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TOWARDS EQUITY, INTEGRITY AND QUALITY
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SUPPLEMENT TO THE FINAL REPORT
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APRIL 2001
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GOVERNMENT OF KARNATAKA
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TASK FORCE ON HEALTH AND FAMILY WELFARE
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GOVERNMENT OF KARNATAKA
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TASK FORCE ON HEALTH AND FAMILY WELFARE
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HEALTH EXPENDITURES IN THE STATE BUDGET
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CENTRE FOR BUDGET AND POLICY STUDIES
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<_ ‘ Al
The Health
Budget
in
Karnataka
A Preliminary Study
Final Report
I
The Health Budget
in
Karnataka
A Preliminary Study
A Indira
Vinod Vyasulu
r
Centre for Budget and Policy Studies,
SV Complex, 1st floor,
55 KR Road,
Basavangudi,
Bangalore 560004
e-mail
cbpsffivsnl. com
cbps@123india.com
April 2001
3
J
Butch, the worst of human ills
[Poor Tattles found] are “little Bills”!
And, with no balance in the Bank,
What wonder that his spirits sank?
Still, as the money flowed away,
He wondered how on earth she spent it.
“You cost me twenty pounds a day,
At least/ Cried Tattles [and he meant it].
She sighed. “Those drawing Rooms, you know!
I really never thought about it:
Mamma declared we ought to go—
We should be nobodies without it.
That diamond-circlet for my brow—
I quite believed that she had sent it.
Until the Bill came in just now—“
“Viper!” cried Tattles [and he meant it].
Poor Mrs. T. could bear no more,
But fainted flat upon the floor.
Mamma-in-law, with anguish wild,
Seeks, all in vain, to rouse her child.
“Quick! Take this box of smelling-salts!
Don’t scold her, James, or you’ll repent it,
She’s a dear girl, with all her faults—“
“She is!” groaned Tattles [and he meant it].
“I was a donkey”, Tattles cried,
“To choose your daughterfor my bride!
‘Twas you that bid us cut a dash!
‘Tis you have brought us to this smash!
You don’t suggest one single thing
That can in any way prevent it—u
“Then what’s the use of arguing?”
“Shut up/” cried Tattles [and he meant it].
Lewis Carroll
-4
Table of Contents
Section 1 Introduction
1
Section 2 Budget System
4
Section 3 Results
7
Section 4 Conclusions
19
List of Tables
Table
1:
Table 2
Table 3
Table 4
Table 5
Table 6
Table 7
Table 8
Table 9
Table 10
Table 11
Table 12
Table 13
Table 14
Table 15
Table 16
Table 17
Table 18
Revenue Expenditure under the major head: Medical and Public Health in the
period 1960-1990
Capital Outlays towards Medical and Public Health in the period 1960-1990
Health and Family Welfare Head wise expenditure (plan)
Health and Family Welfare Head wise expenditure (non-plan)
Revenue Expenditure of Health-related sectors during 1960-90
Capital Outlays on Health-related sectors during 1960-90
Capital Expenditure on health-related sectors in the 1990s
Revenue expenditures on health and health related sectors in 1990s
Trend in expenditure on health related items
Centrally sponsored schemes (revenue a/ c) - current prices
Centrally sponsored schemes (revenue a/ c) - constant prices
Centrally sponsored schemes (capital a/c)
State sponsored schemes (revenue a/c) - current prices
State sponsored schemes (revenue a/ c) - constant prices
State sponsored schemes (capital a/ c)
State sponsored schemes (loan a/c)
Central plan schemes
Proportion of district outlays to State receipts
5"
Acknowledgements
This is a revised version of a study undertaken for the Task
Force on Health and Family Welfare set up by the Government of
Karnataka. A section dealing with foreign loans for the health
sector has been dropped, as, with the available data, the links
between loans and health expenditures were not at all clear. The
paper incorporates changes suggested by the Task Force on the
draft submitted earlier. We hope this report will be useful to all
those concerned with health planning in Karnataka.
We are grateful to all who helped us. In particular, we would
like to thank Dr H Sudarshan, Dr CM Francis, Dr Thelma
Narayan, Shri P Padmanabha, Shri Sanjay Kaul and several other
officials in the Health and Finance Departments for taking time
out to discuss issues and provide help in accessing data.
Comments by Sunil Nandraj of CEHAT in Bombay were especially
helpful. Our colleagues in CBPS worked very hard amidst
frustrations of power failures and data corruption. But none of
them is responsible for errors of fact and opinion that remain.
6
H
The Health Budget
in
Karnataka
A Preliminary Study
1. Introduction
This monograph is organised as follows. In section 2, the budget
system, concepts, and limitations are discussed. In section 3, the results
emerging from an analysis of the available data in Karnataka are presented.
Section 4 is a brief conclusion.
Health, it has often been said, is not just the absence of disease, but a
positive state of well-being for an individual and for a community. And this is
essential in all aspects of life, be it the health of the people or the health of
the finances which are a crucial input into the governing system. Health of
all is primarily a state’s responsibility. The Directive Principles of State Policy
in the Indian Constitution [Part 4] make this clear.
