning
• Approve the areas for research
Receive the information on Health of people and different hospitals in the state and
review them for preparing proper MIS .
Main Accountabilities:
Training Areas:
Planning methodology
Medical systems
53
Job Title:
JOINT DIRECTOR - PLANNING
Reporting To:
Additional Director - Planning
Immediate Level Subordinates:
• Deputy Director - Planning
• Deputy Director - Training
Basic Function:
Obtain reports from different functionaries regarding the status of medical and
public health in the state and suggest for improvements along with the path to follow.
Collates all the information generated through MIS activity and process for future
planning.
Duties, Responsibilities and Authorities:
• Plan for the issues pertaining to institutions coming under the control of the District
Health and RCH and Zilla Parishads as regards upgradation, improvement and
strengthening of existing facilities and the outlayed budget for them.
•
All service matters relating to the District Health and RCH officers Class I Senior and
Deputy Directors
•
Formulate the inputs required for National Nutrition Programme in coordination with
all the functionaries in the department at the district level
•
Suggest the health projects under the State Plan Programme
•
Review and suggest actions based on monthly multilevel review reports and
Karnataka 20 point programme
•
Review the follow-up of special component plan and tribal sub-plan
•
Suggest issues and review the draftnotes for Governer's address and finance
minister's budget speech
•
Preparation of Annual Administrative Reports, Annual Report, Status Report and all
matters relating to Bureau of Health Intelligence including Sushrusha Programme.
•
Formulate matters relating to Tribal Sub Plan, Special component plan and
Karnataka Twenty Point Programme.
Job Title:
JOINT DIRECTOR - RESEARCH
Reporting To:
Additional Director - Planning
Immediate Level Subordinates:
Basic Function:
Identify the areas of contemporary importance to the department and recommend for
research by various agencies / persons
Duties, Responsibilities and Authorities:
• Follow the trends in medial and health care in the state
•
Recommend for research / action research in the areas identified
•
Follow up with the findings
54
•
Recommend for any future directions or corrective actions for policy makers or other
people concerned
Main Accountabilities:
Training Areas:
• Research methodology
•
Action research
Job Title:
JOINT DIRECTOR - MIS
Reporting To:
Additional Director - Planning
Immediate Level Subordinates:
•
Statastician
•
Demographer
•
All programme officers at the district level (administratively)
Basic Function:
Collate all the hospital, medical and health related information in the state
through different hospitals and analyse them for any interpretation.
Duties, Responsibilities and Authorities:
• Head of office to analyse the information about all hospitals in the state
•
Monitor the information generation at different hospitals regarding the treatment of
patients, availability of beds for inpatients, population-bed ratio, etc
•
Collate and interpret information about occurrence of epidemics in different parts of
the state
•
Coordinate with all the programme officers at districts in the state and collate
information they generate about the status of programme and the health condition
in the state
•
Coordinate with all the DHOs and District Surgeons in collecting the information
about the status of their work and inturn the health systems in the state
Training Areas:
• Research Methodology
•
Primary and secondary data collection
•
Report writing
•
Coordination skills
55
Job Title:
CHIEF ADMINISTRATIVE OFFICER
Reporting To:
Commissioner / DGHS
Immediate Level Subordinates:
Basic Function:
Duties, Responsibilities and Authorities:
• Guide the relevant authorities relating to Cadre strength of the department.
•
Preparation of Annual programme of inspections in the state
•
Maintenance of inspection reports after the inspection of officers.
•
All matters relating to establishment of all the cadres of the department, obtaining
sanctions of the Director and other officers of the Directorate such as Additional
Directors, Joint Directorate etc., wherever such sanctions required as per the
delegation of powers issued by the Government from time to time.
•
All matters relating to filling up of the vacancies promotions, declaration of
probationary period disciplinary proceedings, compassionate appointments, time
bound advancements, sanction of leave etc., after obtaining sanctions of the
Director/ Additional Directors/ Joint Director, where such sanctions are required.
•
All matters relating to Legislative Assembly/ Council including answering Legislative
Assembly/ Council questions and parliamentary questions, and all standing
committee meetings of the Legislature
•
furnish replies to the other house committees of the Legislature.
•
Constitution of board of visitors in the Department
Main Accountabilities:
Training Areas:
Public Administration
Cadre management
Transfer policy
Office organization
Time management
56
Job Title:
CHIEF ACCOUNTS OFFICER (FINANCE)
Reporting To:
Chief Administrative Officer - Finance
Immediate Level Subordinates:
Basic Function:
Duties, Responsibilities and Authorities:
• Report all matters relating to financial aspects of the Department both plan and non
plan to the higher officials in the finance/accounts department
•
Reconciliation of expenditure of plan and non-plan schemes.
•
Obtain reimbursements from Govt, of India, pertaining to Centrally sponsored
schemes, Externally
•
Report about the expenditure regarding aided projects and Central sector schemes.
•
Settlement of House building advance, vehicle advance, L.T.C., HTC., sanction of
pension, DCRG, issue of No due certificates etc.,
•
Payment of salaries of the staff of the Directorate of Health and F.W. Services.
•
Z /dit of expenditures in different sections of the department
•
Report about the transactions from the treasury to the higher officials
•
Public Accounts Committee, Estimate committees and other House committees,
relating to finances.
•
Monitoring of Plan schemes including MMR and preparation of performance budget.
Main Accountabilities:
Training Areas:
Arp-MG
57
Job Title:
JOINT DIRECTOR - TUBERCULOSIS
Reporting To:
Additional Director - CMD
Immediate Level Subordinates:
• Deputy Director - Bactriology
•
Deputy Director - Epidemiological Surveillance Unit
•
DHO
•
District TB officer
Basic Function:
Effectively monitor the National TB Control Programme and Aids control programme.
Duties, Responsibilities and Authorities:
•
Plan the activities to be taken up regarding National TB control programme
•
Coordinates with IEC department in educating the masses about the care to be
taken against the spread of Tuberculosis
•
Monitor the activities under the TB control Programme at the district level
•
Coordinate the NTBCP activities at different districts and strive for their joint efforts
wherever possible
•
Monitor the treatment of AIDS patients in the state
•
Submit the reports to the MIS department for proper evaluation of the effectiveness
of different activities under the programme
•
Look after the activities of Lady Wellington TB Demonstration and Training Centre
and other TB related programmes or institutes in the state
•
Monitor the treatment to Aids infected patients in the state.
•
Get aware of the social hazards being faced by the Aids patients and pass the
information to IEC unit and other departments to educate the masses in avoiding
those
•
Monitor and evaluate the effectiveness of treatment to the TB infected patients
•
Monitor proper usage of funds allocated for treatment of TB patients and for various
activities under National TB control Programme
Assess the requirement of personnel in handling the TB related activities from time
to time, as the requirement of District Surgeon and District Health Officer and
communicate to the appropriate authority
Main Accountabilities:
•
Training Areas:
58
-Vol I' :Joh
rxev'/evv cf
Job Title:
DEPUTY DIRECTOR (PHARMACY)
Reporting To:
Joint Director (Medical)
Immediate Level Subordinates:
Basic Function:
Monitor the functioning of different dispensaries and pharmacies situated in all
the hospitals in the state. Monitor timely distribution of pharmaceuticals to the
dispensaries and their proper storage as per the mandatory norms. Plan for the
availability of pharmacists wherever required
Duties, Responsibilities and Authorities:
• Follow-up of matters connected with Pharmacy units at different locations regarding
sending proposals for establishment of Pharmacy/ units, maintenance of pharmacy
equipment / blood banks, etc.
•
Monitor the maintenance of standards in presetting blood, drugs and medicines at
the government pharmacies.
•
All matters relating to selection of drug samples in Govt. Medical stores, District
stores and other institutions for maintenance of quality standards and arranging
analysis in the drug controller's office
•
Receive requisitions from different pharmacies in the state.
•
Monitor the financial limits of each pharmacy in the state and disburse the drugs
Obtaining permission for procurement of drugs and medicines for different
pharmacies in the state.
Main Accountabilities:
• Timely distribution of drugs to the pharmacies and dispensaries in government
hospitals in the state
•
Training Areas:
•
Logistics management
•
Indian Drug and Cosmetics Act
59
Job Title:
DEPUTY DIRECTOR - TRAINING
Reporting To:
Joint Director - Planning
Immediate Level Subordinates:
Basic Function:
Identify the means of aligning the Department's short-term and long-term goals with
that of the individual's aspirations and development, offer career planning options and
provide induction training and as well the refresher programmes for the people in the
department
Duties, Responsibilities and Authorities:
• understand the organization's short-term and long term goals and the expectations
from the people in the department
•
understand the people's aspirations and provide options to link it to the career
planning
•
counsel the individuals and provide options for their growth
•
Plan for the induction training for the new entrants into the system, coordinate with
SIHFW
•
Plan for any refresher courses for the technical as well as non-technical people in the
department to keep them abreast with the latest knowledge
Main Accountabilities:
• Conduct induction training programme for all the new entrants into the system
•
Cover atleast 5 % of the doctors strength in each year for the refresher training
course
Training Areas:
•
Career counseling methods
•
Knowledge about the options available for further growth of the doctors
60
Review of Omen is.
-Voi H
DISTRICT LEVEL
DISTRICT HEALTH AND FW OFFICER
Respective Program Directors and joint Directors of
different functionaries of the department.
Immediate Level Subordinates:
• District Malaria Officer
Job Title:
Reporting To:
•
District Cholera Combat team officer
•
District Leprosy Officer
•
District Training officer (to coordinate with SIHFW)
•
District Surveillance Unit Officer (District epidemiologist)
•
District TB Officer
• Regional Assisstant Chemical Examiner
Basic Function:
Head of all the activities related to Department of Health & FW of Government of
Karnataka at the respective district level. Acts as the single reference point for any
information related to public and medical health in the district. Would be coordinating
between different functionaries and program / project offices for effective
implementation in the district.
Duties, Responsibilities and Authorities:
• All matters relating to Medical institutions in the district except those which are
controlled by the Dist. Surgeons and Director of Medical Education.
•
Responsible to carry-out activities relating to Health and RCH programmes in the
State
•
Responsible for Administrative and technical aspects of all the activities and
programmes of the directors of different functions in the department.
•
Responsible for state government for any queries regarding the health (e.g: spread
of epidemic) of the people in the state
•
Work as per the instructions issued by the Director of Health & FW services, from
time to time.
•
Overall responsibility of all the Family Planning activities in the district, in addition to
the other Health programmes. Responsible Administratively and technically to the
Commissioner - Health
•
In consultation with the M.O.H.F. (FW & MCH) he will draw up advance annual and
monthly programmes in order to achieve the targets fixed.
•
He will visit the IUD and Sterilisation camps and satisfy himself that proper
arrangements are made.
•
He will see that timely action is taken by the M.O.H. (Family Planning & MCH)
regarding stocking and distribution of supplies and equipment.
61
•
He will be responsible for the proper use of all the departmental vehicles for the
Family Planning Programme without hindering the programmes for which the
vehicles are allotted .
•
During the visits to the various Primary Health Centres apart from paying attention
to various other schemes, pay particular attention to the Family Planning Programme
to see that progress of work is achieved and to take action against such of those
who are slake, with a view to gear up the work.
•
Arrange for one of the senior members of his staff namely Asst. Director Health
Officer, Medical Officer of Health (FP), District Extension Educator, Health Supervisor
or District Nursing Supervisor to attend the monthly conference of each primary
Health Centre and review the physical progress achieved.
•
Arrange a quarterly conference of all Medical Officers under his/her control and
review the progress of the Family Planning Programme.
•
Responsible to see that the required reports are sent to the State Family Planning
Bureau every month by the due date.
•
In coordination with the Medical Officer of Health (FP & MCH) he/she will arrange
job orientation training for the peripheral staff.
•
Responsible for the random check-up of atleast 5% of persons who have IUD
placements or sterlisation operations done in the district by Government
Institutions). Voluntary organisation and Private practitioners to ensure that the
incentives are not misused, and that proper follow up has been ensured.
He will have full control of his annual budget and will be responsible for expenditure
therefore within his powers without recourse to higher authorities thus ensuring that
the budget provisions do not lapse.
Main Accountabilities:
•
Training Areas:
62
Job Title:
HOSPITALS
DISTRICT SURGEONS/SUPERINTENDENTS OF MAJOR
Reporting To:
District Health Officer
Immediate Level Subordinates:
• Respective specialists in the hospitals
•
Administrative Medical Officer
Functionaries at CMC and THC
•
Nursing supervisor
• Chief pharmacist (Functionally)
Basic Function:
Duties, Responsibilities and Authorities:
•
He will be the head of institution and exercise administrative and technical control
over the staff of the institution.
•
Maintain the quality of patient care according to the standards laid down by the
medical care / state government
•
Submit to the state government (Office of AD / JD) at intervals, reports on the
quality of medical care and working of the medical staff
•
Act as an ex-officio member of the management team, be involved in the day-to-day
decisions of the hospital at the operating level (can a management team comprising
of DHO, DS, CEO ZP and ZP chairman to work at the district level)
•
Schedule duties, help scheduling of operating room and any other medical or
paramedical services under his/her administration
•
Enforce staff rules and discipline the doctors in consultation with the DHO
•
Sign hospital medical certificates, reply to correspondence and queries about
patients, medical services and paramedical services under his jurisdiction
•
Conduct performance review of doctors in consultation with the DHO
•
Sanction of leave for Doctors and other functionary who are under his/her office and
reporting to him.
•
Out patient and in-patient services, Diagnostic services of day-to-day patients.
•
Procurement of drugs as per the requirement received from the chief pharmacist in
the district/hospital, in consultation with the DHO.
•
Issue fitness certificates, old age pension eligibility certificates and physically
handicapped to whoever eligible and required
AFF -MO
63
of Orqaoisa
; Si P icture
! I! (Job D
Job Title:
RESIDENT MEDICAL OFFICERS
Reporting To:
District Surgeon / Superindent of major hospitals
Immediate Level Subordinates:
Basic Function:
Duties, Responsibilities and Authorities:
•
Monitoring of the maintenance of Drug stores in the hospitals and the availability of
medicines as per the requirement of doctors and patients
•
Diet supplies of the institution to the inpatients as per mandatory stipulations
(clarify)
•
Addressing the medico-legal cases and be responsive to the requirement of law &
order authorities in answering the queries along with district surgeon.
•
Arranging of Casualty services outpatient services, maintenance of cleanliness in the
institutions.
•
Maintenance of punctuality, discipline, maintenance of environment sanitation in the
institution.
•
Posting of s_aff for day-to-day work, providing Ambulance services on requisition,
maintenance of Log book etc.,
•
Maintenance of the equipment in the institution.
Main Accountabilities:
Training Areas:
64
Job Title:
TALUK HEALTH OFFICER
Reporting To:
District Health Officer
Immediate Level Subordinates:
• TLH/CHC/PHC- AMO/MOH/LMO
Basic Function:
Duties, Responsibilities and Authorities:
•
Implement all National Health programmes in the taluks through a net work of
primary Health centres and other institutions.
•
Report day-to-day status of Health condition prevailing in the taluk including
epidemics to higher authorities.
•
He/she is the reporting authority of all the periodical returns the Taluk duly received
from the peripheral institutions and provide feed back to the peripheral institutions &
the DH & FWO.
•
Exercise supervisory control of all the institutions in the Taluk.
•
Represent DHO in Taluk / Panchayat meeting and Gram Panchayat meetings
wherever necessary and co-ordinates all the activities of the department such as
organising. Eye camps, control of communicable diseases, Sushrusha programme,
Malaria control programme, RCH camps, Immunization, T.B. Leprosy and other
related matters.
•
Arrange for proper distribution of drugs, equipment, materials as supplied by DH &
FWO and maintain inventory of all articles received in the Taluk and its proper
maintenance.
•
Conduct periodical inspection of the institutions and report the matter to the DH&
FWQ on all observations made.
•
Plan, manage and implement national health & RCH programmes in the Taluk
•
Inspect all health organizations on regular basis
•
Developmental planning of health institutions
•
Sanction casual, normal and restricted leave to all Medical Officers as and when
required.
•
Prepare confidential reports on Medical Officers and statistical reports of the Taluk.
•
Plann steps to prevent the communicable diseases and report the same to District
Health & RCH Officers and revenue officers in the Taluk.
•
Inspect stores of all health institutions and raise indents with District levels offices
for the various medicines and chemicals required for these institutions.
•
Organise family planning and eye test camps
65
•
Conduct monthly meetings with Primary Health Centre (PHC), Primary health Unit
(PHU) and Community Health Centre (CHC) and review the implementation of
various plans.
•
Conduct meetings with other departments in the Taluk and co-ordinate in their
functioning
Issue certificates for conducting the various festivals and fairs in the Taluk and take
steps to ensure control on diseases.
Any other duties assigned by DH&FWO.
•
66
ti.ire
-Voi!' 'job Desc
JOB TITLE:
SENIOR HEALTH ASSISSTANT
REPORTS TO:
Medical Officer (PHC)
IMMEDIATE LEVEL SUBORDINATES
•
Junior Health Assistant (Male)
DUTIES, RESPONSIBILITIES AND AUTHORITIES
•
Supervise and guide Junior Health Assistant (Male) in rendering the health care
services to the community.
•
Strengthen the knowledge and skills of the Junior Health Assistant (Male) and also in
planning and organising his programme of activities and also prepare assessment
reports on him.
•
Co-ordinate the activities with those of Junior Health Assistant (female) and other
health personnel including Health guides and Dais.
•
Assist the medical Officer of the PHC in conducting training programmes for various
categories of health personnel.
•
Check and indent for the procurement of supplies and equipment at the subcentres.
•
Responsible for proper storage of drugs and maintenance of equipment at the
subcentre.
•
Responsible for scrutinising the maintenance of records by Junior Health Assistants
and consolidation of the reports to the Medical officer of the PHC.
•
Supervise the work of Junior Health Assistant (Male) during concurrent visits and
check 10% of the houses in the village to verify the work.
•
Responsible for taking blood smears, radical treatment and spraying of insecticides
for controlling Malaria
•
Responsible for identification for Kala-azar, Communicable diseases, Leprosy,
Tuberculosis and ensure that appropriate control measures are taken.
•
Inform the Medical Officer PHC about the defaulters to treatment in cases of
Leprosy, tuberculosis etc.
•
Help the community in the construction of soakage pits, manure pits, compost pits,
sanitary latrines, and safe water sources and also supervise the chlorinating of wells.
•
Supervise the immunisation of all children from one to five years and pregnant
women.
•
Assist Medical Officer PHC in organising Family planning camps and drives and
motivate & follow-up cases for family planning.
•
Ensure that all cases of malnutrition among children are given necessary treatment
and refer serious cases to the PHC.
AFF
67
•
Carry out educational activities for control of communicable diseases, environmental
sanitation, MCH, Family planning, nutrition, immunisation, dental care and other
national health programmes.