The UNDP has given the health status of the population an important
place in its Human Development Reports. It also has an important place in
the Planning Department’s Human Development in Karnataka [1999]. The
overall picture emerging from the state HDR is one of deprivation in health
matters. There is also great variation across the districts of the state. There
is much to be done. In appointing the Task Force on Health and Family
Welfare with a distinguished membership, the state government has sought
expert advise in dealing with health matters in a professional manner. This
is to be welcomed, and this small effort of ours should be seen as part of this
overall exercise.
Much has been done in terms of focussing on preventive and public
health, and encouraging public participation in the provision of health
services. The private sector in different forms has played a major role in
service provision, and individuals have spent considerable amounts on
health matters. In spite of this, the state’s role in the overall administration
and implementation to cover the whole population in health matters cannot
be ignored. Rather, the state has a key role to play in ensuring that health
services of adequate standard are available to citizens. In the process, it may
use private parties for certain functions, but that does not absolve the state
of its overall responsibility. It is in this background that we look at health
finances.
Health is a subject in the state list in the Indian constitution: the
primary responsibility for health services provision lies with the state
government. The union does have a role, but it is in providing guidance and
resources for matters of national priority. The state of Karnataka has so far
been providing these services through the Ministry of Health, which is
responsible for policy matters, and the Directorate of Health and Family
b
Welfare, which is responsible for implementing these policies in the state1.
For this purpose, it has an elaborate set up at state, district and lower levels.
This set up is well established in the state governmental system.
In 1993, the Constitution was amended to bring in a third tier of local
self government, and health is a subject that is also in the list of subjects
that states’ may place in the purview of these bodies. In rural areas there are
three levels of panchayats—zilla, taluk and gram panchayats2. These
panchayats are the local manifestation of the state3. All of the department
employees at the district level have been deputed to the zilla panchayats in
Karnataka and they are to implement the various schemes, state, central
and centrally sponsored. There is today some tension between the
departmental employees and the newly established political local
panchayats4. This is not surprising at a time of structural change.
In this transition from a political system that consisted of two levels—
union and state—to one of three levels, union, state and panchayat—several
problems have arisen. These will undoubtedly be sorted out in time5.
However the major responsibility of financing the health sector still rests
with the State government—and it will continue to do so. The zilla panchayat
so far only acts as a conduit for the transfer of funds. It can take on more
responsibility, but the fiscal responsibilities of the GOK will remain.
Health is today set in a complex context of multiple levels of
government action. In Karnataka, which has been a pioneer in panchayati
Raj experiments6, this is especially true. The department is manned by
doctors, administrators, para-medical staff, health inspectors, etc. And the
form of implementation, which was completely departmental, has changed
[to a small extent] to provide a role for panchayats. Elected representatives
now make demands upon the staff of the health department in the local
areas. This has led to controversy and differences of opinion: by and large,
the department is not convinced that transferring responsibility to the
panchayats will serve a positive long term goal7. They would like to limit the
role of panchayats, at least where health issues are concerned. This is the
background for the present study.
1 There is also the Department of Medical Education, dealing with higher education
in the field, that we exclude from this study.
2 The health situation in urban areas deserves an independent study. This is a
limitation of this study to be noted at the outset.
3 A point that is often not realised, or contested. See Vinod Vyasulu,
Decentralisation from Above, CBPS, Bangalore March 2000.
4 D.Rajasekhar, Sashikala Sitaram and Vinod Vyasulu, “Decentralisation in
Kamataka” paper prepared for the World Bank, June 2000. Also, discussions with
the officials while conducting the study.
5 Vinod Vyasulu, “Decentralisation, Democratisation, Finances and the
Constitution,” Paper prepared for the Panel on Decentralisation of the National
Commission to Review the Working of the Constitution, Bangalore, November 2000.
6 For an overview, see D Rajasekhar et al, op cit. Also Vinod Vyasulu,
Decentralisation from Above, CBPS, Bangalore March 2000, op cit.
7 This has been a major area of debate in the Task Force.
3
The present study looks at the following issues: (1) the expenditures
of medical and public health and (2) the expenditures of health-related
sectors at the state level.
Ideally this should include the following:
a. analysis of expenditures of medical and public health - urban health
services (UHS), rural health services (RHS) and public health services
(PHS) for the revenue, capital, and loan accounts and
b. analysis of expenditures of related sectors, viz., (I) water supply and
sanitation; (ii)social security and welfare; (iii) nutrition; (iv) family welfare
To study the above, the data that we have used are as follows:
1. The Research and Statistics Wing of the Finance Department of the
Government of Karnataka (GoK) has collated information on the
expenditure patterns (head of account wise) for the period 1960- 1990.
We have taken the major head-wise expenditures for M&PH; WSS;
Nutrition; General education; and Family Welfare for revenue, capital,
loan accounts, wherever possible - 1960-61 to 1989-90 from this
document.
2. The Finance Department, GoK has an Accounts Reckoner8 for 19902001. This gives the major headwise data for the 1990s. This has been
used to get the figures for revenue expenditures, capital outlay and loan
receipts and disbursements9.