•
Collect and compile the weekly report of births and deaths occurring in the area and
submit them to the Medical Officer PHC.
•
Organise and conduct training of community leaders with the assistance of the
health team.
Provide treatment for minor ailments and first aid for accidents and emergencies and
refer cases beyond his competence to the PHC.
PARTICIPATION IN COMMITTEES / MEETINGS
• Staff Meetings at PHC
•
•
Fortnightly meetings with Junior Health Assistants at subcentres.
MAIN ACCOUNTABILITIES
JOB TITLE:
SENIOR HEALTH ASSISTANT (FEMALE)
REPORTS TO:
Medical Officer (PHC)
IMMEDIATE LEVEL SUBORDINATES
•
Junior Health Assistant (Female)
DUTIES, RESPONSIBILITIES AND AUTHORITIES
•
Supervise and guide Junior Health Assistant (Female), Dais and female health guides
in the rendering of health care services to the community.
•
Strengthen the knowledge and skills of the Junior Health Assistant (Female) and also
in planning and organising her programme of activities and also prepare assessment
reports on her.
•
Carryout supervisory home visits in the areas under National health programmes.
•
Supervise a referral of all pregnant women for VDRL testing to CHC/Sub-divisional
hospital.
•
Assist the medical Officer of the PHC in conducting training programmes for various
categories of health personnel.
•
Check and indent for the procurement of supplies and equipment at the subcentres.
•
Responsible for ensuring that the Junior Health Assistant (Female) maintains a
general kit and midwifery kit and Dai kit and the clean and proper maintenance of
subcentres.
•
Responsible for scrutinising the maintenance of records by Junior Health Assistant
(Female) and consolidation of the HMIS reports to the Medical officer of the PHC.
68
•
Supervise the work of Junior Health Assistant (Female) during concurrent visits and
check 10% of the houses in the village to verify the work.
•
Conduct weekly MCH clinics at each sub centres with the help of Junior Health
Assistant (Female) and Dais.
•
Conduct deliveries when required at PHC and provide necessary domiciliary and
midwifery services.
•
Conduct weekly family planning clinics at each subcentre and motivate resistant
cases for family planning.
•
Provide information on services for medical termination of pregnancy, sterilisation
and refer the cases for MTP to the approved institutions.
•
Help Medical officers in school health services.
•
Supervise the immunisation of all children from one to five years and pregnant
women.
•
Assist Medical Officer HC in organising Family planning camps and drives and
motivate & follow-up cases for family planning.
•
Ensure that all cases of malnutrition among children are given necessary treatment
and refer serious cases to the PHC.
•
Carry out educational activities for control of communicable diseases, environmental
sanitation, MCH, Family planning, nutrition, immunisation, dental care and other
national health programmes.
•
Organise and utilise Mahila Mandals, teachers and other women in the community in
the RCH programmes including ICDS personnel.
PARTICIPATION IN COMMITTEES / MEETINGS
• Staff Meetings at PHC
•
Fortnightly meetings with Health Workers at subcentres.
MAIN ACCOUNTABILITIES
I
69
JOB TITLE:
JUNIOR HEALTH ASSISSTANT (FEMALE)
REPORTS TO:
Senior Health Assistant (Female)
IMMEDIATE LEVEL SUBORDINATES
N.A.
BASIC FUNCTION
DUTIES, RESPONSIBILITIES AND AUTHORITIES
•
Register and provide care to pregnant women through out the period of pregnancy
•
Ensure that the pregnant women undergo all the necessary tests like VDRL test
•
Conduct about 50% of the total deliveries, supervise deliveries conducted by Dais
and refer the cases of abnormal pregnancy to Health Assistant Female or the PHC.
•
Responsible for post delivery visits and advise the mother about the maternal and
child health, family planning, nutrition and immunisation and diarrhoea control.
•
Assess the growth and development of infant and take necessary action to rectify
the defect.
•
Responsible for spreading the message of family planning to the couples and
distribute conventional and oral contraceptives to the couples.
•
Identify women leaders in the area for promoting RCH programmes and participate
in Mahila Mandal meetings and utilise such gatherings for educating women in RCH
programmes.
•
Identify women requiring medical termination of pregnancy and refer them to the
approved institutions and educate them about the services.
•
List the dais in the area and help the Health Assistant in training them.
•
Notify the Medical Officer PHC about the abnormal increase of communicable
diseases and administer presumptive treatment wherever necessary.
•
Maintain all the records relating to register of pregnant women from three months
onwards, Maternal and child care records and submit prescribed monthly report to
the Health Assistant (Female)
•
Co-ordinate the activities with Health Worker (Male) and other health workers
including the Health guides and Dais.
•
Help the medical officers in school health services.
PARTICIPATION IN COMMITTEES / MEETINGS
• Staff Meetings at PHC/Community Development Block
MAIN ACCOUNTABILITIES
70
►
JOB TITLE:
JUNIOR HEALTH ASSISSTANT (MALE)
REPORTS TO:
Senior Health Assistant (Male)
IMMEDIATE LEVEL SUBORDINATES
N.A.
BASIC FUNCTION:
DUTIES, RESPONSIBILITIES AND AUTHORITIES
•
Identify the people affected with Malaria and take the blood smears and begin
presumptive treatment under NMEP.
•
Co-ordinate with the village health guides about the spray dates for the insecticides
and intimate the houses in the village.
•
Enquire about the presence of Kala-azar, Japanese Encephalitis etc and will guide
the suspects to the PHC or CHC for diagnosis and treatment.
•
Identify the cases of communicable diseases, Tuberculosis and Leprosy inform the
Health Assistant (Male) and Medical Officer (PHC) about these cases and also
undertake the control measures.
•
Undertake chlorinating of public water sources at regular intervals and educate the
community on environmental sanitation.
•
Administer DPT vaccine, oral polio vaccine, measles vaccine and BCG vaccine to all
the infants and children in his area in collaboration with Health Worker Female.
•
Assist the Health worker female in administering the immunisation to all pregnant
women, and also for school immunisation programme
•
Educate the people in the community about the importance of immunisation against
the various communicable diseases.
•
Responsible for spreading the message of family planning to the couples and
distribute conventional and oral contraceptives to the couples.
•
Identify male community leaders in the area and train them for promoting RCH
programmes.
•
Identify women requiring medical termination of pregnancy and refer them to the
approved institutions and inform the Health Worker (Female)
•
Identify cases of malnutrition among the children and arrange for necessary
treatment and educate the parents about the nutritious diet.
•
Provide treatment for minor ailments and first aid for accidents and emergencies and
refer cases beyond his competence to the PHC.
•
Enquire about births and deaths occurring in his area and report to the Health
Assistant (Male)
71
Structure
•
Prepare maintain and utilise family and village records, maps and charts of the
village, record of people undergoing treatment for TB and Leprosy and submit
periodical reports to Health Assistant (Male)
PARTICIPATION IN COMMITTEES / MEETINGS
• Staff Meetings at PHC/Community Development Block
MAIN ACCOUNTABILITIES
JOB TITLE:
LABORATORY TECHNICIAN
REPORTS TO:
Medical Officer - PHC
IMMEDIATE LEVEL SUBORDINATES
N.A.
BASIC FUNCTION
DUTIES, RESPONSIBILITIES AND AUTHORITIES
•
Maintain the cleanliness and safety of the laboratory
•
Ensure that the glassware, microscope and equipment are kept clean and well
maintained.
•
Ensure Sterlisation of equipment as and when required.
•
Ensure the safe disposal of specimens and infected material.
•
Maintain the necessary records of investigations done and submit the reports to the
Medical Officer, PHC.
•
Prepare monthly reports regarding his work and submit to the Medical Officer, PHC.
•
Indent for supplies required at the laboratory through the Medical Officer, PHC and
ensure the safe storage of the received material.
•
Carry out examination of urine, stools, blood, sputum, skin and smears for leprosy
patients, semen, throat swabs, drinking water and aldehyde test.
•
Responsible for maintenance of all records and slides examined by him for Malaria
and get them confirmed by the Medical Officer, PHC
•
Maintain the daily progress and output register of blood slide examination and a
backlog chart of pending radical treatment under NMEP.
PARTICIPATION IN COMMITTEES / MEETINGS
♦ Staff Meetings at PHC
MAIN ACCOUNTABILITIES
72
Review of Organis^on Sfr.o'nte
- Vol II (Job Desa
JOB TITLE:
MEDICAL OFFICER - PHC
REPORTS TO:
Taluk Health Officer / District Health Officer
IMMEDIATE LEVEL SUBORDINATES
Health Assistants (M/F)
DUTIES, RESPONSIBILITIES AND AUTHORITIES
1. Organise the dispensary, outpatient department and allot duties to the ancillary staff
to ensure smooth running of OPD.
2. Attend to the cases referred to him by Senior Health Assistants, Junior Health
Assistants, Health guides and Dais from sub-centre level and refer the cases needing
specialised medical attention to referral institutions.
3. Visit the subcentres in the area once in a fortnight to supervise the work and provide
curative services.
4. Ensure that the health team is fully trained in various national health & RCH
programmes and prepare the operational plans for ensuring effective implementation
as per the targets.
5. Provide basic MCH services, implement nutrition and universal immunisation
programmes
6. Responsible for proper and successful implementation of Family Planning
programmes like Vasectomy, Tubectomy, IUD and MTP in the PHC area.
7. Responsible for administrative and technical matters relating to Malaria Eradication &
Vector control programmes in the PHC area.
8. Responsible for all anti Kala-azar and anti Japanese Encephalitis operations in his
area.
9. Responsible for regular reporting to District Malaria Officer/Civil Surgeon in terms of
monitoring, record maintenance and maintenance of adequate provisions of drugs
etc.
10. Provide facilities for early detection and cases of Leprosy, Tuberculosis, and
blindness and ensure that all cases take regular and complete treatment.
11. Responsible for control of communicable diseases and the proper maintenance of
sanitation in the villages and take action in case of any outbreak of epidemic.
12. Ensure that all the cases of STD are diagnosed and properly treated and provide
facilities for VDRL test for all pregnant women at the PHC.
13. Visit various schools for ensuring health programmes,
14. Proper management of cases of diarrhoea and referral of serious cases to the
hospitals.
15. Responsible for organising and conducting training under Medical and Para Medical
personnel scheme and school health service schemes.
PARTICIPATION IN COMMITTEES / MEETINGS
♦ Staff Meetings at PHC
MAIN ACCOUNTABILITIES
AFF -M
73
JOB TITLE:
LADY MEDICAL OFFICER
REPORTS TO:
Medical Officer, PHC
IMMEDIATE LEVEL SUBORDINATES
Workers
Health Assistants & Health
DUTIES, RESPONSIBILITIES AND AUTHORITIES
1. Ensure that all the necessary steps are being taken for the control of communicable
diseases in the village and report the outbreak of an epidemic to Medical Officer incharge.
2. Responsible for diagnosing and treating Kala-azar and Japanese Encephalitis patients
and also for arranging spray activities in the area under the supervision of Medical
Officer in-charge at PHC.
3. Supervise and guide Health Assistants and workers in effective implementation of
Maternal and Child Health, immunisation programme, family planning and nutrition
programmes.
4. Arrange .or the medical check-up at schools and treatment of students found to
have defects.
5. Ensure that all the steps are being taken for provision of safe drinking water and
improvement of environmental sanitation at the villages.
6. Participate in community involvement in the nutrition programme and safe water
supply and environmental sanitation programmes.
7. Responsible for organising camps, meetings, health education talks, and involve
Health Assistants and workers in these activities promoting health education.
8. Organise and conduct training for health guides, primary school teachers and dais
for field training in community health programmes.
9. Assist Medical Officer, PHC in staff development and training programmes for staff at
PHC, subcentres
10. Assist Medical Officer, PHC in conducting field investigations for planning changes in
strategy for effective delivery of health services.
11. Ensure adequate supply of kits, medical drugs, contraceptives, vaccine, equipment
etc at PHC and subcentres.
12. Obtain the reports from the periphery, analyse and interpret the data and utilise the
finding for successfully implementing the health programmes in the area.
13. Scrutinise the work plans of Health Assistants and Health workers and supervise the
maintenance of the prescribed records at the subcentre level.
PARTICIPATION IN COMMITTEES / MEETINGS
♦ Village Health Committee/Village Panchayat Meetings
♦ Monthly Staff meetings at PHC
74
Review of Oroamsata
StruCitirt
-Vci il (Job Dosci ipti&bs
JOB TITLE:
BLOCK EXTENSION EDUCATOR
REPORTS TO:
District Health Education Officer
IMMEDIATE LEVEL SUBORDINATES
DUTIES, RESPONSIBILITIES AND AUTHORITIES
1. Collate information on MCH, Rural development education, social welfare and other
programmes and utilise the same for programme planning.
2. Collect and maintain data on mortality, protection and immunisation rates and utilise
the same for work under FW & MCH programme.
3. Co-ordinate with the local voluntary agencies for training in health and RCH and will
assist the Medical health officer in conducting these programmes.
4. Maintain complete set of education aids for training purposes.
5. Act as a resource person at the block level FW committee and ensure proper
functioning of these committees in the catchment area of PHC.
6. Liason with the media units of other departments, NGOs and organise mass
communication programmes like film shows exhibitions, lectures, dramas with the
help of District Health Education Officer.
7. Responsible for all educational, motivational and communication programmes in PHC
area.
8. Ensure supply and utilisation of information and educational material to health
workers and development functionaries including those of voluntary agencies.
9. Support, guide and supervise the field workers in the area of information
dissemination, education and motivation.
10. Give special attention to resistant couples and drop out by problem solving methods
and committees.
PARTICIPATION IN COMMITTEES / MEETINGS
♦ Block level RCH Meetings
♦ Monthly Staff meetings at PHC
MAIN ACCOUNTABILITIES
JOB TITLE:
DISTRICT PUBLIC HEALTH EDUCATION OFFICER
REPORTS TO:
District Public Health Officer
IMMEDIATE LEVEL SUBORDINATES
• Block Health Educators
• Block Extension Educators
AFP -MC
75
:-n
BASIC FUNCTIONS:
Evaluate the requirement, plan and execute the health education among the
people in the district. Should use his offices to educate the people and thus suggest any
precautionary/remedy measures for sort of issue, which can be addressed easily. Should
effectively use any melas / any big gatherings of people in spreading the message.
All the matters relating to the Health Education will be routed through him/her to
the District Health & F.P. Officer. He/she is the Technical Assistant to the District Health
& FP. Officer, in Health & Family Education matters.
DUTIES, RESPONSIBILITIES AND AUTHORITIES
1. Evaluate the health education related requirements among the people in the district
and submit reports to the office of Joint Director - Health Promotion and DHO
2. Plan and co-ordinate all the health education activities in the district in collaboration
with official and non-official agencies.
3. Determine the relative applicability of the different communication methods including
traditional media, in relation to the local circumstances and ensure through feedback
to All India Radio, State Health Education Bureau, State Mass Media Wing the
contents of such communication are locally relevant and effective.
4. Guide the Block Health educator in preparing talking points.
5. Assess the needs of the educational equipment and materials and arrange for their
procurement/ production, maintenance, distribution a.id utilisation in the Health
Centre.
6. Plan alternate approaches in Health Education and arrange for extra inputs through
different media depending upon the needs.
7. Assist the State Health Education Bureau and Mass Media wing in identifying the
areas of concern and conducting studies
8. Develop one Primary Health Centre as a Field study demonstration area in the
District, preferably near to the district headquarters.
9. Solicit technical guidance and direction from the State Mass Media Wing and the
State Health Education Bureau for reaching out to the people more effectively.
10. Arrange and conduct in-service training Qob orientation) to the newly appointed field
staff making use of the field study and demonstration material.
11. Identify special groups such as factory workers, plantation labour, government
employees, teachers, etc and conduct orientation training involving medical officers
of Health and paramedical workers in the Primary Health Centres.
12. Organise education campaign on occasions such as epidemics, family planning,
immunization etc.
13. Organise exhibitions and cultural programmes at important centres during special
occasions like festivals and fairs.
14. Supervise and guide the Block Health Education Officers and Block Extension
Educators and arrange for the quarterly meeting.
PARTICIPATION IN COMMITTEES / MEETINGS
• Quarterly meeting with Block Health education officers and Block extension
educators.
76
RevwA )f (. i
•
Monthly meeting with the DHO to draw his attention for coordination between
different functionaries in the district (PHC level to the district hospital).
Quarterly meeting with the Joint Director (Health Promotion) along with other
District Health Education Officers to know the progress in other districts vis-a-vis
theirs and discuss about any joint / mutually complementary programmes among
themselves
Arrange for quarterly meeting of the Block Health Educators at the District
under the Chairmanship of District Health & F,P. Officer,
• Obtain and review the reports of Block Health Educators and Deputy Health
Education Officers and submit a consolidated report to the District Health & FP.
Officer
•
•
Tour at least 15 days in a month and make ten night halts.
•
Visit each PHC at least once in three months.
Training Areas
JOB TITLE:
STAFF NURSE
REPORTS TO:
• Nursing Supervisor (Sister)
•
Medical Officer in-charge PHC/CHC
•
District Surgeon in District Hospitals
IMMEDIATE LEVEL SUBORDINATES
•
Ward Staff
BASIC FUNCTION
Staff Nurse is a first level professional nurse who provides direct patient care to one
patient or a group of patients assigned to her/him during duty shift, and assist in ward
management and supervision.
DUTIES, RESPONSIBILITIES AND AUTHORITIES
•
Responsible for admitting and discharging patients and maintain clean and safe
environment
•
Maintain personal hygiene and comforts of the patient and attend to the nutritional
needs of patient and feed helpless patients.
•
Perform technical tasks like administration of medication, assisting doctors in various
medical procedures and the patient care.
•
Update case sheet of patients under their care as per prescribed norms.
AFF -MG
77
Re\.‘ ie\A
fUH: ' ■ !<
•
Follow doctors' rounds and help them in diagnosis and treatment in the absence of
Nursing Supervisor.
•
Co-ordinate patients care with various health team members.
•
Responsible for keeping the ward neat and tidy.
•
Handover and takeover the patient and ward equipment and supply.
•
Maintain safety of the ward equipment.
•
Assist ward supervisor/sister in ward management and officiates in her/his absence
and assist in taking inventories.
•
Supervise students and other junior nursing personnel working with her/him and
maintain ward record and reports assigned to her/him.
•
Participate in clinical teaching both planned and incidental.
•
Teach and guide domestic staff and help in orientation of new staff.
•
Participate in staff education programmes and guide student nurses.
PARTICIPATION IN COMMITTEES / MEETINGS
MAIN ACCOUNTABILITIES
JOB TITLE:
NURSING SUPERVISOR (SISTER)
REPORTS TO:
• Nursing Superintendent (hospitals above 400 bed strength) or
•
Medical Officer in-charge (PHC/CHC) or
•
District Surgeon (Other hospitals including District Hospital)
IMMEDIATE LEVEL SUBORDINATES
•
Staff Nurse
BASIC FUNCTION
Nursing Supervisor is accountable for the nursing care management of a ward or a unit
assigned to her. She is responsible to the Nursing Superintendent/Assistant Nursing
Superintendent for her ward management. She takes full charge of the ward and
assigns work for various categories of nursing and on-nursing personnel working with
her. She is responsible for safety and comfort of the patients in her ward. In a teaching
hospital she is expected to ensure good learning fields.
78
Re eu
?*
Srn
-Voi II (Job Deso- vo
DUTIES, RESPONSIBILITIES AND AUTHORITIES
•
Plan nursing care and make patients assignment as per their nursing needs.
•
Assist in the direct care of the patient as and when required and to see the total
health needs of her patients are met.
•
ensure safety, comfort and good personal hygiene of her patient.
•
take nursing rounds with staff and students and to ensure that proper observation
records of the patients are made and necessary information imparted to the
concerned authorities.
•
Review case sheets updated by the staff nurses on a regular basis
•
make rounds with doctors and assist him in diagnosis and treatment of his patients.
•
implement doctor's instructions concerning patient treatment.
•
assist patients and their relatives to adjust in the hospital and its routine and also
co-ordinate patient care with other departments.
•
ensure safe and clean environment for the ward
•
Responsible for preparation of duty and work assignment plans, ward statistics,
indent ward stores and check inventory at regular intervals.
•
make list for condemnation of articles and submit to all the concerned.
•
establish and reinforce ward standards prescribed in the procedures and manuals
of the ward and the hospital and policies that are in force.
•
act as a liaison officer between ward staff and hospital administration and also
maintain good public relation in her ward.
•
write confidential reports of her reporting staff.
•
organise orientation programmes for new staff and guides in formulation of nursing
care studies and nursing care plans etc.
•
evaluate nursing students performance and submit reports to the school
authorities.
help in medical and nursing research.
PARTICIPATION IN COMMITTEES / MEETINGS
• Ward conferences and meetings
MAIN ACCOUNTABILITIES
• Hospital infection control
AFF -MC
79
Review of Organisation Structure
"0/ // (Job Desu^tionio
JOB TITLE:
NURSING SUPERINDENT
REPORTS TO:
Medical Superintendent
IMMEDIATE LEVEL SUBORDINATES
• Nursing Supervisor (Sister)
BASIC FUNCTION
Nursing superintendent is responsible to the Medical Superintendent in a hospital having
400 or above bed strength. She s accountable for the safe and efficient running of the
various Nursing departments in the hospital.
DUTIES, RESPONSIBILITIES AND AUTHORITIES
• Responsible for setting up the higher standard of professional conduct.
•
Plan and administer rules and regulations to maintain efficient nursing services.
•
Implement recommendations and regulations that are issued from time to time by
DHS/DME or Medical superintendent of the hospital.
•
Make regular visits to hospital kitchen and supervision rounds of all hospital wards
and departments.
•
Secure the necessary equipment, linen and ensure good nursing care.
•
Receive reports from the night duty nursing supervisors and analyse them for any
corrective actions
•
Organise in-service education programme and orientation to new staff.
•
Ensure adequate supply of cleaning materials and ensure cleanliness of hospitals and
environment.
•
Arrange for the proper disposal of hospital waste especially in relation to Hepatitis
and HIV etc.
•
Prepare budget for the nursing services in collaboration with the other staff.
•
Sanction casual leave arrangements for warned leave and days off etc. for ????
•
Conduct the following activities for school of nursing attached to the hospital
■ Carry on periodical inspection of nurses' hostel and attend to the complaints and
welfare of student nurses.
■
■
■
■
•
Counsel and guide the staff members and ensure discipline at nurses' hostel.
Ensure proper care of student nurses during illness and arrange for regular
health checkup.
Assist school of nursing in selection of student nurses.
Arrange for teaching programme, practical experience and examinations in
collaboration with the School of nursing.
Responsible for maintaining attendance register, leave register, duty rosters and
health records of the staff members.
A-F -MG
80
J
JOB TITLE:
SENIOR PHARMACIST
REPORTS TO:
Chief Pharmacist
Administrative Medical Officer / Resident Medical Officer
IMMEDIATE LEVEL SUBORDINATES
• Junior Pharmacist
DUTIES, RESPONSIBILITIES AND AUTHORITIES
•
Responsible for Main stores, Sub-Stores, Dispensary and I.V. Fluid sections.
•
To ensure preparation and updation of the indents, day book of receipts, issue
register, inventory stock book, Bin card, expiry date register, drug sampling,
statistical data of demand and supply of drugs and test reports and inspection book
at main stores, sub-stores, dispensary and I.V.Fluid manufacturing section.
•
To verify in random the items received in respect to order placed, label specification,
volume/weight/measurement with respect to label claims and for consistency.
•
To carry out qualitative simple physico - chemical tests to ascertain the quality of
drugs and maintain a record of such works and submit his observations to the Chief
Pharmacist/ RMO / AMO and also about such drugs failing to pass the qualitative
tests.
•
To maintain the stores in clean and hygenic conditions.
•
To keep all Poisonous drugs, expensive drugs, narcotic and psychotrophic drugs
separately under lock and key as per technically viable administrative directions.
•
Responsible for preparation of annual expenditure programme within the budget
allocations and needs of the hospital.
•
Responsible for disposal of expired drugs.
•
To assist the Chief Pharmacist/Graduate Pharmacist in manufacturing and testing of
I.V.Fluid including animal house maintenance.
•
To prepare the mixutres and formulations and dispense the drugs as prescribed by
the Medical Officer.
•
To participate in various Health education programmes of the institution and in the
therapeutic assessment of quality of drugs in the hospital.
•
To attend to emergencies in the absence of Medical officer in rendering first aid and
common ailments.
•
To dispense the OPD drugs for common ailments without prescription in the absence
of Medical officer in-charge.
AFF -MC
81
L
DISTRICT HEALTH AND FAMILY PLANNING OFFICER,
a. He will be in overall charge of all the Family Planning activities in the district, in
addition to the other Health programmes.
Responsible Administratively and
technically to the Director of Health & FP. Services and state Family Planning Officer.
b. In consultation with the M.O.H.F. (FP & MCH) he will draw up advance annual and
monthly programmes in order to achieve the targets fixed.
c. He will visit the IUD and Sterilisation camps and satisfy himself that proper
arrangements are made.
d. He will see that timely action is taken by the M.O.H. (Family Planning & MCH)
regarding stocking and distribution of supplies and equipment.
e. He will be responsible for the proper use of all the departmental vehicles for the
Family Planning Programme without hindering the programmes for which the
vehicles are allotted.
f. During his visits to the various Primary Health Centres apart from paying attention to
various other schemes, he will pay particular attention to the Family Planning
Programme to see that progress of work is achieved and to take action against such
of those who are slake, with a view to gear up the work.
g. He will be responsible to arrange for one of the senior members of his staff namely
Asst. Director Health Officer, Medical Officer of Health (FP), District Extension
Educator, Health Supervisor or District Nursing Supervisor to attend the monthly
conference of each primary Health Centre and review the physical progress
achieved.
h. He will arrange a quarterly conference of all Medical Officers under his control and
review the progress of the Family Planning Programme.
i. He will be responsible to see that the required reports are sent to the State Family
Planning Bureau every month before the due date.
I
connection with the Medical Officer of Health (FP & MCH) he will arrange job
jorientation training for the peripheral staff.
k. He will be responsible for the random check up of atleast 5% of persons who have
IUD placements or sterlisation operations done in the district by Government
Institutions). Voluntary organisation and Private practitioners to ensure that the
incentives are not misused, and that proper follows up has been ensured.
l. He will have full control of his annual budget and will be responsible for expenditure
therefore within his powers without recourse to higher authorities thus ensuring that
the budget provisions do not lapse.
AFF-MC
82
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0
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Content List
A - Introduction
1
B - General Description of Externally Aided Projects (EAP’s)
4
C - Project Goals, Focus and Distribution
7
D - Overview of Programmes and Activities
15
E - Overall Strengths and Weaknesses of EAP’s
17
F - Lessons from some Case Studies
26
G - Some Policy Imperatives Including Integration and
Sustainability
30
H — Some Reflections on Financial
EAP’s
38
Economic Implication of
I - General policy concerns : Are we reinventing the wheel ?
43
J - Final Conclusions and Recommendations from a future
policy point of view
46
K - Limitations of the Review Exercise
50
L — Acknowledgements
51
M —Bibliography
52
N - Tables
I
1Externally Aided Projects - General Description
II Objectives / Focus / Regional Distribution
III Programmes and Activities by - Review of Budget Heading
IV Some Strengths and Weaknesses
O - Case Studies
A. Training Experience in a Northern District
B. An Urban Health Centre
P - Appendices
Project Proposal
i)
ii)
Some issues and questions addressed in the review and
A conceptual framework for review - Diagrammatic
presentation.
5
8
15a
19
27
29
PROJECT REPORT: Review of Externally - Aided - Projects (EAPs) in the
context of their integration into Health Service Delivery
in Karnataka.
A: Introduction
Since the early 1970’s the Karnataka Government has negotiated and received
various grants and loans from international funding agencies, including the World
Bank, for health related projects that supported the growth and strengthening of
primary and secondary health care services in the state. These externally aided
projects have had their own particular focus; objectives; framework; operational
strategies; and management information systems geared to support and or enhance
both quantitatively and qualitatively, different aspects of Health Sector
Development in the state. Each of them has their own cycles of mid-term reviews
and concurrent reviews. The Human Development in Karnataka Report 1999
described five of these (see box).
i
Currently there are however atleast ten major externally aided health projects in the
state- IPP VIII, IPP IX, KHSDP, OPEC, KIW, RCH, RNTCP, NACO, NLEP,
DAN-PCB being implemented through the Government and Directorate of Health
and Family Welfare Services. In addition UNICEF has provided project support to
different health related sectors including Child Development and Nutrition; Water
and Environmental Sanitation; Education; Child Protection; Communications and
Strategic Monitoring. For the purpose of this Review all UNICEF Projects have
been taken together as one and NLEP has been left out for unavoidable reasons.
Health related externally aided projects, e.g. for nutrition, water supply and
sanitation, implemented through other departments are not included under the scope
of this review.
The Karnataka Task Force in Health, while reviewing these projects in their
interactive and informal discussions and deliberations have raised some important
questions for review and enquiry:
i)
ii)
iii)
What are the learning points from each of these projects?
How can they be integrated into the health system incorporating beneficial
points and avoiding distortions.
What has been their experience concerning issues of sustainability,
accountability and transparency.
In the late 1990's, policy researchers, academicians and decision-makers have also
begun to seriously review the "piecemeal pursuit of separately financed projects^’ as
against bthe evolving options of more appropriate sector wide approaches’. This is
linked to the growing recognition of some of the problems associated with single
-1 <
■
Important externally assisted health projects
Karnataka Health Systems
Development Project
(KHSDP)
I
Krcditanstalt fur
Wiederaufbau (KfW)
India Population project
(IPP) VIII
India Population project
(IPP) IX
Reproductive and Child
Health Services (RCH)
Project
The Karnataka Health System Development Project is proposed to be
implemented over live years (1996-2001) with assistance from the
World Bank.
Its main objectives arc improvement in the
performance and quality of health care services at the subdistrict and
district levels, narrowing current coverage gaps and improving
efficiency,
Major components include improvement of the
institutional policy framework, strengthening implementation
capacity, development of a surveillance system, extension and
renovation of all secondary level hospitals, improvement of their
clinical effectiveness and establishment of a properly functioning
referral system. The project outlay is Rs, 546 crores.
The KfW of Germany is financially assisting a project in the four
districts of Gulbarga division with objectives similar to those of the
KHSDP. The project outlay is Rs.59 crores of which 90% is being
. provided by KfW as a grant. The project was launched in 1998.
IPP V111 is being implemented in the slums of Bangalore since 199394 with World Bank assistance. Major objectives are improvement in
maternal and child Health and reduction of fertility among the urban
poor.
Strategies adopted include involving the community,
improving the quality of services provided by the City Corporation,'
strengthening existing delivery services, establishing new facilities
and providing services at the doorsteps of the urban poor. The
project cost is Rs.39 crores.
This is the fourth in the series of India Population projects following
IPP I and IPP HL The project is under implementation since 1994 in
13 districts. The main objectives are reduction in the crude birth and
death rates as well as the infant and maternal mortality rates and
increase in the couple protection rate. Strategies adopted include the
promotion, strengthening and delivery of services through the
involvement of the community and improvement in the quality of
services by providing training and strengthening the monitoring and
evaluation systems. The project outlay is Rs, 122 crores.
The Reproductive and child Health Services Project marks a change
in the existing culture of achieving targets by shifting to a policy of
provision of quality services. The project helps clients meet their
own health and family planning needs through the full range of
family planning services. It is a natural expansion of the earlier child
survival and safe motherhood programme which was under
implementation till 1996.
It also includes the treatment of
reproductive tract infections, sexually transmitted infections and the
prevention of AIDS. All the districts of the state are proposed to be
covered under the project.
The budget for RCH project for five years (1997-98 to 2002-03) is
__________________ Rs. 190 crores.
Source Human Development tn Karnataka - 1999
-2-
locus sector project assistance, which include:
• Fragmentation;
• Conflict and or duplication;
• Donor driven agendas;
• Recurrent operational costs;
• Undermining of national capacities,
• Lack of flexibility,
• Varying standards of provisions, and
• Issues of ownership.
This short-term interactive review has been undertaken to explore some of these
issues and address these concerns in the context of the Task Force recommendations
for the Health Sector development policy for the state.
Within the time constraints, the researchers have tried to achieve the following:
a)
Review all the externally aided projects not just individually but in their
collective context reviewing available documentation as well as interacting
with programme managers.
b)
Using a SWOT approach, trying to identify the key strengths, weaknesses as
well as opportunities and threats (distortions) from all these projects.
c)
Trying to do this review in such a way so that the stakes of programme
managers and hopefully the Health Directorate to learn from project
experience and address seriously the concerns and issues of sustainability
and integration are enhanced especially by improving in-house capacity and
system development.
(See Appendix "A'’ for Project protocol and issues and questions to be addressed.)
-3-
■1
B: General Description of EAl^s
TabIc_I_shows the 10 LAPS included in the review. F.
From the table the following
key general observations on EAP's in Karnataka can be made.
1.
Number
1 here are ten EAP's which contribute to the Health Service Delivery in the state.
(NLEP has not been included in the review fully).
2- Programmes / Projects
While some are state
«
components of GOI programmes (RCH, RNTCP, NPCB,
KSAPS, UNICEF); others> are state level projects (eg. KHSDP, IPP - VIII,
IPP - IX, KfW, and OPEC)
3* World Bank : Main player
I
•
While UNICEF and DANIDA have been long standing partners since 1970's the
World Bank has become the key partner now supporting six out of the ten
projects (this is particularly so since the 1990's) and there is reason to believe
that since the World Bank takes over as the key player the other funding partners
are getting some what sidelined or ignored.
4- Grant to Loans in the IJWO’s
•
While the earlier bilateral donors were providing grants like UNICEF and
DANIDA, the trend in the 1990's has increasingly moved towards more loan
component in the projects with varied interest rates and associated
conditionalities. The World Bank support being mainly in this category it is
therefore even more important today to ensure that these funds are utilized
efficiently with greater accountability and transparency since if they were
misutilised fhen we would have the double problem of ineffective utilization
coupled with a debt burden.
•
The German government (KfW) and the Organisation for Petroleum Exporting
Countries through the OPEC fund have joined World Bank in supporting
primarily infrastructure development. The former is a grant and the latter is a
soft loan to be paid over a twelve year period after a five year initial gap.
5. Stand alone
* HEach of these projects are relatively distinct entities with clear cut objectives,
framework, programmes and though they have to be complementary or
supplementary to each other due to overlap at the field level (similar districts,
health centres, health teams) this is not at all emphasized in the project reports or
-4 -
pH iqo
1IC49 |
built into their outlines. There is a fair degree of compartinenlalizalion and
hence they mostly stand alone with little dialogue between projects and seldom
visualized as smaller components of a larger strategic plan. Iwen I hough
presently the KfW project utilizes the engineering division and other resources
from KHSDP, this linkage was not originally planned and took place only
because the ZP engineering divisions envisaged to make decentralised decisions
could not maintain requisite standards.
TABLE-I
Externally Aided Projects in Health Service Delivery in Karnataka
GENERAL DESCRIPTION
S.No / Name
1.
India Population
Project
IPP VIII
(Family welfare - urban
slums project)
2.
India Population
Project
IPP IX
Year of
Starting
1993-94
1994
(Strengthening of Family
welfare and MCH services)
Main Source of Funds*
World Bank
a. Improvement in MCH
& Fertility Reduction in
Bangalore's urban slums
b. Extended to 1 I cities
and towns due to savings
and differences in
Foreign exchange
conversion rates.______
World Bank
Reduction in CDR/ CBR
& IMR in Rural areas
through PHC Strategy.
(13 Districts)
Total Project
Size**
39 Crores
(387.2million)
Part Loan / Part
Grant
Period
1993-2001
(in phases)
122 Crores
(1220.9million)
Part Loan / Part
Grant
Launched in
1994
3. Karnataka Health
Systems Development
Project (KHSDP)
1996
World Bank
Improvement of Quality
and Performances of
Health care at District
and subdistrict level
546 Crores
(109 per year)
Part Loan / Part
Grant
| 1996 -2001
I 5yrs
4. Kreditanstalt fur
Wiederaufbau(KfW)
1998
KfW of Germany
Improvement of Quality
and Performance of
Health care at District
and subdistrict level
(Gulbarga Division 5
backward districts)
59 Crores
( 0.38 million
DM)
Grant
Launched in
-5-
1998
S.No / Name
-s- Organisation of
Petroleum Exporting
Gountries Fund for
International Development
1OPEQ________
6. Reproductive and Child
Health Services (RCH)
Project
>
Year of
Starting
1991
Main Source of Funds
OPEC Fund
350 Bed Multi specialty
hospital in Raichur.
1997
World Bank
Improving Quality of
Family Welfare Services
Total Project
_____ Size
29.25 Crores
(OPEC - 90%
25.7 crores)
Soft loan
Period
Agreement
in 1991
190 crores
38 crores/year.
Part Loan / Part
Grant
7 Crores
(2000-01)
Part Loan / Part
Grant
1997-98 2003
7- Karnataka States AIDS
Control
(Karnataka State AIDS
Prevention society)
1999
8. Revised National TB
control programme
(RNTCP)
1994
World* Bank
Supporting new
approaches to effective
TB control in state using
SCC/ DOTS and other
components.