Both these sources present data at the state level—district-wise
break-ups at local levels are not available. Moreover with the data it is still
not possible to do (a) breakup between UHS, RHS and PHS and (b) to say
what proportion of loan is towards health per se from the larger division
between central schemes, centrally sponsored and state sponsored schemes.
It is understood that the loans from the Government of India come in
different forms for the central schemes, centrally sponsored and state
sponsored schemes. The breakup is 70:30, meaning, 70% of the funds come
as loans and rest 30% comes as grants-in-aid. Even where funding from
donors abroad is concerned, it reaches the state government in this form.
For the state, 70% is a loan to be repaid to the union. The state is not
concerned in repayments abroad, and the risk from exchange rate
fluctuations—rupee depreciation—is borne by the union of India10.
The first data is from 1960-1993, the second source is only for the
1990s decade. The base for the calculation of deflators has been changed in
1993-94, the cut-off point in the first data set. But both data-sets come from
the Finance Department of the GOK. Hence what we have done is to
8 This is an internal document of the Finance Department meant for the use of
officials, which was kindly shared with us.
9 The codes in the budget documents are 2210 and 4210 for medical and public
health, and for health related sectors they are 2211, 2215, 2225, 2235, 2236. For
capital account it starts with 4.
10 The union budget may have some information on this aspect—in this study we
have not ventured into this analysis. It has to be undertaken for a complete picture.
S
calculate the growth rates separately for both the data-sets. There are large
gaps in the earlier period of 1960-90 for some heads, namely social security
and welfare, nutrition, etc. It has not been possible to examine whether the
two data sets are comparable and represent a continuous series. Hence it
would not be justified to link them and draw a trend line.
Before proceeding further, it may be helpful to recall a few facts to
provide a context. These are taken from the Government of Karnataka’s
1999 report Human Development in Karnataka. While the social sector
expenditure of the state has been hovering around 38% of total revenue
expenditure, the average annual expenditure on health-related items of
expenditure accounts for 25.7% of the total expenditure on social services.
This is second only to the share of the education sector of 53%. There is also
considerable private expenditure, but that is outside the scope of this paper.
2, The Budget System
Each year, in February or March, the finance minister of the state
presents a budget to the state assembly, under Article 202 of the
constitution. This lists the revenues available with the state, and the manner
in which they are to be spent. This is in an essential sense, the major policy
statement of the government, concretely listing its priorities. This budget
must be approved before the start of the next financial year—April 1. The
budget shows in detail what the government plans to do over the coming
financial year. It also presents revised estimates of what has been
accomplished in the current year and actual figures for the year past. An
analysis of the budget then represents what the government has actually
done, as opposed to what it claims in other forums. Hence the importance of
ongoing budget analysis.
Apart from the well known Revenue and Capital accounts,
Government accounts in India are divided into two categories, “plan” and
“non-plan”. Plan figures represent new initiatives, while non-plan figures are
in the nature of expenditures on past commitments. At the end of a plan
period—five years—plan programmes are to be transferred to the non-plan
category.
The budget allocates money to “schemes”. Schemes are specific
proposals for spending money. An example would be a scheme for the
eradication of leprosy—a worthy cause. The scheme would then define how
leprosy is to be identified, how its magnitude is to be assessed, and how,
given certain parameters, the scheme is to be implemented. A scheme brings
with it a set of rules and guidelines on how it is to be implemented, and it
provides no scope for modifications11. It would specify how much of the
allocation may be used in salaries for nurses, how much for the purchase of
11 Given that it is designed by bureaucrats in the capital—of the union or the state—
it is designed to meet the requirements of the “average district”. No district, is
however, average in this sense: each has specific features of its own. Thus it is
difficult to implement a scheme at the ground level. But although this is known
funds are not given on a broad programmatic basis, such as eradication of chronic
diseases, but on clear cut schemes.
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medicine—in some cases, which medicine also. These schemes are locally
implemented by the departmental machinery.
Sometimes it is not possible to transfer a plan scheme of one plan to
the non-plan account of the succeeding plan, for a number of reasons—
usually a shortage of funds. In such cases, these schemes are carried on
under the plan head. This means that salary and other routine payments are
paid from plan funds meant to finance new schemes. This has two
implications: funds for new and innovative ideas get squeezed, and salary
and other routine expenditures make their appearance in the plan account.
Thus, for recent years and plans, it cannot be assumed that plan
expenditures represent new schemes or investments. In fact, as a plan
progresses, the salary component of the plan account increases, so that it
often only in the first or second year of a five year plan that investment can
take place. The usefulness of the ‘plan’ and non-plan’ categorisation has
been questioned for such reasons.
Each of the major departments of the state government—of which
Health is one—^prepare a budget estimate, based on the priorities of the
government, and send it to the Finance Department in the second half of the
financial year. This forms the basis on which the Finance Minister makes
allocation decisions for the various ministries in the government—there is of
course a great deal of discussion that precedes the decision. Once approved
by the Assembly, it becomes the programme that the ministry will implement
in the coming year.
Decisions about plan expenditures at the local level are made in the
Planning Department of the state government. The system works as follows:
Based on the allocations for schemes in the current year, and actual
expenditure patterns, and the target’ for the district indicated by the
Planning Department, the district officers prepare a draft budget for the next
year12. This, after formal approval in the zilla panchayat, is referred to the
Planning Department. The Planning Department, in consultation with the
Finance Department, has a tentative figure within which the year’s
expenditure must be kept.
Once the estimates are received from the districts, discussions take
place between the district officials and the Planning Department officials in
the Planning Department, at the end of which a decision is reached about
the level of expenditure on plan subjects in each district. This, after
consultations with the Finance Department, becomes part of the state
budget. Once the budget has been passed by the Assembly, the moneys are
transferred to the districts and can be spent. This is the theory.
In reality, the releases of funds approved to the districts depends on
many factors—the Ways and Means position of the state, for example. It is
not uncommon for small sums due from a government department to be
12 In practice, they take the figure for the year past, increase it by 10%, and forward
it to their departmental heads. There is little by way of zero base budgeting and the
like.
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held up for such reasons. Those who are to receive the money are often in
the dark about the reasons for the delay. In recent years, with the
deterioration in the state of government finances, this problem has become
more acute. Thus, the budget figures speak of intentions, but cannot be
taken as a firm basis for decisions involving spending because of this
problem of delayed releases. It adds an unnecessary element of uncertainty
into the local system. Programme and scheme implementation then suffers.
Across districts in the State, many of these activities are co-ordinated
by the Rural Development and Panchayati Raj Department, under whose
control the Chief Executive Officer of the zilla panchayat works. At the local
level, the CEO must work in co-ordination with the elected president of the
ZP.
It is possible that several departments are undertaking expenditure
that pertains to health. For example, the Department of Disabled Welfare
may have an item on, say special hospitals for handicapped people. There
could be others of this type. Such items, should rightly be included in a
study of health expenditures. But it is a tedious task that cannot be easily
undertaken without access to the detailed budget documents. They are not
taken into consideration in this study. This limitation should be noted at the
outset.
The link documents provide information on the amounts allocated to
each district under different major and minor heads. It must be noted that
actual expenditures may differ from these allocations. Thus, these figures
may be seen as representing the stated goals of the government. There may
be a difference with what actually happens13—this has to be studied
separately by looking at the district level expenditures. Such figures are not
available in the state capital in detail—collecting them from each district is a
tedious and time consuming task.
The state government can only spend money on the basis of approvals
by the Assembly, and the procedures that have evolved over the years are
rigid and time consuming. For one reason or another, no government has
made any attempt to modify these procedures. Thus, even after approval in
the Assembly, there are a large number of rules and regulations that make
the spending of money by government departments slow and time
consuming. Often this results in the objective of the exercise being lost in a
morass of paper work.
Recognising this rigidity in the financial system, many states resorted
to the method of setting up “autonomous” societies under the Registration of
Societies Act, to undertake important projects. These societies were designed
to function under the Minister and Secretary of the concerned Department,
with a specially appointed Project Director to run the society which enjoys
considerable financial autonomy14. But it must be noted that they led to
13 A. Indira: A study of zilla panchayat budgets in two districts, CBPS, Bangalore
March 2000. Also, Vinod Vyasulu and A Indira, “Education Finances; A District
Level Study in Karnataka” CBPS, April 2001, unpublished.
14 We wonder if the KHSDP is such a body?
7/2
greater centralisation at the state level, for they by-pass local governments—
and they also did not come under detailed legislative scrutiny15. Many of
these societies also created a parallel local structure for their work, thus
bloating the bureaucracy16.
The funds available came from different sources. There were the own
revenues of the state—what it collected from taxes in its jurisdiction. There
were the transfers of the state’s share of union taxes, shared with the states’
on the basis of the recommendations of the Finance Commissions. And then
there were transfers from the Planning Commission17. These were union
finances that it passed on to the states in programmes of national
importance, on soft terms18.
But the releases to local areas19 depended, increasingly so in recent
years, upon the ways and means position of the state government. Thus,
even after budget approval, funds were often not made available because of
cash crunches in the state. It is therefore important, to understand the
expenditure process at local levels, to distinguish between allocations
approved, and releases made to local bodies. Money allocated may be
released in February—then it will be difficult to spend it effectively. To fully
appreciate the complexities involved, a study of releases is also necessary. In
this study however we have not taken into consideration releases but actual
expenditures at the state level as these are the audited figures placed in the
House. At the district level, we deal with allocations only. Further work is
needed to confirm or reject these findings on an empirical basis. This is only
a “first-cut” analysis.
3. The Results at the State Level
We present below the results of a simple analysis of the data available
under the heads of health, and health related finances at the state
government level.
3.1 Medical and Public Health:
Here under Medical care is included medical relief, which consists of
conventional curative medical facilities such as PHCs and sub-centres,
hospitals and dispensaries; indigenous systems of medicine; health
insurance schemes for formal sector employees and their families; medical
education and research; direction and administration. Under Public Health
15 For details, see L.C.Jain and A Indira, “Budget Analysis: For Whose Sake?”,
Keynote Address at an international conference in Bombay, November 5-9, 2000.