Phase III
18.3 Crores
Part Loan / Part
Grant
1994Neelasandra
1998
Entire
Bangalore
corporation
1996 Chitradurga
Bellary
Raichur
Bijapur
1999 Davangere
Koppal
Bagalkote
9. National Programme for
control of blindness
(DANPCB) now NPCB - K
1990
danida
To reduce prevention
of blindness from 1.4%
to 0.3% by 2000 AD
3 Crores
30 million
Grant
Till 2001
*0- UNICEF-GOK
Programme of Cooperation
in 2001.
1970's
UNICEF
To promote
comprehensive and
holistic survival, growth
and development of
children in the state
6.3383 Crores
(2001)
Grant
UNICEF
has
been
supporting
concurrently
since 70’s.
World Bank
Reducing the rate of
growth of HIV infection
in the state and in
strengthening the states
capacity to respond to
HIV/AIDS
*
All these projects have a contribution from state
or central government
respectively.
**
See Table V and VI for further details.
-6-
1999- 2004
C: Project Goals, Focus and Distribution of EAP^s
A perusal of Table II on the project goals, focus and distribution helps to identify
certain significant trends.
1. Prim an- Vs Secondary
•
7 out of 10 projects support Primary Health care level while 3 out of 10
projects support secondary care level (one of three also support Tertiary
care).
•
If the project costs / budgets are taken into account as a sign of priority or
emphasis then only thirty three percent (386 crores) is on primary care and
sixty six percent (634 crores) focussed on secondary and tertiary care.
(Using project size as a general indicator)
2. Comprehensive Vs Selective
i
•
Within the Primary Health Care group two of the projects IPP IX and
UNICEF are more comprehensive in their design focussed on 'Urban and
Rural' primary health care and child health (and social development)
respectively, but the remaining five are more selective primary health care
strategies with RCH being a slightly more composite package and the
remaining three being focussed vertically on single disease problem of
AIDS, TB, and Cataract Blindness.
3. Population agenda
Even IPP VIII and IPP IX are strongly driven by the Family planning or
population agenda with health needs other than fertility related, getting much
less focus.
4. Diversity and overlap
When the objectives and goals of these EAP's are reviewed collectively then the
following observations can be made (refer Table II)
Each project is relatively multidimensional with different components
and strategies. At the implementation level some components get more
emphasized than others.
The objectives vary from very general ones to very specific outcome
oriented ones as seen in AIDS. TB, and Blindness control.
TABU. - II
f
I \tei nally Aided Projects in Health Service Delivery Karnataka
OBJECTIVES/ EOCUS/ REGIONAL DISTRIBUTION
sName
<)bjectives/ Goals
I. NT \ II!
•
Deliveiy of FVV &
MCI I to urban poor
Focus______
Urban Poor.
' Selective Primary
and promote CS & SM. i Health Care focussed on
FW-MCH ‘-CSSM+
• Reduce Fertility
rate and promote late
marriages.
• Promote male
participation in FP.
• Awareness and
action for personal
hygiene, better
environment and
prevention of diseases
I
• Non Formal
Education (NFE) and
vocational training for
women
• Promote Female
I-ducat ion
2. IP!’ r\
• Implement a
program sustainable at
village level to reduce
CBR, IMR and MMR
and increase CPR
(Couple protection rate)
through
•
Involve community
in promoting delivery of
family welfare services.
• Strengthen delivery
of services by support
i to drugs, kits, supplies
to TBA's SC and PHC,
mobility of ANM’s;
buildings of center and
residential
accommodation.
• Training to
Personnel and TBA's,
Community leaders and
voluntary workers.
• Strengthen
Monitoring and
i evaluation by MIES
I (from district to state
level )
I
•
Rural
(Family welfare
and MCI I)
Primary Health care
Focus
Regional Distribution
Bangalore urban slums.
• 0.851 million
population of urban poor in
about 500 slums in an area
of 225 sq. kms.
• Civil works Focus
Bellary, Chickmaglur,
Dakshina kannada, Hassan,
Kodagu, Mandya, Mysore,
Uttar kannada, Shimoga,
Chitradurga, Belgaum,
Bijapur, Gulbarga
*
1EC / MIES Focus
In all districts
I
S.No/ Name
3. KHSDP
________ Focus
Objectives/ Goals
• Improvement
• Secondary level
in performance and health care
Quality of Health
Care services at District - To provide critical
and Subdistrict level
I support to Pl 1C Networks
• Narrowing
i - Establish essential
the current
linkages with tertiary
coverage gaps by
level.
facilitating access
to health care delivery.
• Achievement of
better efficiency in
the allocation and use of
health resources.
By
-Strengthening
implementation
capacity.
- Strengthening delivery
of service.
- Improving
functioning of referral.
- Establishing effective
surveillance system.
- Improvement
of cost recovery
mechanisms.
- Improving access to
disadvantaged
sections SC/ST/women
i
Regional Distribution
• Renovating = 70
CHC-14
Taluk Hospital - 34
Sub Dist HQ Hospital - 9
District Hospital - 6
Women & Children
Hospital - 5
Epidemic Diseases
Hospital - 2
• Extending =131
CHC-28
Taluk Hospital - 71
Sub Dist. HQ. Hospital — 16
District Hospital - 9
Women & Children
Hospital - 6
Epidemic Diseases
Hospital - 1
Grand Total = 201
-9-
IJ
4
S.No/ Name
4. KfW
i
a
$
Objectives/ Goals
• Significant
Improvement in the
Health status of socio
economic backward
region / state.
• Setting up a
Comprehensive referral
system in the division
through strengthening
and
revamping
secondary hospital
network.
• Sustainability of
Infrastructure and
Equipment.
• Increase
Sustainability of
Health care.
________ Focus_____
• Secondary level
Gulbarga district.
(Northern disadvantaged
districts)
*
Bidar
- 6 hospitals
Bellary - 10
Gulbarga - 18
Raichur - 13
47 hospitals
Renovation
and upgradation of
facility.
Improvement
Maintenance
Regional Distribution
Gulbarga Division
26 in Phase One
21 in Phase Two
of
Improving
Sustainability through
fee collection.
i
5. OPEC
6. RCH
• To build a 350 bed
multi speciality hospital
which will cater to
Raichur District and
four districts around.
(Med/Surg/ENT/ ortho
Physiotherapy,
Cardiology /
Cardiothoracic,
Ophthal, Dental,
Nephrology, Urology,
Burns wards,
Gastroentorology,
Biochem, Path,
Microbiology
Radiology and CSSD).
_• 0 To meet individual
client health and family
planning needs and to
provide high quality
services through a
gender sensitive and
responsive client based
approach.
• Aim to reduce the
burden of unplanned
and unwanted child
bearing and related
mortality and morbidity
* J Reducing 'unmet
need' increasing 'service
coverage' ensuring
quality of care.
• Secondary and
Tertiary health care
• Old District hospital
will remain as a women
and children hospital with
skin, psychiatry. Leprosy
and TB (250 beds)
• Selective Primary
Health Care with focus on
Reproductive and child
health.
• Prevention and
Management of unwanted
pregnancies.
• Maternal care
- Antenatal
- Natal
- Post natal
- Child survival
- Treatment of
Reproductive tract
infections and STDs.
-10-
• Raichur - / Gulbarga,
Bidar, Gadag, Bijapur (and
some neighbouring districts
of AP will be benefited.
•
•
• All districts in 3 years.
Districts categorized
into A, B, C category
A = better off
B = average
C = weaker
1M year - 9 District
A2. BI,C3
2nd year = 8 Districts
AL B4, C3
3rd year = 3 Districts
B3
(Rationale of selecting
districts not clear).
_ S.No/ Name
7. KSAPS
Objectives/ Goals
• To assist state in
reducing the rate of
growth of HIV infection
and strengthen capacity
to respond to HIV /
AIDS on a long term
basis.
This includes:
- Delivering cost
effective prevention
against HIV / AIDS
- Promotive intervention
for general community.
______ Focus_______
• Selective Primary
Health Care /AIDS / HIV
Control
- Surveillance and clinical
Management.
- Sentinel Surveillance
- Blood safety
programme.
Regional Distribution
• 14 sentinel sites in 10
districts
• 25 NGO's in 9 districts
(15/25 in Bangalore)
• 30 S fD clinics in 21
districts.
- STD control
- IEC
- NGO coordination
- Training programmes
- Low cost AIDS care.
- Institutional
strengthening.
- Intersectoral
coordination.
8. RNTCP
• Detect at I east 70%
of estimated incidence
of smear - positive
cases through quality
sputum microscopy.
• Administer
standardized SCC
under DOT during
intensive phase and
quality supervision
during continuation
phase.
• Achieve 85% cure
rate among all newly
detected sputum
positive cases.
Selective Primary Health
Care including
• Strengthening and
reorganizing state TB
control unit.
• Rigorous method for
detection treatment and
monitoring.
• Strengthening
training research capacity
• Targeting smear
Positive cases.
• SCC with DOT
• Decentralizing
service delivery to
Periphery
•
Rigorous system of
patient recording and
Monitoring.
-11-
• Initially Bangalore
Urban only Now 7 districts
of Chitradurga, Bcllary.
Raichur, Bijapur, Mandya,
Bangalore urban (excluding
BCC area)
*
S.No/ Name
oTImnpcb
Now NPCB-K
10. UNICEFGOK
Objectives/ Goals
Reduction in the
prevalence of cataract
blindness from 1.4% to
0.3% by 2000 AD
_________ Focus_______
- Selective Primary
Health Care and
Secondary care.
- State Opthalmic Cell
- Upgradation of Medical
colleges. District
hospitals. Taluk
hospitals, mobile units
and PHC’s
- Eye Bank
- Training of surgeons and
ophth assistants.
- District Blindness
control societies.
- Cataract surgeries
- Microplanning
IEC, MIS, SES
• To promote
- Multidimensional child
health care and social
comprehensive and
holistic survival, growth
development. (Primary
Health care)
and development of
children in state through • Community,
- Improved new born
convergent action (CCA)
care.
• Health Action
- Development
• Child Development
protection and early
and Nutrition.
stimulation of
• Water and
vulnerable 0-3 years.
Environmental Sanitation.
- Enjoyable and quality
•
Education
education for pre
• Child Protection
school and primary
level.
(Sericulture and Bonded
labour)
- Access to clean water
and sanitary
• Communication and
environment.
strategic planning.
- Protection from child
labour.
- Improved Nutritional
status.
- Better child care
practices.
- 12-
Regional Distribution
Focus on all districts in air
divisions.
(Performance very good in
Bangalore urban Udupi,
Bagalkot, Dharwar,
Gulbarga.
Very poor in Chitradurga,
Chamrajnagar, Kodagu,
Gadag, Haveri, Belgaum,
Bijapur, Davangere).
• Different Districts
• CCA - Mysore,
Chitradurga, Gulbarga
and Raichur.
• Health - Bidar, Raichur,
Gulbarga and Bijapur.
• School sanitation
Mysore, Tumkur,
Chitradurga. and Raichur
• Other Activities
In all districts
There is overlap between projects in lil fcrenl areas e.g
• IPP IX and RCII have lair degree of overlap
• Training overlaps in many of them, (see also case study)
• Also IEC and MIS
• Surveillance and Health Management Systems especially since
they often focus on same districts, same categories and same
health centres and teams. (This will be considered again later).
5. Equity Focus
•
The focus on disadvantaged or marginal groups in the community varies from
explicit to ambiguous. In IPP VIII (Urban poor) and KHSDP (disadvantaged
sections /ST/SC/women) it is more explicit while in all the others it is
ambiguous, mostly with a sort of'reaching all' focus. In RCH there is specific
reference to 'Gender sensitivity’ and in UNIfTT's programmes focus on 'child
labour' is emphasized, which are significant.
•
In terms of addressing Regional disparities in health structures and systems in
the state, EAP’s have a very varied contribution
KfW and OPEC are specifically focussed on the disadvantaged
Northern Karnataka (Gulbarga Di\ ision), though the donor decided
this focus in the latter loan, not the slate.
IPP VIII is focussed on urban poor in Bangalore being the largest
urban conglomeration in the state though in the next phase other
cities and towns are being covered.
KHSDP, KSAPS, NPCB-K focus more widely.
Others like IPP IX, RCH, RNTCP and UNICEF do focus selectively
on some districts more than others for different components, but
while the disadvantaged Northern Districts of Karnataka do get
.included quite often, the focus is not based on data for regional
disparities or need, but seem more adhoc, responding to more
extraneous pulls and pushes for selection including districts
patronized by politicians or other ’lobbies’ or other such non
technical reasons.
6. Local and National Agendas
* □Finally except OPEC and KfW’ which are only Karnataka determined and
focussed; and KHSDP which is Karnataka focussed but has counter parts in
Punjab, West Bengal and now Orissa; all the other projects are similar to those
promoted by the funding agencies in other slates as well. Many like RNTCP,
AIDS,
NPCB-K, perhaps even RCH and IPP IX are evolved as framework /
-13-
packages at National level and then offered lo the ante as a ‘ '
‘fixed package deal',
Sometimes the state directorate and experts have tried lo modify
or review these
national level prescriptions and tried to adapt them io state level
realities hut by
and large this process of adaptation is rather weak and adhoc.
!
3
*
OPEcTiPP1 V?i le,SC,1SC
0WI?ershiP b> lllc slale 'v;ls very strong in KI ISDP /
■
r
,
VVaS re,atlve|y much less in the others and very little nerhans
in RC11 which showed absence of stakes in planning and formulation.
4
: InmdentaHy in 1PP VIII especially in the sector of innovative schemes there are
ilfaent approaches and schemes being tried out in Bangalore. Hyderabad
elhi and Calcutta - a diversity which was both welcome and significantly
different from the usual 'central top down' prescribed packages.
•
Regional disparities between
states and within states are so stark that greater
emphasis on • District 1level planning in the context of local "socioepidemiological
evidence“ anci situation analysis is an important policy
.
operative EAI s could well be an instrument to experiment with such diversity
or approaches.
“wisny
si.;
No;
Status of Bank Group Operations in India (March 31, 1999)
Original Amount with USS (Millions)
Project
i Fiscal IBRD IDA Cancel;
Un
i year i
i|Population Vlll (iN-PE-9963y
' disbursed
ri992’t””-”'”f 79.00;
2; National Leprosy'Elimination
i(_I_NPE-10424) ’
3 Karnataka Wafer Suppiy and
Environment Sanitation
....J(l_N-PE-10418) *
4;PopuTation'(TN-P'E'lTb457y*’'‘'
|
SjMalaria ControT’dN^p^Vo^l l”)”
!
I
Sifubercu’losis Control (Tn-PE-" '
j10473) *
55.86 F ..... S
24.’71: ”s
9.07i
1 1993 ?
92.00:
!
; 1994 ;
88.60:
117.80 j
~50J6t
S
S
"’8l'.38?
S
s
350.00
263.'ir'
S
S
pggyT
; 248.30 :
.1.
233.16-
S
S
[‘19977
;“1997T'
: 164.80;
’T’l 42.401
’15745?’
128.631’
S
U
S
U
1
' 1995
i
31.64
U “ Lnsatlsfuct()ry and HS - Highly Unsatisfactory
o e. is table is not specific to Karnataka but is an overview of the All India situation
Projects
which are relevant to Karnataka are shown by an asterisk.
Source Report No. 1891 •-
s
85 00’'
SiBlindness Controi‘(iN-PE-i0455j
’”t
;VTl994T
6jState Health System ii
.....JONPE-35825) ’
: 7|!Reproductive Health
Develop: Implemental
Obj : Projects
Rrou-ct Ipprmxal Document May i3
- 14 -
■'99
HS
si• S
IJ
I): Overview of Prognimines and Activities
•
la hie III provides an overview of the overall focus of the programmes and
activities using budget headings including special programmes and allotments.
About 34 components were idcntil'ied ol which 13 were the commonest in all
the 9 projects (UNICEF was excluded in this table), fhcse were
6 and more than 6 out of 9
Construction;
Furniture;
Equipments;
Drugs and supplies;
Local training;
Local Consultancies;
Maintenance of Vehicles and Equipment;
Contingencies.
4 and less than 6 out of 9
Staff salaries
Vehicles
Management Information System (MIS)
Information - Education - Communication (IEC)
Project management
NGO support.
Hardware over Softw a re
lhe main focus of most of these have been hardcore infrastructure development
(Buildings, Equipment, Vehicles etc) and though software- like training, IEC, MIS
and NGO support were included and envisaged, at the operational level, hardware
always got greater focus than software. Also hardware was seen as absolute
necessity so often as in IPP IX and KFISDP. constructions were focussed upon
rather than initiating some of the software using locally available facilities and
resources concurrently. Also hardware investment was substantial and needed
greater supervision and control distracting from software development which
however is probably more important if long term sustainability is to be thought off.
•
Inadequate quality improvement focus
Another feature of the overview findings are that some elements which contribute to
improving quality especially at operational or performance level were not always
included in the project design and cost allotments.
Fhcse included
Provision for books and training materials;
Training material development;
- 15 -
Innovative schemes;
Revolving funds;
Lv aluation studies;
Documentation.
Very tew projects had them as special allotments. No doubt some may have spent
on these items under other budget heads but allotment of a budget need for any
programme activity is definitely a sign of priority or significance.
Equity focus
Finally special locus on poor, disadvantaged and on women was mentioned in many
projects but only in IPP VIII and KHSDP were their specific programmatic
allotments for women orientation and involvement (IPP VIII and KHSDP) and for
safety net for the disadvantaged (KHSDP). Only a special allotment can ensure that
the thrust is part of operational policy.
i
Additional iteins
However since there were variations in the focus of the health problems addressed
by different projects specific allotments for specific additional themes were
observed. These included waste handling (KHSDP); Blood safety and voluntary
testing and counseling (KSAPS); Adolescent Health (RCH); School Health
(NPCB-K) all very important and significant. Some elements like school as a focus
ot health activity should be a compulsory component of all health projects because
preparing / orienting future citizens is a policy imperative.
*
Learning from previous experience and each other
While UNICEF schemes were not included in the table their allotment to a range of
themes around child health exemplified a much more holistic; practical and
operational approach. The programme highlights included convergent community
action, border -cluster strategy for MCH and ICMI (Integrated Management of
Childhood Illness); Child development and nutrition; Water and environmental
sanitation; Janashctla, programme child labour protection; HIV / AIDS prevention
activities, etc.
NB: It is unfortunate that UNICEF's longer experience of moving from
biomedically defined technological approaches' to more 'holistic initiatives
responding to broader socio-economic cultural realities' has been totally ignored and
World Bank's 'selective prescriptions and initiatives' allowed to distort health
planning and in many cases leading to a reinventing of the wheel. Dialogue
between project funders and building on past experiences is crucial otherwise EAP’s
could be a wasteful distortion and also being 'loans’ rather than 'grants' could be
wastefully counter productive.
- 16 -
I : Overall Strengths and Weaknesses of E/XPVs
IV lisls out the key strengths and weaknesses of different programmes as
identified by literature review and endorsed by interactive discussions. 'They vary
from programme to programme and cover wide range of sectors and issues.