16 Discussed in Vinod Vyasulu Decentralisation from Above, op cit.
17 These transfers include funds from external donors.
18 These have been changing. At present 30% is grant and the rest a loan on varying
terms, to be repaid over a long period like 25 years. The exchange risk in the case of
hard currency loans is borne by the union government.
19 M. Govinda Rao, in a personal communication, has spoken of the results of his
recent research, which shows that, at an all India level, devolutions to local bodies
come to 0.04% of the GDP. The local governments cannot be very important!
u
comes prevention and control of communicable diseases, health education,
immunisation and other public health activities.
As a percent of SDP it is seen that the expenditure on health services
in the 1960s it was 0.6%, 0.8-1% during 1970s; and from 1 to 1.1% in
1980s and 90s. The per capita expenditure has risen from around Rs.8/- in
1960-61 to Rs.21/- in 1989-9020. Whether this is adequate or not needs to
be judged with reference to a standard norm—we are not aware of one. Also
relevant will be the efficiency with which money is used—how much benefit
do we get for each rupee spent? This is another matter requiring careful
study.
Table 1: Revenue Expenditure under the major head Medical and Public
Health in the period 1960-1990
(Rs. In crores)
Year
P
NP
Total
1960- 61
1.63
3.01
4.64]
1961- 62
1.13
4.03
5.16
1962- 63
1.30
6.37
7.67
1963- 64
1.29
5.13
6.42
1964- 65
1.32
5.40
6.72
1965- 66
1.60
5.53
7.13
1966- 67
1.58
6.99
8.57
1967- 68
2.23
8.03
10.25
1968- 69
2.67
9.07
11.73
1969- 70
2.33
10.56
12.89
1970- 71
3.06
12.88
15.94
1971- 72
1.73
13.19
14.92
1972- 73
2.93
18.15
15.22
1973- 74
2.94
16.25
19.18
2.80 ’
1974- 75
19.43
22.22
1975- 76
4.02'
26.62
30.65
4.54’
1976- 77
28.50
33.03
1977- 78
6.57’
28.88
35.45
9.14’
1978- 79
31.98
41.12
1979- 80
7.29’
36.93
44.22
7.56 ~
1980- 81
44,68
52.23
12.21
’
1981- 82
54.16
66.37
1982- 83
15.26 ’
80.74
65.48
1983- 84
14.84 ’
63.19
78.03
25.30 ’
1984- 85
77.21
102.50
18.33"
1985- 86
91.54
109.87
1986- 87
21.45" 106.59
128.04
31.67" 115.70
1987- 88
147.36
1988- 89
42.00" 129.15
171.15
1989- 90______
39.17
144.39
183.56
Average growth
12.78 "
14.27
13.81
Source: GoK Finance Report
20 Dr.S.Subramanya, IAS, Government Health Expenditure in Karnataka since
1960, KHSDP Paper made available to us by the Task Force.
d
In the above table 1, the figures are shown at current prices—inflation
has not been adjusted for. The real increase then may be much less than
these figures suggest. The growth rates at current prices show that the plan
head has grown at 12.78%, non-plan at 14.27% and total at 13.81% in the
period 1960-90.
In terms of percentage of total state government expenditure it is
interesting to note that M&PH has always hovered around 6%.
Table 2: Capital Outlays towards Medical and Public Health in the period
1960-1990
(Rs. In crores)
Year
P
NP
Total
1960-61
0.61
-0.84 ~~ -0.23
1961- 62
0.13
0.13
1962- 63
-1.55
-1.55
1963- 64
-0.07
-0.07
1964- 65
0.26
0.26
1965- 66
-0.06
-0.06
1966- 67
0.35
0.35
1967- 68
0.68
0.68
1968- 69
1.17
1.17
1969- 70
1.47
1.47
1970- 71
-2.75
-2.75
1971- 72
-1.49
-1.49
1972- 73
-0.08
-0.08
1973- 74
1.36
1.36
1974- 75
0.94
0.00
0.94
1975- 76
0.96
0.96
1976- 77
1.43
1.43
1977- 78
1.39
1.39
1978- 79
1.36
1.36
1979- 80
1.21
1.21
1980- 81
0.94
0.94
1981- 82
1.50
1.50
1982- 83
2.58
2.58
1983- 84
3.71
3.71
1984- 85
4.52
4.52
1985- 86
4.81
4.81
1986- 87
5.08
5.08
1987- 88
1.23
1.23
1988- 89
0.88
0.88
1989- 90
1.64
1.64
Source: GoK Finance Report
As can be seen, a great deal of data is missing. The capital outlays on
M&PH (Table 2) shows little non-plan expenditure. The plan expenditures
have grown at 1.08% for the period 1960-90 at current prices. Capital
expenditures are those that are expected to give returns over a term longer
than one year. Is the state discounting the future?
h
We next present the plan and non-plan expenditures incurred on
M&PH for the period 1990-91 to 2000-01. We have the [implicit] deflator
figures with 1993-94 as the new base till 1998-99 which is used for deflating
the expenditures in current terms.
Table 3 Health and Family Welfare Head wise expenditure (plan) (Rs. in Cr.)