Strengths
I aken as a composite group the key strengths of these projects are:
1 Infrastructure (levclopment
I hey have focussed primarily on infrastructure development, which includes
buildings lor hospitals and health centres, operation theatres, staff quarters etc.
While these were necessary since the directorate had not invested in adequate
maintenance ol existing infrastructure nor invested in adequate construction to fill
up the lacunae in the past, the demands of infrastructure often have tended to
overshadow all aspects of the project.
2. Support field action
In the situation when programme action budgets are shrinking with salaries taking
over greater and greater percentage these projects help to promote specific action
components and field activities.
2- framework of strategy : planning capacity enhanced
Conceptually whether primary or secondary, comprehensive or selective, many of
these projects have led to generation of some framework of strategy and action and
have been supported by a degree of background homework. Though the data base is
otlen patchy it is better than some of the adhoc decisions in the past which were
often repetitive without adequate evidence or data. Project formulation including
setting objectives; outlining strategies; identifying action plans; identifying outcome
and impact indicators and benchmarks all have helped build planning capacity even
though the compartmentalization causes overlap and some distortions.
4. Innovations
Project autonomy, which is relative has allowed many innovations to be
experimented with, which is a change from the routine generalized top down
prescriptions thrust on the whole system in different districts uniformly and at all
levels in the past. All the innovations cannot be listed out here but from the table
some of them need to be highlighted. These are
a. Link workers ('IPPV1II)
b. Women’s clubs (SHE clubs) - IPP VIII
c. Gender sensitivity and women’s orientation - IPP VIII
- 17 -
u
d. 1 lerbal gardens - IPP VIII
e.
1 lelp desks and Boards of visitor^ 1PP \ III
Tribal ANM training - IPP IX
g- Partnership with NGOs to run centres. (IP? VIIL IPP IX, RCI1 and KSAPs)
h. Special interventions for disad\aniaged ? allow card. KI1SDP
i.
Comprehensive MIS being evohcd - 1<11SI )P
j- Improvement of referral links - KI ISDP
k. Good mechanisms for construction and supcr\ ision - Ki ISDP
l. Efforts al quality improvement (IPP VIII. KI ISDP)
m . hocus on women specific and budget heading ( KI ISDP)
n. Decentralization of accounts (K lA\ )
o. Focus on Northern disadvantaged districts UxfW. OPEC. RCI I. UNICEF)
P- Einks with Literacy campaign (RCl 1)
q- Focus on adolescent age group (RCl 1)
r. Partnership with private sector - some contract services (KI ISDP)
s. Involvement of Medical colleges (RCl 1. I N1CEF)
t. Newsletters (KFISDP)
r.
Many more may be there but these arc a representative sample. However there
seemed little effort at documenting these *inno\alions' and even less on monitoring
or evaluating them in any sort of methodical
rigorous way. It is important to
ensure that they add value in quality and efficiency to the existing PFIC option
programme before they get adopted by the whole system as an added innovation..
I his element ol operational research was signii'icanlly absent.
Weak ii esses
The key overall weaknesses of EAPs were
1.
Overemphasis on infrastructure
While focus on infrastructural development was a strength as pointed out earlier, it
also tended to-overshadow all the so called 'software' or action / programmatic
components.
-
In house Planning Capacity not enhanced
Many of the projects used external consultants who helped to improve project
planning capacity but this did not necessarih get internalised in to the existing
health system.
I
TABLE - IV
I
Externally Aided Projects in Health Service Delivery in Karnataka
!
SOME STRENGTHS AND WEAKNESSES
j
J
*
a
I
4
i
I
J
!
l
7
S.No/EAP ____________ Strengths_____ ___
1. IPP VIII
• Comprehensive Conceptual
Framework
(Family Welfare, MCH, CSSM
Water supply and sanitation
Education, Community
Development).
• Involvement of Community
through Link Workers, Women's
clubs (SHE clubs) (Social Health
and Environment) etc.
• ’ Establishing crdches, NFE and
Vocational training.
I
• Involvement of NGOs
• Gender sensitivity and women
orientation
• Flexibility e.g. different
innovative schemes in Bangalore,
Calcutta, Delhi and Hyderabad.
• Social paradigm awareness
stronger at all levels.
• Operational guidelines for
most aspects of project quite good.
• Some good practices:
- Help desks in centres.
- Herbal gardens in all
- Overall morale and
discipline of staff good.
- Contract for cleaning /
security efficient
2 Board of visitors.
- NGO participation.
• Citizens charter
• Slum based centre (more
accessible)
• Human Resource Development.
■i
!
1
i
I'
- 19-
____________ Weaknesses___________
• Focus on Family Welfare
predominant other programmes present
but adhoc and not adequately integrated
perhaps even inconsistent. (Need to
actively convert from FWC to urban
Primary Health care centre).
• Long term sustainability especially
regularization of centre staff not
adequately addressed.
• Partnership and Liaison of project
team with Corporation Health Centres
problematic (ownership by corporation
inadequate)
• IEC more material preparation than
field use.
• Orientation and motivation of
Doctors not maintained after initial
training (need for more problem solving
sessions;
• Many innovative schemes built upon
but not in a sustained way.
• Involvement of NGO's and
community and G Ps patchy. Not
adequately evaluated or monitored.
• Lab facilities and services to be
improved.
u
S.No/EAP
2. 1PP1X
_____ Strengths_______________
• Focus on rural Primary Health
; care - Filling gaps.
• Flexibility in project formulation
and utilization across financial years
without lapsing of funds.
• Software inputs like IEC,
Training included in project
components
• Innovations like
- Tribal ANMs for tribal area (relaxed
requirements strengthened training)
- NGO take over of PHCs
(two
experiments)
- In some activities like IEC focus on
Northern Karnataka based on regional
disparities has been project emphasis
(at proposal level only)
- Short listing of NGO's done through
a planned / realistic procedure
though time consuming.
____________ \\ caknesses
• Hardwaretcivil works)
Moved better than software.
• Overall implementation
delays with complacency in the initial
stages and some lack of clarity/ capacity.
• Ownership by District Health officers
Inadequate.
• Centralized implementation except
for building aspects.
• Operational guidelines for many
aspects were not initially catered for e.g.
Fund flow mechanism to ZPs.
• Monitoring mechanism
not adequate to support effective
implementation.
• Community involvement of village
committees - not adequately
implemented. Involvement of NGO
equivocal.
• Lack of continuity of
key personnel in the project handicapped the project.
• I EC virtually a non
starter
• Training process direction given to
NIHFW (National) rather than S1FHW
(State) which led to delays.
• Government level
decision making bureaucratic •• 3 standing
committees delav decision
3. KHSDP
• More than just secondary
Care. Conceptually also focuses on:
- Special interventions for
Disadvantaged (Yellow card scheme).
- Comprehensive Surveillance system
- Trauma centre
i
- Hospital Waste Management.
- Blood Bank modernization.
- Improvement of Referral links.
• KHSDP. OPEC, KAV
share capacity building initiatives.
• Good mechanisms for
Construction and infrastructure
development has been organised that
can be used by other projects as well.
• Some areas of focus relevant for
, Quality development — Equipment
maintenance. Quality, Women and
disadvantaged. Drug procurement
i policy. Medical waste management.
• Delay in construction
and civil works continue and 'local
problem solving' to get over constraints
not yet adequately decentralised.
• Huge cost over runs affecting
planning and process. Contracting out
and partnerships with NGO's and others
not being adequately monitored (Are the
effects really better?)
• Strategic planning cell has not been
developed adequately at capacity level
and from the point of sustainability of
planning process it is adhoc, marginal.
• Ownership problems especial I)' foi
longterm suslainabilitx not adequalcl)
addressed. DHS or ZP who will
maintain?
- 20-
I
__ J
S.No/EAP
4. KfVV
____________ Strengths___________
• Focus on a disadvantaged
Region.
• Linked to KHSDP for most
of software development.
• Account in Gulbarga
(helped decentralised utilisation by
Additional director for project
stationed there.
• Improve Administrative facilities
at hospital level as well as for District
I lealth officers and Taluk Medical
officers.
• Strengthen referral.
• Additional staff.
• Project conceptually includes focus
on disadvantaged and women.
• Epidemic preparedness.
I
5. OPEC
• Focus on a disadvantaged
region of the state (but the choice
seems to have been by the donor).
- 21 -
____________ Weaknesses_________
• Only lip service for
Software components (Training,
referral. MIS, support services not
adequately addressed inspite of
availability of KHSDP support system).
• Slow fund release /
Utilization.
• Seems mostly brick and mortar
project.
• Decentralised utilisation of funds
without close monitoring led to
problems of leakage, poor quality
control, ’thoughtless payments'
(Dilemma of centralization Vs
decentralization)
• Foreign consultants (SANI Plan)
from Germany were not very effective in
their coordination with local consultants
hence inordinate delays.
Affected by Indo - German relations.
Scaled down after the nuclear bomb!
• Not a comprehensive
plan. Very focussed on just a hospital
and not need based.
• Inadequate local planning and
ownership.
• Delays and adhoc action.
• In the planning no clarity on how to
implement or actually go about running
the institution.
• No clarity on how government will
raise minimum Rs. 10 crores per annum
to run the hospital (Now approaching
Private sector for partnership!)
• No clarity on how tertiary,
secondary input would link or support
PHC through referral system.
• Presently the hospital has been
inaugurated and providing minimal OPD
services. Plans have been initiated to
find a private sector partner!
S.No/EAP
6. RCH
____________ Strengths___________
• Attempt to adopt Community
Needs Assessment approach (in
principle).
• Adolescent Health priority.
• Links with literacy campaign
• Financial envelope idea:
- Focus on disadvantaged.
- States free to choose intervention.
- Flexibility etc.
• Focus on Northern districts
- Gulbarga, Bidar, Raichur, Koppal,
Bijapur, Bagalkote.
• Bellary sub project which involved
NGOs.
• Partnerships with NGOs,
Professional bodies and medical
colleges initiated.
I
-22 -
___________ Weaknesses___________
•
The work of UNICEF support in the
earlier phase of RCH not acknowledged.
Programme not learning from earlier
experience and strategies.
• Civil works preoccupation like
• Other WB projects with delays and
cost over runs.
• Software components like I EC,
Training, moving very slowly or not
at all.
• Too much Family planning oriented
not integrated with health adequately
(Population agenda strong).
• Delays in basic training / delivery
kits etc.
• Focus on Secondary care more than
primary care - institutional services more
than field services.
• Top down Package deals oriented
rather than 'process' and local planning
and empowerment oriented.
• Overall progress of RCH project
which is high priority is very slow and
financial utilization seems quite
sluggish.
• Nutrition neglected in programme.
• Consultants not clear about actual
roles.
• Not adequately integrated at project
planning level (left to adhoc decisions).
• Too women oriented need to retain
balance and involve men as well.
• Sustainability not addressed
Community Needs Assessment on
paper.
II
S.No/EAP
7. UNICEF
____________ Strengths_________
• Complementarity of initiatives like
CSSM, RC11, and immunization.
• Using fixed day session and
campaign approaches.
• Pilot schemes tried out in some
districts or towns and then expanded /
replicated in other areas.
• Generation of training materials
and training programmes more local
and relevant.
• Involvement of Medical colleges,
research centres in MICES survey and
other projects.
• Learning from experience and
responding to local needs and demands
good.*
• Policies, guidelines manuals
evolved with local expertise.
•
• Policy to focus on Northern
Karnataka and districts with weakest
child development indicators.
__________ Weaknesses
• 1 ligh vacancy rates of AN Ms m
disadvantaged Northern districts.
• Logistics of cold chain Drucs. kits
not adequately tackled delays etc.
• Orientation / training of Programme
managers to deal with many departments
network, sustain partnership is still not
adequately developed.
• Complementary of UNICTI- and
• RCH (WB) programmes not
adequately tackled due to project
compartmentalization.
Inspite of attempts to promote inter
sectorality UNICEF support programmes
still get listed to one department or the
other.
8. RNTCP
Very important priority problem.
Hence selective strategy still required
and emphasized.
• Many DTC’s do not still have
District TB officers (9)
• Laboratory technicians posts \ acant.
• Abrupt transfer of trained personnel.
• Some DTC’s have no building (9).
• Complex procurement procedures.
• Lack of cooperation from medical
colleges / major hospitals.
• Inadequate budgetary support at state
i district level.
• RNTCP districts Vs short course
chemotherapy districts of SCC
continuing ambiguity.
• Overall TB still low priority.
-23 -
S.No/E/VP
9. KSAPS
Phase I
____________ Strengths___________
• Zonal blood testing centres
established.
• Modernisation of Blood banks.
• Surveillance centres set up (8 + 5
new)
• NGO involvement good leading to
development of AIDS Forum
Karnataka - mostly Bangalore
(includes work with sex workers,
truckers and care and support for
PLWHA’s)
• Strengthening of STD clinics.
• IEC activities at many levels.
• Training activities on a regular
basis.
• State AIDS prevention society set
_________
Weaknesses____________
• Supply of drugs delayed and
continuity of care and treatment (due to
complicated procurement procedures)
• Lab diagnostic facilities for voluntary
testing in all districts still inadequate.
• Lack of full or sustained partnership
with NGO’s in other parts of Karnataka.
• Lack of counseling facilities in
District and major Hospitals.
• Inadequate policy guidelines on HIV
testing.
up.
3
Inadequate operational management capacity
Overall there were inordinate delays between launch of the projects and getting
operational strategies of the ground. These seemed to be lack of capacity at all
levels to convert ‘good project objectives’ into ground level strategies. While these
improved over time at the state level as seen in KHSDP, IPP IX, at the ground level
i.e., the District level; the PHC level and Panchayati Raj Institutions (PRI) level
these remained a weak chain in the link
4. Maintenance of Infrastructure not built in
Inspite of predominant infrastructure development, no planning or provision has
been made for future maintenance of the developed infrastructure. The state or ZP's
capacity to maintain them adequately has also not been addressed.
5. IEC non starter
IEC was an overall weakness - with preparation of materials often overshadowing
actual efficient use in the field. Often materials did get printed / produced but
logistics of distribution were not adequately planned and operational use by health
workers and others at the field level were most inadequate with a few exceptions.
-24 -
11
HMLS\ Monitoring and Evaluation weak
rhe monitoring and evaluation of the projects seemed weak inspite of efforts at
building up M and E strategics and lots of effort in some projects to evolve HMLS
systems. Most of the HMIS seemed to be used only by higher levels to help the
central planning process or monitor the programme. At the field level or base the
quality of I IMIS data was often poor since the ‘collector of data’ did not see himself
or herself as a user of the data for their own planning purposes and was collecting it
disinterestedly for someone else at a higher level.
7 Sustaining innovative ideas was inadequate
Many innovative ideas were being tried out but their long term integration or
sustainability was not properly planned for. To begin with even their complete
documentation has* been inadequate. Many schemes started but were discontinued
without proper evaluation; while many others were continued just for the sake of
continuity without monitoring evidence of value addition, if any.
Some other issues are included in the next chapter as policy imperatives.
An Innovative Scheme
Under an innovative scheme the IPP IX project has provided funds to the
Vivekananda Trust to train girls from the tribal hamlets and post them as ANMs in
those hamlets. This training is a one-year course following the governmentapproved ANM curriculum with an added component of tribal medicine. The
training has not been recognized by the Nursing Council, and the trained tribal
ANMs are working through the NGOs working in these areas. Following
discussions with the MOHFW, the trained ANMs have been accepted as trainees in
the ANM training centers at the completion of which they will also be eligible for
employment in the non-tribal areas. An evaluation of the first batch of 40 tribal
girls trained as ANMs indicated a satisfactory knowledge of MCH, herbal medicine,
nutrition, and personal hygiene. However, their knowledge of the reproductive
system and human anatomy needed strengthening, and this will be rectified through
training in the government ANM training schools. This scheme ensures access to
MCFI services in the remote and underserved tribal areas, and the presence of a
female service provider at the SCs. Another important benefit is the opening up of
job opportunities to tribal women within and outside of the tribal areas”.
Source IPP IX World Bank Review Mission /I ide Me moire
- 25 -
V
u
F. Lessons from Case studies
In spite of the time constraint the researchers felt that it would be a good idea to add
a tew case studies of the situation on the ground vis a vis some operational aspects
of these EAP’s. Using two strategic opportunities - a quick assessment of Training’
opportunities experienced by a group of medical officers in a Northern district was
included as case study A and a surprise visit to an urban health centre covered by an
EAP was included as case study B. Both case studies focus on some learning
experiences from ground level realities and are not meant to be taken as any sort of
rigorous evaluation.
1 Lessons from ease study - A
An interview of 6 doctors in a surprise visit to a Northern district showed the
quantity and quality of training inputs from a wide variety of EAP’s (around five
EAP’s) These are 'described in case study A. They show the following important
trends:
i
i.
ii.
iii.
iv.
v.
vi.
vii.
Five out of the 6 doctors had undergone some training or the other with three
of them having attended 5-6 training programmes. Most of these have been
in the past 5 years (1995 onwards) This has not been a uniform process with
some getting more opportunities than others.
The EAP’s supporting these training programme included IPP IX, RCH,
NACO, DAN-PCB AND CSSM (UNICEF)
The programmes ranged from 4 days to 18 days.
Most of them were in the Rural Health and Family welfare training centre
though one was at Hubli and other at Bangalore Medical college.
Most of them wanted CME’s atleast once or twice a year.
They suggested better skill orientation in training programmes and more
comprehensive induction training when they first join as PHC medical
officers.
Have suggested better resource persons and better centres than at present.
On the whole the case study shows that the EAP’s have managed to support training
of project mangers at field level even in the disadvantaged Northern districts which
is very creditable. However since these are done by different project administrations
there is overlap in themes and focus and the selection of courses do not fit in to any
available training schedule or CME of a local PHC. The selection and deputation
seems adhoc and opportunistic. Very often the MO gets transferred after a special
training programme so he is not able to add value after training to his ongoing work.
-26-
'H
C/kSi: STUDY -
:
Training Experience in Northern district
A tew Doctors with Government service varying from 6 months to 20 years were interviewed
icgaiding their training under various projects / programmes. Some details about the training of
these doctors are given below:
&
'■
Di~- A with about 7 1/2 years of government service had undergone the following training
I a.
MCH Training______
CSSM
1 week
1995
RHFWTC
b.
FP & MCH Training
RCH
I week
1997
c.
FP Training_________
CSSM
2 weeks
1998
jL
Management Training
1PPIX
2 weeks
1999
e.
Administrator Training
MO
1 week
1999
Nauzad
Training
Ahmed, Rural
Development
Training
It
II
iHspite of all the regular training feels necessity for skill based training in MTP, tubectomy (leaw
u ec omy nmself) and CME's (atleast twice a year). Also felt that quality of training at RFWTC
could be improved by getting trained resource persons from private / professional institutions.
PE-LMrs.) B with about 5 1/2 years service.underwent the following:
CSSM Training___________
CSSM
RHFWTC
Combined Medical Education
1PP IX
18 days
I C.
Blindness Training
_____
DANPCB
Leprosy Training
4 days
c.
AIDS/STD Training______
NACO
4 days
At Hubli
|T ______
RCH Management Training
RCH
___________ 5 days
RHFWTC
Had. . not been given any training in -MTP
- - Or
vil UIUI OUVIl OI\lll
tubectomy. ■Felt
that such skill based training would
enable to cater to the female population. Felt the need for CME’s (1-2 per year).
E
k
II
tl
Dr. C with I year
’
service (excluding 4 years contract service). Very capable, efficient
young MO, underwent the following training:a.
Reorientation Training
1PP IX
2 weeks
1996
RHFWTC
b.
MCH Training______
RCH
2 weeks
1997
c.
Leprosy Training
1 week
1998
d.
Management Training
1 week
2000
STD/AIDS Training
II
NACO
1 week
2000
f.
Medico-legal Training
2 weeks
2000
Bangalore
Medical College.
Is able to assist in tubectomy only. Feels the requirement of better training
courses and skill based
training in MTP and tubectomy. Also feels that he could benefit from CME's.
If
4. Dr. D having 6 1/2 years service has underwent only Orientation training and Management
training under IPP [X. Has assisted in tubectomies. Feels the necessity for more comprehensive
inauction training and training in Administration and Medico-legal aspects.
5. Dr (Mrs) E also serving in the District with 5 months service has had no l
training whatsoever
(t-egular KIISDP appointment). Feels the requirement of rigorous training i
, in all aspects to
ertectively perform the job responsibilities of a PHC doctor/
m
pCrv‘n^ ,n t*le Disfrict with 5 years Government service underwent only 3 weeks continued
Medical Education Training under IPP IX on induction (1995 October) and no other training Assists
in ptactical training of ANM’s at the co-located ANM Training Centre. Feels the requirement of
regular training especially skill based and activity based training. Training needs identified include
mu, tubectomy (including laprascopic), anesthesia and Medico-legal training (including oostmortem is a must), as he has performed 30-35 autopsies in his short service.
^7
u
2. Lessons from Case Study - B:
A visit to an urban family Welfare (Health centre) supported by an EAP showed
some interesting features described in the observations listed out in case study B.
I he case study emphasizes that inspite of quite a good level of conceptual
framework generation and the evolution of a large number of guidelines the gaps
between concept and practice can be wide.
Various local adhoc, modifications of programmes: temporary or permanent short
cuts: lack of continuing education: supportive supervision and motivation of field
staff: poor logistical support to supplies: and lack of sustained efforts to maintain an
innovation can lead to discontinuation of innovations; closure of certain functions;
modifications of strategies which can be wasteful or counterproductive; or result in
glaring mismatches and distortions as exemplified by the observations.
While some functions go on fairly well ancj as per the objectives, some get distorted
or modified. The case study exemplifies the need for continuous monitoring and
evaluation; efficient supplies and logistic support; constant problem solving
supportive supervision; and good team work and continuing education to ensure the
quality of the implemented programme and to reduce what is often called in policy
circles The implementation gap’.
• 28 -
iI
CASE STUDY B- An Urban Health Centre
SECTOR OF WORK
I - Family Planning Oriented
2. Referral Oriented
T Laboratory services not available
4. Family Planning services
5- Drugs Inadequate
6. SHE clubs defunct
7- Link workers a strong asset
8. LHV / ANMs from corporation
9. Immunization
10. Health Education I EC activities
discontinued.
* ' -ISO 9002 Certification
Fall in activities / performance
OBSER\ ATIOINS
No male patients seen;
No well baby clinic;
No well women clinic;
No screening for Breast Cancer or Cancer of the Cervix;
Only IUD insertion carried out, CCs and OPs distributed
No normal deliveries conducted even in day time.
All deliveries referred to Maternity Centres (MCs)
Referral card not well designed and common to all categories.
ANC card not given to the patient.
Laparoscopic Tubectomy or Tubectomy at MCs only.
Only Haemoglobinometer available cases usually referred to MCs,
long queue;
Tests sometimes done at UHC by visiting Lab technician's;
Lab tests -VDRL Hb, Blood group. Urine Albumin._______
Only where LMO trained, only Menstrual Regulation
Conditional i.e., only if patient willing for tubectomy / IUD.
Inadequate quantity to routinely treat OPD patients.
Very limited antibiotics.
No pediatric preparations/ syrups, no eye/ ear drops
(except chloroapplicaps) or skin ointments.
Definitely not Rs.50,000/- p.a. worth of drugs.
LMOs give prescriptions for purchase from outside.
Earlier vocational training - now discontinued.
Only serve as community feedback group.
From community, dedicated.
Low honorarium so frequent turnover.
Bring ANC cases early as well as children immunization.
Experienced, competent (could be corrupt)?
Cold chain maintained.
Vaccines available.
Outreach immunization also.
Twice a week, so load less.____________
Do not put posters in slums as destroyed by children.
A-V van discontinued due to corruption.
Mainly printing - less lecture demos.
Purely technical assessment.
Based on parameters like cleanliness, record keeping, waste
disposal, sterilization of OT and equipment etc.
Would not significantly improve quality of care.
False sense of perfection._______________
Since start of centre all activities have reduced significantly.
Assessment required of reasons for this.
Glossary IUD - Intrauterine devices
MC - Maternity Centres
OPD - Outpatients department
CC - Conventional contraceptive
(Condom)
LMO - Lady Medical officer
ANC - Antenatal card
UHC — Urban Health centre
OP - Oral Pills
- 29 -
u
G : Sonic Policy Imperatives Including Integration and Sustainability
The previous chapters provide an overall framework of the 10 EAP's in Karnataka
and some of the quantifiable or qualitatively describable indicators and features of
these projects to help the project overview. As indicated in the project protocol this
exercise was primarily a critical policy review and not an evaluation exercise of
each of the EAP's per se. Some of the finding in the previous chapters and tables
have addressed some of the questions that were included in our original list. In this
chapter we try to address those which have not been adequately covered by the
earlier one as well as provide some additional critical comments even on those that
have been covered, drawing primarily from the very candid and frank interactive
discussions we had with a wide variety of project directors. These policy issues and
imperatives are as follows:
1 • Scope of Projects
All the projects focus on Health System development with varying degrees of
emphasis on Primary Health care. While some focus on secondary level (e.g.
KHSDP) there is a built in assumption that the secondary care support is with a
view to support through efficient referral systems - the primary health care network.
While in practice the links may not be so well established the conceptual framework
is well directed to this issue. It is at the "Public Health" context level however that
the projects show a general weakness inspite of the fact that unlike other states in
the country "public health expertise’ is available even among the senior leadership
of the state. One can only surmise that in the changing financial situation perhaps
financial management contingencies and bio-medically defined management
framework are inadvertently distorting public health concepts and priorities. The
focus on basic determinants of health is weak (nutrition, water supply, sanitation,
environment) both at content level, emphasis and linkages; key public health
components like surveillance and health promotion are inadequate; and the ‘new
public health’ emphasis on empowerment of the community and public at large in
health decision making is totally overshadowed by top down provision of specific
packages euphemistically called social marketing. This lacunae / weakness needs to
be seriously addressed.
2. Project Planning
in the absence of a strong Strategic Planning Cell in the Directorate (inspite of a
provision in KHSDP for this) problems of project flexibility, design, long lead times
and delays, in preparation, complications in procedures and various ongoing
management and operational problems, all of which have been experienced in one
GAP or another — are a symptom of lack of adequate attention to building in-house
capacity for more realistic project planning and management. This has led to
compartmentalized planning, inadequate collection of field based data or evidence,
and adhocism in decision making further compounding the problem. Lessons are
not learnt from positive and negative experiences of a particular EAP or its success
■ jo
at some form of system development so the ‘wheel is reinvented' each time by each
and ^lc systenl 's not enriched by the collective experience. E.g. Different
EAP s have had different experiences of dealing with the ‘NGO sector' or the
pnvate sector - some positive; some not so positive; some even disastrous in terms
of unreliable partners or even ‘fly by night’ operators but the whole system does not
learn from this to evolve a Directorates policy for NGO or Private sector
partnership. This situation may change with the Task Force recommendation on
state policy directives but for the present this is a lacunae to be urgently addressed
J- Who drives the projects?
fhis was a very difficult policy issue to address. On the face of it, the State
oveinment / State Health Directorate drives the project not the funding partners or
their external consultants and all sorts of mutual consultations / reviews are
organised. However two factors do affect the ’driving’ of the project.
•
Absence of local homework
i
------------------------------------------
In the absence of rigorous ‘policy’ and evidence based homework on the
governments / directorate side due to a lack of strategic planning capacity as
mentioned earlier, external consultants of funding partners are often able to drive
the decision by just providing more options, more evidence based on data
marshalled from experience elsewhere and the state policy makers are then more
easily influenced or ready to accept them. e.g. During the study period an external
funding agency resource person provided more data and perspective on private
sector in Karnataka, than could be marshalled by local expertise thus inadvertently
pushing the private sector agenda. The reliability of this data or whether it was
extrapolated from quite different sources could not be commented upon adequatelv
without local homework.
7
•
Conditionalities of funding partners
World Bank loans more than other agencies are also usually supported by some
conditionalities that are clearly stated in their documents.
i.
The need for economic reforms.
ii.
The need to engage the private sector.
iii.
The need to promote user fees as a means of cost recovery.
iv.
The need to follow certain forms of Tender’ or ‘consultancy ‘laid down
by bank’etc.
There does not seem to be adequate home work in-house on these and
implications especially long term options, before loan agreements are signed.
-31 -
their
Some World Bank conditions
“ I he Country Approach Strategy (CAS) recommends focussing Bank-group
financed investments on states that are undertaking economic restructuring
programmes and supporting sectoral policy reforms. Karnataka is one of the state
that has initiated important fiscal, sectoral and governance reforms. Further more it
supports the CAS objectives by strengthening institutional capacity
,
engaging the private sector
,
“Each project state
shall levy user charges in district and subdivisional
hospitals in accordance with a program and time schedule acceptable to the
Association(IDA)”.
“Goods and works shall be procured in accordance with provisions of section I of
the guidelines for procurement under IBRD loans and IDA credits” (International
competitive bidding, bid packages etc).
,
“Consultants services shall be procured under contracts awarded in accordance with
the provision of the Guidelines for the use of consultants by World Bank borrowers
and by the World Bank as executing agenev - published by the Bank in August
1981”.
Source
I artous reports of the Bank and Project Agreements
Both these factors lead to the continuing perception and the fact that indeed the
'external agent1 does drive the project intentionally through general conditionalities
or ‘inadvertently through inadequate borrowers homework1. This needs to be
addressed urgently.
Even where conditionalities are inevitable, these should be closely monitored and
either reviewed -if they have negative consequences or internalised into the system if
they have positive implications.
4. Are there areas of overlap / duplication ?
•
Compartmentalized projects by the very fact of being developed independently
as 'stand alone1 projects and not as components of a larger wholistic integrated
project are bound to produce overlap and duplication.
•
Not surprisingly the chairperson of the Task Force during one of his recent
inspection visits found ‘three operation theatres in a PHC compound1 built by
different EAP's with no evidence from the MIS of local needs that warranted
such investment. In HMIS, IEC. and Training there are many overlaps and
duplications .
- 32 -
So different projects produce manuals and teaching aids or audio visual
aids for Health Education which are quite similar in content;
Health functionaries arc expected to maintain a wide variety of registers
that cater to the needs of different HMIS of different EAP’s ; and
Doctors go for different training programmes organised by a wide
variety of EAP’s that add to variety but not to a coordinated training plan
at district or PHC level (see case study A)
An overall integrated planning and training exercise is therefore urgently
required. At the directorate / state level there are efforts to prevent this
duplication of input and efforts but systematic change to streamline this process
and prevent even accidental or inadvertent duplication is required since the
health sector functions under a constant financial resource constraint and any
effort to ensure more efficient deployment of available resources is welcome. A
good example of adhoc integration is the utilization of KHSDP Resources for
KfW project needs.
I
Ownership and Leadership
In most projects the state level ownership is strong except perhaps in those
projects which are ‘package deals’ decided at the centre.
Because some of the EAP’s have established independent structural identities
e.g. KHSDP, IPP VIII, IPP IX, the links and feeling of shared ownership by the
parent directorate (in the case of KHSDP and IPP IX) and the parent Municipal
Corporation (in the case of IPP VIII) is weak. E.g. no serious consideration
regarding sustainability issues and integration challenges relevant to KHSDP or
IPP IX projects have been addressed at the directorate or Health secretariat. Nor
is the Municipal Corporation adequately concerned about the very same issues
vis a vis IPP VIII project.
•
Another significant lacunae seen in the EAP’s as they are presently structured, is
that ownership at District level - at the point of implementation is quite weak vis
a vis District Health Officers and PHC MOs; and perhaps non-existent vis a vis
PRI institutions. All these three groups are crucial to ensure the integration and
long term sustainability of all these projects. Ownership can be enhanced by
involving all of them from the very inception and conceptual planning stage of
such projects.
Leadership of the project directors has been good as long as there have not been
frequent changes of leadership or the burdening of project directors by multiple
and additional responsibilities.
•
However the leadership and ownership are particularly crucial if EAP’s have to
become more complementary or supplementary to each other and the whole
- 33 -
health care delivery system,
promotes linkages is crucial.
•
Leadership that eoordinates, networks and
Public Health orientation and socio-cpidemiological orientation of the leadership
- whether generalist administrator or medical / technical leadership is an
important necessity to prevent inadvertent distortions due to extraneous lobbies
or market forces. This will also enhance capacity to negotiate with external
consultants and others as well.
6. Intersectorality
While in many EAP’s the importance of this factor is mentioned, the intersectoral
coordination between departments and programme managers and decision makers
ot different concerned ministries is still not given adequate priority. At the heart of
good ‘public health strategies’ is the emphasis on intersectoral coordination and
while EAP’s may have not seized the opportunity in this aspect so far, the evolving
Integrated Health, Nutrition and Population^ project (HNP) must focus on this aspect
urgently and significantly. Even at the grassroots level a better coordination
between PHC, ICDS centre, local schools, women credit cooperatives and
development workers would strongly strengthen programme performance and
outreach.
7. Integration
There is urgent need to integrate Health with Family welfare; public health , primary
health care and the population agenda with each other to avoid not only duplication
by compartmentalization but also to reach the community and tackle the health
problems of people especially the poor in a more integrated way. Much lip service
has been paid to the issue of integration but the stand alone EAP’s have not tackled
this issue adequately. In fact different EAP’s focussed on different problems even
further disintegrate the work of the directorate.
DHO’s and M0’s are constantly preoccupied or distracted at ground level by
frequent visits of consultants, review teams, project teams asking for this and that
data or teed back; the more EAP’s the more such distraction from the normal
planning and management routine.
At the directorate level different EAP’s require different protocols to be filled,
(different MIS mechanisms) so quite a bit of directorate staff time is spent in filling
up questionnaires, schedules enhancing paper work but not necessarily enhancing
efficiency of planning and management.
Consultants for each EAP provide their own framework of ideas and deciision
making. These do not allow for any inter-EAP consultant communication. / One
EAP may appoint a consultant that suggests one type of ideas, another EAP another
type and all these have to function at the same PHC level or the same district level
-34 -
necessarily leadXadiZsm InJ^X^edahJ m lE'absence JstateScy
guidelines. Integration and coordinated communication is urgently required.
Another urgent area for integration to avoid wasteful duplication of time and
procedure is tlle need tor integrating all the single project related district level and
state level societies into one Health society at both levels to receive and disburse the
funds, berious policy reflection also needs to be done to ensure that the District
society s work under the purview of the Zilla Parishad and PRI,
8. Equity
sEc/s? Ssss
noted. HMIS of all EAP’s as well as the Directorate must begin to focus on Equity
in a more concerted way in the years to come. This ‘equity imperative' must include
i.
ii.
iii.
iv.
Geographical - Within districts and between districts.
Gender - between male and female sections of the population and
especially focus on girl child.
Class / Caste - Between rich, middle class and poor or the so called
haves and have - nots or ‘landed’ and ‘landless’ etc.
Marginalisation - SC / ST or special groups such as child labour or rural
migrants to urban areas, street child, elderly, people with disabilities etc.
Unless the HMIS focusses on disaggregated data the equity principle cannot be
furthered by active policy or programmatic intervention. EAP’s could build this in
to their framework more concretely so that they go beyond policy rhetoric.
9
Partnerships
All EAP’s have built some form of partnerships with the voluntary sector, NGO’s
private sector, academic institutions or research institutions. But these do not build
on a larger policy framework of the state since guidelines on such partnerships are
not available. They tend to be some what adhoc. The directorate should actively
move towards some form of Resource Directory; Accreditation system- or
reviewing and registering system for such partners so that EAP’s and different
ea th departments can draw from pooled experience and pooled resource lists A
partnership cell in the Directorate like the erstwhile Society for Coordination of
o untaiy Agencies (SCOVA) idea could build such directories, framework of
guidelines and linkages, of use to all departments and projects.
Community Partnership and Empowerment
1 he resistance of the Health department to work with Panchayati Raj Institutions is
*ell known and though some of the reservations of the health leadership may be
-35 -
very genuine and based on difficult or awkward situations of ‘interference’ or
extraneous push / pull factors in decision making - there is urgent need to review
this and get over the problem rather than ignore it. With increasing political
decentralization, PRIs will play an important part in local planning and
administration in the future and EAPs should promote this process and not distort it.
The district level societies which leave decision making in the hands of the
bureaucracy may be good for efficient disbursement of EAP funds but they
definitely mitigate against active community participation. EAP’s in particular must
begin to focus on human development more than infrastructure; and in this human
development component strengthening of community based organizations like PRI
institutions to contribute to local planning and ensure accountability and
transparency through capacity building will become as crucial as building health
teams to deliver the programmes efficiently and effectively.
11 • Accountability / Transparency
i
EAP’s may develop their own monitoring system and evaluation systems, even
audit systems but they are not accountable to the people, the political system, the
legal system in the same way as the directorate and its regular programmes. While
bureaucrats and technocrats may be closely involved with the development of these
projects and the evolution of their frameworks of action there is still the danger of
creation of a parallel system of decision making and programme management which
may be seen as relevant in the short term but could become problematic in the long
term.
However it was noted that overall some of the guidelines and procedures of the
projects were able to immunize the project from the corruption and political
interference which affect the larger system all the time since it does prevent the
influence of extraneous ‘push’ and ‘pull’ factors due to clear cut guidelines that are
not easy to circumvent.
In the short term review we were not able to make clear cut judgement whether
extraneous interference’s were making any sort of affect on programme formulation
or implementation. The use of retired government personnel as consultants was
common (a sort of ‘old boy’ network) which affected the dynamics of the
programme and subsequently its performance in some cases but not necessarily to
integrity. On the whole it may be surmised that EAP's are as subject to outside
interference as the rest of the system not necessarily more.