Constant Prices
_____ Current prices
Year
TOTAL
M&PH
FW
Deflator
TOTAL
FW
M&PH
86.41
88.94 46.86 39.54
76.85
41.68
35.17
1990- 91
99.47
43.65
55.82
90.25
89.77
50.38
39.39
1991- 92
94.33 56.10 58.28 114.39
107.90
54.98
52.92
1992- 93
62.60 59.42 122.02
100.00
122.02
59.42
62.60
1993- 94
106.98
81.59 71.56 153.15
163.84
87.29
76.55
1994- 95
114.80 104.13 75.62 179.75
206.35
119.54
86.81
1995- 96
123.43 116.88 60.46 177.34
218.89
74.63
144.26
1996- 97
129.62 121.68 81.85 203.53
263.81
157.72 106,09
1997- 98
138.46 106.51 61.28 167.79
147.47
84.85
232.32
1998- 99
327.89
1999- 2000RE 160.04 167.85
372.90
177.69 195.21
2000- 01BE
7.65
4.99
9.55
Avg growth
Source : Finance Department GOK
Table 4 Health and Family Welfare Head wise expenditure (non-plan)(Rs. in Cr.)
Constant prices
______ Current Prices
Year
TOTAL
FW
M&PH
Deflator
TOTAL
FW
M&PH
3.49
186.82
183.34
88.94
166.16
163.06
3.10
1990- 91
3.86
227.81
223.96
90.25
205.60
3.48
202.12
1991- 92
267.48
3.98
263.50
94.33
252.31
3.75
248.56
1992- 93
269.22
3.62
265.60
269.22
100.00
265.60
3.62
1993- 94
274.73
4.34
270.40
106.98
293.91
289.27
4.64
1994- 95
252.71
4.07
248.64
114.80
285.44
290.11
4.67
1995- 96
248.08
243.56
4.52
123.43
5.58
306.20
300.62
1996- 97
278.16
4.90
273.26
129.62
360.55
354.20
6.35
1997- 98
343.84
5.55
138.46
338.29
7.68
476.08
468.40
1998- 99
575.89
564.86
11.03
1999- 2000RE
639.73
649.91
10.18
2000- 01BE
7.01
7.04
5.30
Avg growth
Source : Finance Department GOK
In the period between 1990-91 to 1998-99, medical and public health
shows an average growth of 9.55% under plan head as against 7.04% for
non-plan head in the same period (Table 3 and 4). Correspondingly for
family welfare average growth under plan head is 4.99% and 5.30% for non
plan head. It is seen that the average growth is marginally higher under plan
head for total of medical and public health and family welfare at 7.65% as
against 7.01% under non-plan head. If the contention that plan figures
represent new investment can be taken to be valid today—and this is
questioned by economists—then this is an encouraging sign.
Family welfare has largely been under the plan head. It is important
to study how family planning is linked to health in the short term. Can it not
16
u
be argued that improvements in the health situation will improve the
prospects of success in family planning? If so, are these the right priorities?
3.2 Health related sectors
Under this can be included the following heads21.
a. Family Welfare - includes maternal and child health and family planning
b. Water Supply and Sanitation - includes outlays on provision of potable
water supplies, sewage and drainage, and waste disposal facilities in
rural and urban areas.
c. Nutrition - programs to supplement nutrition for children and pregnant
and nursing mothers and the Integrated Child Development Scheme.
d. Social security and Welfare - dealing with the disabled welfare and old
age pensions
21 There is a certain judgement involved in this. Ultimately, every thing is related to
everything else—where do we draw the line? For example, should pensions be part of
the health-related sector?
1?
u
Table 5 Revenue Expenditure of Health-related sectors during 1960-90 (Rs. In cr.)