However in the matter of construction costs' and delays and whether some
contractors were favoured rather than others — These areas were difficult to explore
in the time constraint. There was hearsay evidence of this type all the time
including architects inflating designs / and enhancing profit margins in other
ways, etc.
- 36 -
12. Sustainability
This was one area on which there was very little real focus or policy discussion or
planning in the projects at any level - project plans, project dialogue, project
implementation mechanisms and so on. It is important to emphasizes that
sustainability is often seen as being financial only. It is actually more than this and
includes staff and other policies as well.
The overall assumptions which ignored this imperative and the trends seen were as
follows:
i.
The projects were seen as filling lacunae in the existing system and not
creating additional structures or functions.
ii.
The parent unit or department like the BMP in the case of IPP VIII and
Health Directorate in the case of IPP IX, KHSDP etc were expected to take
over the project when the period of the project was over. There seemed to
be no contingency plans being evolved for this inevitable reality.
iii.
In some project documents there was mention of cost recovery usually
through user fees mechanism; or sustainability was to be made possible by
NGO - or private sector partnership or take over but this was not followed
up by serious operational guidelines or planning with the concerned parties.
iv.
Sustainability as an issue seemed to be considered in the last year of the
project as a knee-jerk reaction rather than as a serious plan evolved from the
very beginning.
v.
Unless the directorate estimates recurrent costs, running costs, maintenance
costs and other such definable entities seriously as the time for phasing out
of the project nears and unless these costs are budgeted for or recovery
planned in some sort of methodical way - Sustainability like cost recovery
will remain rhetorical and ultimately ignored or considered as someone
else’s problem at a later date.
vi.
In some cases there seemed to be a confidence that some project donor
would always step in to fill the lacunae if one donor phased out - so again
this complacency led to a fatalistic non-planning situation which was not at
all uncommon.
Sustainability of these relatively large EAP’s is a 1very serious policy issue that
needs urgent attention at the highest level and the active involvement of the finance
ministry as well.
-37 -
\l
IF Some Reflections on the Financial / Economic implications of EAPVs
I nderstanding the Financial / economic implications of the increasing reliance on
I .AP's to support the health care delivery system in the stale and the gradual shift
Irom grant giving funding partners to becoming ’borrowers' of loans, was not an
easy policy issue to review due to atleast two constraints.
• 1 he financial management of the EAP's are separate systems not easily listed to
the states own health budgeting / accounting system.
*
fhe loan implications and the debt burden and debt servicing implications are
not easy to explore in a short time constraint under which the project functioned.
I he reviewers studied some earlier analysis particularly the review document
(.Analysis of Expenditure Medical and Public Health, Family welfare by
S.Subramanya) and the more recent study of Dr.Vinod Vyasulu and group and also
studied the credit agreements of various projects and the budget and account
statements as well’as status of project tables from World Bank and other sources,
from a review of all these secondary sources of data the following conclusions and
policy concerns are listed out: (See also box items which are extracts from authentic
source and support our conclusions)
I. While the overall expenditure on health and family welfare is gradually
decreasing and hovering between 1.1 and 1.4 of net state domestic product
which is itself an overall low investment (ICSSR 1CMR. recommend 8%), the
reliance on EAP's is increasing which means Non-plan expenditure is coming
down and Plan allocations are increasing. This is not a very healthy trend.
2. Most of the expenditure in non-plan is now directed to salaries with less and less
available for programme / action components. E.AP's arc tending to take over
more and more of this programme component - again not a healthy trend.
3. Considering that EAP’s arc now more and more loans rather than grants or long
term soft loans this is a worrisome development. If these loans are not utilized
with efficiency then we have the double burden of continuing ill health and a
’debt burden'.
4.
fhough all the projects talk about sustainability and cost recovery and user fees
mechanism is often mentioned as a long - term option there is no indication that
this mechanism is effective in reality.
While some recovery has been
demonstrated; and some efforts to identify those who cannot pay etc is being
experimented; and the decision to let the amount revenue collected be kept at
the institutional level for local use rather than transferred to the general account
or treasury - none of the mid-term reviews show that this could be a major
option for sustainability even though in the short term they may help to improve
quality by enhancing consumer participation. Researchers and programme
evaluators are not unjustified in their concern that ’user fees' may ultimately
-
-
Vn \nah sis
/ . -• flicicncv: I arec kev r. .m-
uh regard
- cl need to he iddrcsscd. I
1 lie overall
mm. 1990s.
.
m'crioratcd sharph since me
■-rcasc in interest pavnicni
i share of
outstanding as a share >>i .
. ■
hc domestic
mail linancial situation laced
a : dth sector,
; die states
fhe share o I he:dm. aud family
’ idgcl has declined since
/..111
m
curly 1990s
a health sector's share in ihe budget has
med.
The decline in the health lector's share
ger capita expenditures in all stales up to 1991,
expenditures
rose
-.han
faster
health
:ing is about I SS 2-3 per m. mi for health
meet ihe government's
-■ ol
stated ob|cclivcs.
To
funding a
J basic pack.me of health
ources lor health care arc rcquirc<l. but the
am
c pose a serious problem.
Second, within the
re’-oiirce allocation in the public sector is skewed in
miatr. c to needs at the primarv and secondary
■• .
muniiv hospitals,
t hird, much of the resources
; .:c recurrent cudgel lor '>pcralions and
:cr-i’indcd and the programs arc not fully
are f inancing : The resource constraints faced
' ;m-
: alternative methods of health cairn financing to
Mternative methods of financing health care.
: mm. ate insurance, and participate •i-. schemes,
fata indicate that cost recover’
"
in the health
■ ■ sge m India, although there arc problems in
n '.he problems faced with cost recovery include:
.nanism within the government io review user
i ■•in for collecting user fees:
■r ibr exemption from user fees: .mJ
to •.
f-'inion of funds generated through user charges at
mcc it should be noted, however, ’hat a cost
• heal th sector is about the most ihal can be
• he puhli.
m the long run. issues such as private insurance
:
be addressed, as the industrial and urban
-s-ntainment becomes increasing!;, important".
State Health binances
■\on Plan expenditure, which is met from resources raised internal 1\ by the stale,
accounted .i r 63-69 percent of the total expenditure on health and family welfare
w'lweei ; -9()-9| an(j 1994-95; this came down to ^7 percent in 1995-96.
bcduction ;n the proportion of non-Plan expenditure in 1995-96 is because of
increase in Plan allocations and capital outlays. One reason tor this increase could
be the a\.liiability of funds from externally assisted population and health projects
and (‘enirai government aided projects such as the AIDS control programme”.
"A ’uh expenditure on health and family welfare accounting for only 1.21 percent of
the net State Domestic Product down to 1.14 percent in 1991-92. but up to 1.24
percent in 1992-93. decreasing again to 1.22 percent in 1993-94 before increasing to
L37 percent in 1994-95. It is clear that Huctuations of this nature are undesirable
:>'r (he growth of’the health sector as also that expenditure on health and family
welfare is. by any reckoning, inadequate. , A study group on Health for All. set up
jointly b\ the Indian Council of Social Science Research and Indian Council of
Medical Research, recommended ‘a substantial increase in public expenditure on
health at about 8 or 9 percent per year (at constant prices) over the next 20 years".
> ' dopment tn Karnataka - 199)
dc-cmphasizc the need to focus on the marginalised. Other problems with this
mechanism arc highlighted in the box items as well.
I hcrc is a danger that increasing reliance on EAP's will ensure that programme
costs in the regular non-plan health budgets will be ignored with a long - term
tlistortion in budgeting creeping in.
(This will perpetuate long standing
budgetary imbalances with long term implications for health budgets).
6
1’hcre seems also a tendency to be more extravagant with issues like
consiructions, consultancies, equipment, vehicles, etc because EAP's promote
unwittingly a more 'private sector' ethos so thrift, careful planning, basic
simplicity and other such values that would ensure ‘quality' al low cost or a
more judicious use of resources so that more is available for grassroot needs is
being affected.
Email} it may be important to caution that reliance on EAP's should only be a
short term plan. Ultimately health budgets like the investment on education and
welfare (social sector) should be increased as a long term investment in quality
human development. Enough economic analysis and theory - including the
more recent endorsement by the work of economists like .Amartya Sen and
otltcrs show this direction as the way ahead. This needs political will and
commitment and some courageous state development policy planning. Let short
term solutions like EAP's not come in the way of concerted, action for sustained
dcxelopmcnt and higher investment in health.
Hi
§
J- General Policy Concerns : Arc we reinventing the wheel?
The key researcher for this study and some of his colleagues had reviewed the
World Bank activities in the Health Sector in India based on a case study on “The
World Bank s role in the Health system in India” facilitated by the Sector and
1 hematics Evaluation Group of the Operations Evaluation Department of World
Bank in August 1999.
That review had raised seven sets of questions / findings for a policy meeting
organised by the Bank with Planning Commission, Ministry of Health and Family
Welfare and others. The review of EAP’s in Karnataka was a good opportunity to
look at these propositions in a wider variety of project initiatives and with
partnerships beyond the one with the bank. Our findings suggest that many of these
concerns are very real ones even in the context of the current EAP’s in the state and
need to be given serious consideration by policy makers and project directors within
the state before these distortions and concerns become too systemic. They are
equally important for the funding partners. These concerns are enumerated as a set
of policy questions that project directors and partners should reflect upon as they
review their projects for long-term sustainability and integration within the larger
system.
— ^ublic Health not being adequately emphasised in problem analysis
nroject planning and formulation?
Is there a confusion in understanding public health?
Is economic or techno-managerial context taking precedence over socioepidemiological analysis?
Are the wider determinants of health like nutrition, water supply, sanitation,
and pollution not adequately addressed?
Is the focus on poor, indigent, marginalised not central?
Are regional diversities and differentials not central to decisions on focus of
programme?
ITimarv Health Care being given adequate emphasis and priority ?
Is there focus on selective ‘cost effective treatment strategies’ rather than
enabling / empowering processes?
Is there focus on first referral units rather than primary health centres,
subcentres and home based care?
Is community involvement in planning and organisation mostly
rhetorical with community capacity building made subservient to
exigencies of top down management systems.
Are Panchayati Raj institutions generally ignored and registered societies
promoted as an instrument of decentralization but under bureaucratic
control?
-43 -
3. Are these partnerships adequately transparent and accountable ?
Are the partners willing to share the costs of failure and distortions due
to poor programme design or planning which ultimately affects the poor?
Is long term sustainability or integration into existing health care system
being adequately addressed or followed up as an end of project after
thought?
Is there unhealthy competition between projects rather then collaboration
and sharing of expertise and experience?
Are accountability and transparency systems not clearly defined and
hence not actively monitored?
4. Some ethical issues and dilemmas ?
What is the ethics of promoting NGO-private sector partnership in the
absence of solid evidence that these are more efficient operational
options?
What is the ethics of taking credit when an initiative is successful and
yield positive results while pointing a finger to the directorate or ministry
when the initiative is problematic?
What is the ethics of expanding quality at the cost of or absence of
adequate and operational quality control?
What is the ethics of promoting infrastructure and ‘hardware’ at the cost
of ‘software ‘ that can more easily focus and reach the poor?
5. Some management issues and dilemmas?
In spite of marshalling lots of expertise both local and foreign is there a
tendency to:
Develop ‘hardware’ rather than ‘software’?
Expect ‘training’ to get over needs for serious management reforms?
Little thought to social accountability and transparency?
Inadequate attention to building ownership among different stake holders
particularly district level players?
- Focussing on ‘user fees’ as the only primary fund enhancing option
rather than looking at diverse options?
Overall neglect of health human power issues like continuity, skill
development and promoting team concept?
6
Is the political economy adequately addressed?
Are the health projects adequately located in a broader, political, social,
institutional analysis and adequately based on evidence of how projects
run or do not run?
-44 -
i]
Are issues such as political will; corruption and influence of lobbies
political interference; market economy; being given adequate emphasis
in the strategic planning exercises?
Without developing a strong ‘public health policy resource group’ within
the directorate is the free lancing, free floating, adhoc Consultancies and
commissioned studies not allowing the means of change to become
systemic?
7. Is cultural context being disregarded?
Inspite of a rich and diverse tradition of Indian and alternative systems of
medicine, including promotion and investment in health humanpower
development in these systems by government and private initiative; are
the EAP’s ignoring the local cultural context and these alternatives in
their formulation?
All these issues are relevant today and it was surprising to find that most of them
were applicable to all the EAPs in the state and not only for those supported by
World Bank. However it must be noted that the current health leadership both
bureaucratic and technocratic seemed much more alive to these policy issues. That
was a positive finding, symbolizing future potential. However as was brought out
again and again in the interactive discussions local holistic problem analysis and
policy homework was inadequate in all these aspects. Strengthening of
strategic policy analysis and development was an urgent action imperative.
Policy makers and project managers need urgent orientation to Public Health
aspects of decision making and socio-economic politico - cultural aspects of
health situation analysis. Any strategic planning exercise in the future for the
continuation of the existing projects or the evolution of newer one must take these
crucial questions into account so that the projects can be implemented more
effectively and in a more realistic context with reduction in the implementation
gaps.
-45 -
J- Final Conclusion and Recommendations from a future Policy point of view
The previous sections highlight the key findings and trends that emerged from the
review process. However taken as a whole set of project experiences the key issues
and conclusions that have emerged as significant for a concerted policy response are
the following
1. While the EAP’s do focus on a large number of health problems and health
sector development issues, addressing various lacunae in the existing Health
care delivery system in the state at both primary and secondary level, they do
evolve, exist and function in relatively compartmentalized ways without
fitting cogently into a comprehensive, integrated strategic larger state
health policy / plan evidenced by •
The absence of any state health policy document that includes serious reviews or
details of all of them.
•
Any coordinating mechanism at directorate level that addresses them in a
collective context.
•
Any consistent and rigorous strategic planning exercise / document that was
used by programme designers when these EAPs were evolved.
Some
congruence / complementarity between / across projects has evolved since the
members of the project committees overlap with senior policy makers common
to all, but this is ‘adhoc’ and not always intentional.
l
[Probably the HDR Report, Karnataka Task Force in Health and the recently
evolving HNP project are fore-runners for this much needed paradigm shift from
selective compartmentalized programme planning to more comprehensive
integrated Health sector planning processes].
2. On the other hand while compartmentalized evolution may have lead to some
problems of duplication and integration, especially in IEC and training, but also
sometimes’ in infrastructure \ development,
the very feature of
compartmentalization has also lead to a certain degree of project autonomy that
has lead to many interesting initiatives and innovations in structure, framework,
operational mechanisms, evaluation and monitoring, some of which have been
identified by this short-term review. These need to be rigorously documented,
objectively evaluated further and adopted / adapted by the whole system as the
projects phase out and get taken over and integrated by the ongoing larger
systems.
-46-
3. Overall the Directorate / EAP’s have shown
•
An ability to evolve laudable objectives for each EAP.
•
General lack of competence in the evidence based homework required to
translate objectives into implementable strategies leading to delays in starting up
times.
•
Diffidence in guidelines and systems development leading to operational and
execution delays.
•
While ability to handle the hardware (infrastructure construction - civil works,
equipment and transport) has been established, effective software development
(training, IEC and Quality Assurance) has remained a weak skill / capacity.
Also cost over runs have been many compounded with poor utilisation in other
areas showing in-different financial management capacity as well.
4. Like the general health care services development, the projects have not shown
any evidence-based focus on equity, gender, regional disparity or other
policy imperatives like impact assessment, community partnership and
ownership, partnership building and decentralization and hence though there
are some successes and some failures as well, in none of these areas can EAP’s
be shown to have used their own programme / project autonomy to enhance the
health sector experience in these areas. This is partly a reflection also that at
the Ministry level there are no clearly circulated policies or programme
guidelines on these policy imperatives and hence project managers have had to
explore these dimensions if at all with diffidence rather than confidence and
clarity. Similarly the issues of corruption, political interference, transparency
and accountability seem to effect them just as much as they affect the larger
public health system- no less, no more though perhaps in the tendering /
purchase policies sometimes as conditionalities of the funding agencies, there
seems to be an overall feeling among programme managers that outside or local
interference-is less!
5. Lack of continuity of key personnel has been an important handicap and lack
of systems to monitor quality of care and responsiveness to local needs had
handicapped the establishing or the enhancement of effectiveness. In addition
selection of consultants and senior project consultant need to be critically
reviewed and made more competence based and transparent. Apart from an oldboy network phenomena selection is not always focussed on skills for the job.
-47 -
6. While the general impression of the programme managers seemed to be that
these EAPs were not consciously donor driven and there was space and
opportunity for local technical opinion to evolve project formulation, the
impression of donor driven agenda was often attributed to lack of local
homework and evidence generation and hence a tendency to accept the
suggestions / frame work / ideas of working external consultants as an easy
option. This aspect again underlines the urgent need to develop and enhance the
strategic planning capacities of the Ministry / Directorate and making it multi
disciplinary as well [The KfW and OPEC experiences have however been good
examples of the need ‘to look at gift horses in the mouth’ seriously which could
have avoided all the problems that have followed. They have also shown the
absence of long term planning capacities especially in human resource
development for the hospitals being upgraded].
7. Integration as an issue does not seem to have been seriously considered by any
of the projects' since many projects were seen as stand alone or focusing on
infrastructure not process. [The absence of clarity in development of a referral
system complex between primary and secondary care (for example: IPP VIII,
IPP IX and KHSDP) is a case in point. Similarly IPP VIII, IPP IX and RCH
could have been more complementary, etc.] This leads to wasteful duplication
at the ground - level.
8. Sustainability is another policy imperative that does not seem to have been
taken seriously by the whole system since in many ways this should be a long
term concern of the Directorate and not just of the EAPs. KfW project had some
serious options outlined in the project part which were not adequately
experimented with. [Efforts to evolve systems of user fees; efforts to identify
and hand-over (contract) out services to NGO’s and or private sector etc. are
being experimented with in KHSDP, IPP VIII, RCH but these experiments seem
adhoc and not within a clear-cut policy framework. Nor are they being
evaluated objectively to establish relevance or effectivity]. Overall the human
power development experience that is crucial for sustainability has often been
ignored or inadequately addressed.
9. Overall EAPs do not seem to be adequately drawing upon the Public Health /
Community Medicine capacities of the state in any concerted or formal way
nor for that matter on the phenomenal inter-disciplinary capacities of institutions
such as IIM, ISEC, NLSUI and other resource centers of health, social
development or strategic planning expertise- many of which are also available in
other districts and regions. In fact there seems to be an overall lack of public
health / sociological orientation in problem identification, situation analysis
or programme planning in the EAPs evidenced by a sense the researchers got
of the dominance of:
Infrastructure over human resource development.
Bio medicine over socio-epidemiology.
-48 -
Secondary care over primary health care (especially preventive
public health).
Centralization over decentralization.
Provision of services over enabling / empowerment strategies.
10. Finally a review of EAPs undertaken by us, inspite of the time and
methodological constraints, lead us to suggest that there is urgent need to:-
a)
Develop strategic planning capacities in the Health sector of the
State to handle the complexities of Health sector development as
well as the challenges of negotiating sustainable projects with
external agencies and funding partners that develop not distort /
enhance capacities all round/and integrate not disintegrate.
This capacity should be multi-disciplinary, directorate-based and as
an immediate starting point should also become the integrated
evidence based monitoring ^nit for all the health programmes of the
state including EAPs.
b)
Develop mechanisms of integrated planning that would start as a
first step of all programme managers and programme implementers
being networked into a coordinated planning mechanism thatfrom
time to time focuses on integration and sustainability issues beyond
the dynamics of compartmentalized projects / program. [The project
preparatory committee of the current HNP project could well become
the starting point of such a mechanism].
c)
Both these mechanisms should draw on multidisciplinary
professional expertise in the state especially public health and the
behavioral sciences from all the resource centres both public, NGO,
private and the professional colleges. (The HNP project is trying to
do this by involving a multi disciplinary group like Community
Health Cell (an NGO) but this needs to be done with greater clarity
and flexibility.
c)
A more detailed internal review and analysis of current EAPs
should be undertaken as an in-house exercise by both (a) and (b)
supported by (c) so that the positive lessons from EAP experience is
integrated into health sector development in the state and
distortions /problems handled by a more decentralized programme
implementation mechanism or countered through more effective
evidence based long term strategic programme planning.
-49-
K. Limitations of the Review Exercise
•
The task of reviewing ten Externally aided projects in Health in the state in a
short term framework of 4-5 months was a very stupendous and exhaustive task
and perhaps quite unrealistic as well.
•
Hundreds of pages of reports, reviews and other documents had to be perused
and interactive interviews had to be arranged with a large number of very busy
government officials and project managers within this short term framework by
researchers who also had to work within a framework of complementary
demand and deadlines.
In two cases RNTCP and KSAPS interactive discussions with programme
directors could not be completed so we used reported information monthly both presentations at KTFH meetings and documents and one other programme
due to time constraint. NLEP (Leprosy control) was not included. Since this
review was trying to identify the broader policy issues relevant to Externally
aided projects in general all the nitty gritty’s of all the projects were not
focussed upon.
•
The study was also focussing on many issues that are neither easy to measure
nor always easy to elicit because qualitative judgements on qualitative issues
are often not easy to collect especially if the judgements are negative or critical.
We must record however that most of the people interviewed showed a
phenomenal degree of openness, frankness and willingness to discuss even
‘sensitive’ areas and this candidness is really appreciated.
•
We have tried to do our best integrating the rich, response and feedback that was
received in the interactive discussions supported by background notes and
papers and our own reading and critical analysis of all the documents that we
were able to access. The effort has been made to make this review a learning
experience as a partner not as a critical external reviewer.
•
We hope we have been able to collate and highlight the salient features - both
strengths and weaknesses of EAP’s when taken collectively. Much more needs
to be done to address all the questions originally listed out, some have been
answered, others only just considered. More time would definitely have helped.
However the experience has shown that full justification can only be done if this
review, both
in-house and external becomes part of the ongoing Strategic
Planning Cell of the Directorate / Ministry. -If our study has helped to get this
message across we would have felt fully complimented by our efforts.
-50-
L. Acknowledgements
To the Karnataka Task Force in Health for the opportunity to make an overview of
the externally aided Health projects of the state.
To all the project directors particularly Mr. Arvind Risbud (KHSDP, OPEC, KfW),
Mr. Krishna Rao (IPP VIII and IPP IX), Dr. G.V.Nagaraj (RCH) and Dr’
Jayachandra Rao (IPP VIII) Dr. Shamanna (NPCB-K) and all their consultants and
supportive staff for the frankness and openness with which they participated in the
review and made available reports and other documents.
To Dr. Thelma Narayan and Dr. C.M. Francis who shared insights as the Task Force
process continued; and all the CHC team members who encouraged and supported
the project framework.
Finally to Mr. Anil Kumar (Secretarial cum Account Assistant) who typed the
manuscript, Mr. M.Kumar (Administrative Officer) and the rest of the CHC office
team, who particularly helped with all tlie operational aspects of the short term
project.
Dr. Ravi Narayan,
Community Health Adviser,
Community Health Cell,
Bangalore.
Dr. Sampath.K.Krishnan,
Policy Fellow &
Research Associate,
Community Health Cell,
Bangalore.
Dated: 28th March 2001.
-51 -
M. Bibliography
(This is a partial bibliography which includes the main document / reports. It doesn’t include all the
aide Memoir’s, review mission notes, newsletters, credit agreements, project partnership documents,
submissions by project directors and other formal and informal documents).
General:
1.
2.
4.
5.
6.
7.
8.
Human Development in Karnataka, 1999. Planning Department, Government of Karnataka.
Analysis of Expenditure on Medical and Public Health, Family Welfare (Dr. S. Subramanya,
KHSDP)
Case study of World Bank Activities in the Health Sector in India, May 1999 (Sector and
Thematic Evaluations Group, Operations Evaluation Department, The World Bank).
Comments on ‘Case study of World Bank Activities in the Health Sector in India’, Ravi Narayan
et al in Health and Equity - Effecting change, HIVOS Technical Report series 1.8 (2000).
A guide to sector - wide approaches for health development - concepts, issues and working
arrangements, Andrew Cassels. (WHO, DANIDA, DFID, European Commission), WHO, 1997.
Towards Equity with Quality in Health (Karnataka), Interim Report of Task Force on Health and
Family Welfare Karnataka.
Health Budget in Karnataka - Vinod Vyasulu a report presented to Task Force on Health and
Family Welfare, Karnataka).
Handbook of Health and Family Welfare - Sector investment programme Department of Family
Welfare, GOI and EC Health and FW programme office, March 2000.
1PP VIII:
9. Family Welfare (Urban slums project) Brochure of IPP VIII, Bangalore.
10. Staff Appraisal Report, India, Family Welfare (urban slums) project, May 1992, The World
Bank (India county operations department (10548-IN)
IPP IX:
11. Strengthening of Family Welfare and Maternal and Child Health services India Population
Project-IX Proposal, Department of Health and Family Welfare, Karnataka June, 1994.
12. IPP IX Background notes for World Bank Review Mission November 1999.
13. IPP IX Project Review and implementation status Report for World Bank Review Mission May
2000.
14. India: Family welfare project (Population IX) World Bank Review Mission Aide Memoire (May
2000).
15. IPP IX - Project implementation status, September 2000.
16. IPP IX World Bank Review Mission, Aide’Memoire, September 2000.
17. Evaluation of ANM training for Tribal girls under India Population Project -IX - Innovative
scheme (P.J. Bhattacharjee and R. Venugopala Raju), Population Centre, Bangalore, March
1999.
KHSDP:
18. Karnataka Health Systems Development, Project proposal Department of Health and Family
Welfare, GOK, May 1995.
19. KHSDP project proposal - January 1996.
20. KHSDP Referral system manual, June 1999.
21. Staff Appraisal Report, February 1996, The World Bdnk, (State Health Systems Development
project II).
22. Procurement Workshop Manual, Second State Health Systems project (Karnataka, Punjab, and
West Bengal) September 1996.
-52-
23. Status Report of Manpower position in Karnataka Hospitals, KHSDP, April 2000.
24. Overview of Training programmes under KHSDP and KfW project, KHSDP, June 1999.
25. Newsletters of the Strategic Planning Cell, KHSDP.
KfW:
26. Upgrading secondary level Health care facilities in the state of Karnataka, Final project proposal
for KfW, Germany, Department of Health and Family Welfare, GOK, July 1995.
27. KfW project - Progress Reports numbers 8 to 12.
OPEC:
28. Project Proposal for OPEC Assisted Hospital at Raichur, Department of Health and Family
Welfare, GOK, May 1996.
RCH:
29. Reproductive and Child Health services, Programme. District level Implementation Guidelines,
RCH project Bureau, April 1999.
30. A brief note on Reproductive and Child Health, GOK, November 2000.
31. Reproductive and Child Health Project - status^eport, sub project Bellary, October 2000.
UNICEF:
32. Approach paper for 2000 - Karnataka, Hyderabad Field office, UNICEF.
33. Border Cluster Districts Project, A strategy paper (Sanjiv Kumar)
34. Reproductive and Child Health - UNICEF Cooperation - Achievements, Impact, Constraints - a
hand out
RNTCP:
35. Project Report for Revised National TB control programme, Department of Health and Family
Welfare, GOK, 1997.
36. RNTCP - Project implementation plan, DOHFW / GOK April 2000.
DANPCB / NPCB-K:
37. National Programme for control of Blindness, Karnataka State profile. August 2000, State
Ophthalmic Cell, GOK.
38. NPCB - Schemes for implementation during IX plan, 1997-2000 Ophthalmology / Blindness
control section, DGHS, MOHFW, GOI. \
39. NPCB - Guidelines for District Blindness control society, GOI.
40. NPCB - Course material for training in District programme GOI.
41. NPCB - Schemes for participation of voluntary organizations GOI.
42. DANPCB - Eye care through Primary Health centres.
43. DANPCB - Creating awareness and demand generation for cataract surgery.
44. DANPCB - Rapid Assessment of cataract Blindness, February 1997.
NACO/KSAPS:
45. The Karnataka Strategy on Management of HIV / AIDS - The way forward, KSAPS, September
2000.
46. NACO, Scheme for prevention and control of AIDS - Phase II.
47. KSAPS Project implementation plan, - Phase II - December 1998.
-53 -
TABLE III
Externally Aided Projects in Health Service Delivery in Karnataka
COMPONENTS OF PROJECT PROGRAMMES AND ACTIVITIES FOCUS
(Review of Budget Headings)
SI
No
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15'
16
17
Component
Land Purchase / prepn
Construction
Furniture / Equipment
Drugs and supplies
Vehicles
7
+
9
6
5
7
6
+
+
2
+
1
Books / Training Mtrls
+
2
<
Innovative schemes
Additional staff-salaries
IEC Materials prodn
Revolving Fund
Maint Vehicles & Eqpt
Training Material
Video / Media
~T
Surveillance
22
Safety Net for Disadvan
23
24
Improving women health
MIS
25
26
27
30
Design and Engineering
Project Manageroent
Sustainability
Contingencies
NGO support
Blood safety
31:
Voluntary testing
32
33'
Adolescent Health
2
4
r
5
1
+
+
5
+
+
+
+
2
2
2
ZI
4+ !
Waste Handling
21
34
+
Consultancy (Foreign)
18
29
2
+
+
+
Consultancy (Local)
Training (Foreign)
19
28
KfW OPEC RCH KSAPS RNTCP NPCB-K Score
Training (Local)
Evaluation studies
Kits
20’
IPP-8 IPP-9 KHSDP
1
1
—
2
+
1
---------
2
+
—4-
1
+
+
+
+
4
1
4
1
6
5
f
+
+
E
E
-
Remunerations
School Health
15a
+
J_ £
x
+
1
I
APPENDIX -1
PrajEct Prapnsal
Review of externally Aided Projects
in the context of their integration into the
Health Services Delivery in
Karnataka.
I
Content List
1. Introduction
2. Objectives
3. Methodology
4. Budget
5. Project Outcome
6. References
7. Appendices.
Submitted by
II
I
Dr. Ravi Narayan, M.D. (AIIMS), D.T.P.H, (London), D.I.H. (U.K.)
Community Health Adviser
Community Health Cell
367, 'Srinivasa Nilaya', Jakkasandra 1st Main,
Koramangala 1st Block. Bangalore - 560 034.
Tel / Fax: 5525372
Email: sochara@vsnl.com
I
AJ
1 Introduction
Since mid 1990's, Karnataka Government has negotiated and received grants ' loans from
Intel national Funding Agencies for an increasing number of Health related projects
r xrmpaVe.,nClUded IPI> ' 8’ IPP’9' KIISDP' KFW' RC11' 1’revention of Blindness,
1C1 and other projects. These externally aided projects have their particular focus
and framework and operational strategies to support and enhance both quantitatively and
qualitatively different aspects of the Health Sector development. Each of them has had
various mid term and concurrent reviews and some of them are currently reaching the end
of specific phases. The Karnataka Task Force in
„
in Health while
reviewing these projects
informally in their discussions and deliberations have raised' some important questions for
review.
i.
What are the learning points from each of these projects"
ii. How can they be integrated into the health system incorporating beneficial
points and avoiding distortions?
iii. What are the issues for consideration of sustainability, accountabilitv and
transparency" (1)
I his pioject proposal is a short-term initiative to explore some of these issues
qualitatively as a preliminary to perhaps a larger study at a later date.
Community Health Cell is ia technical
• • - Community
Health and Public Health oriented
policy research and training group that has reviewed external aided projects in the past.
Four policy initiatives are relevant to this study.
1) Review of health projects in India supported by Misereor / Germany. (7)
2) Review of Health Partnership of Memisa in Netherlands.
(6)
3) Review of partnership in Health (Cebemor Netherlands Government) (5)
4) Policy reflections on World Bank Activities in India - (see references) (3)
2. Objectives— of Study
1. The study will review all fthe externally aided projects not just individually but in their
collective
context
Primary
Health Care and Public Health
i
. . and relation to the --------j ---------- —iivcuui system
cdevelopment
1- ,'
*tn the
* state using a SWOT approach
More specifically it will------look. at
a. The Strengths of each project and the positive learning experiences.
b. The Weaknesses or difficulties encountered in each project.
c. The Opportunities that have been created or exist to enhance primary and
public health care svstem development in the state.
d. The Threats or distortions that may have been inadvertently caused by the
project assistance to the health sector or that may be caused during the process
of integration.
Some specific questions are in Appendix one, though a more structured approach will
emerge after the literature, review.
!(
I>
3. Methodology
The time frame work of three months is too short to evolve a rigorous data based,
quantitative approach to project design and therefore a more qualitative approach that
will focus on a participation, interactive process is being suggested rather than an expert
external review the method suggested will try to make it a collective learning experience
for all concerned. Each project will be requested to allot atleast one project staff to be
part of an evidence collecting, evidence sifting; and evidence collecting exercise.
The steps of the process will be
A. Phase one 15th September - 15,h October 2000
i.
ii.
Literature Review of all project proposals and mid term/ concurrent reviews and
aide memoirs.
Informal discussions with all project leaders and support team to clarify the
nature and process of review and4 seek required support and participation (As a
half day interactive workshop together, tentative date 10lh October 2000.)
B. Phase Two - 1511' October - 30th November 2()()0
Qualitative interviews with Directors and staff of each of these projects and with
a small representative sample of other stake holders including medical officers
and other staff. (Some visits outside Bangalore will be required)
ii. Interactive participation workshop with representatives of all the projects to
address the issues of sustainability accountability etc. and all those issues, which
are common to all projects and derive from phase one review, (atleast two, to be
discussed at A. ii)
iii. A questionnaire survey of some key aspects relevant to the study to be filled up
by each project as 'evidence contribution' to the review.
i.
C. Phase Three - 15th November - 15th December 2000
i.
Integration of all the data/evidence from phase one and phase two processes into
a project analysis document.
ii. Circulation of this document to all concerned with a weeks time framework for
replies.
iii. Incorporation of all comments / suggestions and final editing of a document to be
submitted to KTFH hopefully not later than 15th October 2000.
'u’i
11
4. Budget
PTSal t0 SUPP°rt the StUdy and incllldi”g c<>sls l,f Researchers, other
sta Sn
traierofSUPPOrt| 'nC
8 PhotOCOPyillg- -"’P“>er tacilhics. postage,
cos s r d
reSearCl1 aSS1Stant and eo-ordinator of studv and some supportive
costs for three interactive workshops is included in Appendix l uo'.
’'
The study will be undertaken by Dr. Ravi Narayan of CHC supported bv a full time
research associate for 3 months and drawing upon short-term research assistance from
some other members of CHC team on a flexi-time basis
Some elements of the study / review are
a. complementan to the project proposals of
Mr. Vinod Vyasulu of Centre for Budget
t and Policy Studies. Dr. Ramesh Kanbarai of
ISEC; Mr. As. Mohamed of SJMC
and Dr. Pankaj Mehta of Manipal Hospital and so
their involvement in some aspects of the study will be operationalised through informal
interaction at no additional cost.
Finally to make the short term process(more cost effective and efficient under the
circumstances - close co-ordination with the project leaders rvlll he established so that
ZZor
te
including 11K inttr“live
oPXiZ“±Z Pro8ram,“S " .......... ..
» thai
5. Project Outcome
miSeCt rfPOrt hlghl.lghtinS a SW0T rev‘ew of the External Aided Projects and Policy
g idehnes for integration, sustainability and future projects of this type.
6. References
i.
Topics for Action Research Studies identified by Task Force ( a KTFH handout)
2
JOmprehe^lve Health, Nutrition and Population senices development initiative in
Karnataka (An idea draft from CHC)
Comments on Case Study of World Bank Activities in the Health Sector in India (A
CHC policy reflection)
4. A Guide to sector-wide approaches for Health development - c<
- concepts, issues and
working arrangements (Andrew Cassels) A WHO/DANIDA/DFID
• D publication.
5. Programme Evaluation-Basic Health Services
India (cebemo / icco/DGIS). October
1994. (CHC)
6.
Partners in Health - Challenges for the next decade: A process renew of the Indian
I artnership of Memisa-1989-1994, (October 1994. CHC)
7.
Promoting Health in India: A process review of the Indian Partnership of Misereor.
December 1994. (CHC)
IV
I A
APPENDIX - II
Integration of Externally Aided Projects in Health Services Delivery
(Karnataka)
Sonic Issues and Questions to be addressed in the Review Project by
Literature Review and Interactive discussions.
A Check List
1. Descriptions of each project including year of starting, period, focus, objectives,
components, programmes, budgets, reviews, etc.
2.
Was the ‘problem analysis' and the ‘problem solution’ comprehensive or selective?
If selective then factors used for prioritization? or selection of strategies?
How does the project support,
a) Health System Development ?
b) Primary Health Care?
c) Public Health?
<
4. How is the project funded?
a) Direct or indirect
b) Loan agreement/conditionality
c) Repayment
d) Budget components etc.
5. What has been the experience of
a) financial management
b) disbursement
c) expenditure
d) delays
e) shortfalls, etc.
6. Is the project funding leading to distortions in spending priorities?
7. Are a reliance on projects perpetuating long-standing budgetary imbalances;
implications on existing state health budget etc.?
8. Are there diversities in accounting/auditing procedures?
9. Strengths, Weaknesses, Opportunities, Threats of each project including those
identified by mid-term reviews.
10. Are there problems of
a) Project flexibility
b) Overdesigned
c) unnecessary long lead time, preparation delays
d) Slow rates of disbursement
e) Complicated procedures
f) Any other managerial/operational problems.
V
4
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