Social Security &
Family Welfare
Nutrition
Water Supply &
Welfare
Sanitation
P
NP
Total
P
NP
Total
NP Total
P
P___
NP
Total
1960- 61
0.35
0.76
1.11
0.29
0.01
0.30
1961- 62
0.06
1.16
1.22
1962- 63
0.46
2.84
3.30
1963- 64
0.19
3.17
3.36
1964- 65
0.24 3.37
3.60
1965- 66
0.36
3.21
3.57
1966- 67
0.61
3.15
3.76
1967- 68
0.48 4.02
4.50
1968- 69
0.50
3.71
4.21
1969- 70
0.79 6.27
7.07
1970- 71
5.71
0.84
6.55
1971- 72
1.16 6.99
8.15
2.25
2.25
1972- 73
1.17
8.57
9.74
3.85 0.02 3.88
1973- 74
0.94 8.08
9.01
3.27
3.27
1974- 75
1.28
1.02
2.31
0.10
0.05
0.15
5.70
5.70
4.92
2.72
7.65
1975- 76
0.68
1.29
1.97
0.20
0.20
0.39
7.28
7.28
5.84
2.63
8.47
1976- 77
0.01
7.20
7.21
0.18
0.23
0.40 12.40
12.40
8.89
2.20 11.09
1977- 78
1.69
1.57
3.26
0.21
0.27
6.96
6.96 10.23
0.48
1.96 12.18
1978- 79
2.74
2.41
5.16
0.23
0.29
7.70
0.53
6.84
7.70
4.93 11.78
1979- 80
1.38
5.92
7.30 0.29
0.51
8.03
0.22
8.03 10.85
5.18 16.03
7.07~
1980- 81
2.41
9.48
0.11
8.25
0.12
0.23
8.25 14.74
3.78 18.53
1981- 82
2.97 8.67' 11.64 0.09
0.19
9.64
0.10
9.64 22.26
4.53 26.79
1982- 83
3.93 10.89 14.83
0.01
0.10 12.78
0.09
12.78 34.71
4.37 39.09
1983- 84
5.47 12.19' 17.66' 0.01
0.06 16.57
16.57 43.56
0.05
2.68 46.25
10.47' 16.74' 27.22'
1984- 85
0.03
0.03 21.43
21.43 43.29
7.16 50.45
17.29 ~ 29.16' 46.44'
1985- 86
28.68
0.02
7.83 57.69
0.02
28.68 49.86
18.48' 33.70' 52.19
1986- 87
0.02
28.63 51.51
0.02 28.63
10.71 62.22
1987- 88
22.04 87.53 109.57 ’ 42.71
16.41 59.12 40.95 1.25 42.20 54.97
6.47 61.44
1988- 89
18.71 85.02' 103,73 ' 40.18 15.23 55.40 34.38 1.71 36.09 44.89
8.03 52.92
22.74' 91.32' 114.05' 45.92 17.75 63.67 41.34 1.83 43.17 46.99
1989- 90
7.34 54.34
Avg growth 16.13" 16.37" 16.30'
34.73 30.05
14.5
14.93 31.16
6.74 28.36
Source : Finance Department GOK
Year
Under health-related sectors on the revenue side (Table 5), it is seen
that in this state there has been an increase in expenditure from 2% of SDP
in 1960-61 to 5.8% in 1989-90. From 1972 onwards there is increased
expenditure in health services as well as health-related services22. In the
period 1960-1974, the cells are blank under the heads of family welfare,
Water Supply and Sanitation, and nutrition. Does this mean there has been
nearly no expenditure in these areas? This needs to be probed carefully.
As a percent of total revenue expenditure the health-related sectors
accounted for 21% in 1960-61 and rose to 30% in 1989-90.
22 Dr.S.Subramanya, op.cit
12
It is seen that all health-related sectors have received attention (Table
5). Even so nutrition expenditure has been poor. Family welfare largely a
plan expenditure has also grown in the later years. It is quite clear that
WSS, FW and nutrition have received more impetus in the latter part of
1980s, that is seventh plan onwards. The figures cannot tell us why this is
so—that information has to be sought elsewhere once this fact is
established.
It would appear that the state takes "health related’ sectors more
seriously than health itself, as health expenditure has hovered around 6% of
the total.
I
Table 6: Capital Outlays on Health-related sectors during 1960-90 (Rs. In crores)
Year
CO on Water Supply &
CO on Family Welfare
CO on Nutrition
Sanitation
P
NP
Total
Total
P
NP
P
NP
Total
1960- 61
0.11
0.11
1961- 62
0.22
0.01
0.23
1962- 63
1.11
1.11
1963- 64
0.62
0.62
1964- 65
0.50
0.50
1965- 66
0.03
0.03
1966- 67
1.25
1.25
1967- 68
-4.27 -4.27
1968- 69
6.02
6.02
1969- 70
-3.91 -3.91
1970- 71
0.94
0.94
1971- 72
0.54
0.54
1972- 73
2.01
2.01
1973- 74
-0.23 -0.23
1974- 75
0.90
0.90
1975- 76
0.33
0.33
0.03
0.03
1976- 77
0.01
0.01
0.22
0.22
1977- 78
0.00
0.00
0.00
0.00
1978- 79
0.07
0.07
0.00
0.00
1979- 80
0.05
0.05
0.00
0.00
1980- 81
0.02
0.02
0.00
0.00
1981- 82
0.06
0.06
1982- 83
0.07
0.07
1983- 84
0.14
0.14
1984- 85
0.26
0.26
1.02
1.02
1985- 86
0.43
0.43'
7.42
7.42
1986- 87
0.21 '
0.21
11.27
11.27
1987- 88
0.60
0.60
7.80
7.80
1988- 89
0.03
6.78
0.03
6.78
1989- 90
7.36
7.36
_______ _______
Source : Finance Department GOK
The capital outlays however show expenditures only under water
supply and sanitation which has received attention under all the plans.
There may have been an improvement in the infrastructure - laying of pipes,
IS
1
h
etc. But is that alone enough to improve the health status of a community?
This is a complex matter that again needs a ground level probe.
We next see how the capital outlays have been in the recent decade of
1990s.
Table 7 Capital Expenditure on health and health-related sectors in the
1990s (Plan)___________________________________________________ (Rs in crores)
Year
Current
Constant
M&PH FW
WSS
WSS
SSW
Deflator
M&PH
FW
1990- 91
1.67
4.90
0.98,
5.51
0.00
0.00
88.94
1.88
1991- 92
2.93
2.35
3.07
90.25
3.25
2.60,
0.00
0.00
1992- 93
6.75
0.37
2.43
94.33
7.16
0.39
0.00
0.00
1993- 94
9.99
0.26
0.00
0.68
9.99
0.26
100.00
0.00
1994- 95
10.91
0.21
0.00
1.49
106.98 10.20
0.00
0.20
1995- 96
13.82 3.10
0.00
1.15
2.70
0.00
114.80 12.04
1996- 97
7.93
2.46
2.00
123.43
1.99
0.00
0.00
6.42
1997- 98
68.16 15.53
0.00
2.16
0.00
129.62 52.58 11.98
1998- 99
87.88 22.52 147.93
1.28
138.46 63.47 16.26 106.84
1999- 2000RE
79.78 39.32 159.90
2.39
2000- 01BE
55.38 33.45 107.89
2.34
Avg growth
47.87 12.78
Source : Finance Department GOK
Capital outlays (table 7) made under the various heads have been
small. There is nearly nothing under non-plan and all the expenditures
largely remain as plan expenditure. Surprisingly under WSS no expenditures
were seen in the early years in the documents for which no plausible
explanation can be given. The medical and public health shows an average
growth of 118.24% during the period 1990-91 to 1998-99.
Table 8: Revenue expenditure on health and health related sectors in 1990s
(Rs. In crores)
____ Year
Health and FW
WSS
Nutrition
1990-91
________ 494.50
123.80
142.80
142.80
1991-92
________ 520.60
137.30
1992-93
158.10
________ 594.80
50.20
1993- 94
________ 599.10
181.50
39.00
1994- 95
________ 669.60
225.60
51.40
1995- 96
________ 743.10
296.10
75.50
1996- 97
301.00
________ 619.20
89.10
359.70
1997- 98
________ 709.10
87.40
257.60
________ 873.60
1998- 99
82.50
1999- 2000RE
________ 940.80
268.40
83.70
Source: Expenditure Pattern of the Health Sector in Karnataka, Subramanya and
P.H.Reddy, Southern Economist, 1997
The revenue expenditure on the health-related sectors is given in
table 8. The annual compound growth rates for health and family welfare is
7.4%. It is 8.9% for WSS and 5.8% for nutrition. The expenditure on each
component has increased at different rates. Health and family welfare
increased from 15.8% to 16.9%, that of WSS increased from 3 to 4%. The
share of nutrition declined from 5.1% to 1.5% during the nine-year period of
ZC
SSW
1.10
3.40
2.58
0.68
1.39
1.00
1.62
1.67
0.92
-1.93
ii
1990-91 to 1998-9923. Is this because the nutrition status has improved?
That view may not be supported by the data in the state HDR.
We now look at the trend in expenditure on health related items24.
Table 9: Trend in expenditure on health related items
Per capita
Per capita
Exp. On
Exp. On
Exp. On
exp. On
exp. On
health
health and
health
health
health and
related
FW as % of
related
Year
related
FW
items as %
state’s
items as %
services at services at
of state’s
revenue
ofSDP
current
current
revenue
exp.
prices Rs.
prices Rs.
exp.
1990- 91
526.10
110.50
29.10
6.10
5.60
1991- 92
548.80
114.70
28.50
6.00
5.30
1992- 93
128.90
28.10
6.40
562.10
5.40
1993- 94
5.30
583.10
127.90
28.70
6.30
1994- 95
611.90
132.30
29.10
6.30
5.40
1995- 96
666.80
134.50
29.00
5.90
5.70
1996- 97
5.60
674.70
126.60
27.40
5.10
1997- 98
5.70
730.40
143.10
29.30
5.70
1998- 99
808.50
6.00
174.10
28.10
1999- 2000RE
863.10
185.10
28.50
6.10
Exp. On
health and
FW as % of
SDP
The per capita expenditure on health related activity in 1999-00 is
Rs.863 and that on health and FW component Rs. 185. The health related
activities account for 28.5% of total revenue expenditure of the state and the
health and FW account for 6.1% of state revenue expenditure. The
expenditure on health related activities formed 5.7% of SNDP in 1997-98
and on health and family welfare was 1.1%. Experts have to say on the basis
of accepted norms if this is adequate—the figures do not, cannot, speak for
themselves.
It would be useful at this point for us to look at the various loan
components of the funds that the state receives. Most of the loans come
under three well-defined schemes: central schemes, centrally sponsored and
the state-sponsored schemes.
23 Dr.S.Subramanya, op.cit
24 Source: Expenditure Pattern of the Health Sector in Karnataka, Subramanya and
P.H.Reddy, Southern Economist, 1997.
1.20
1.10
1.20
1.20
1.20
1.10
1.00
1.00
J
Table 10: Centrally sponsored schemes (revenue a/c) - current prices
______ Year
M&PH
FW
WSS
SSW Nutrition
Total
1990-91
379.30 3050.45
2068.87
111.19
6263.12
1991- 92
392.92
1909.97
2274.19
144.25
0.94
5165.04
1992- 93
621.59 4143,76
2250.82
24.79
19.01
7348.87
1993- 94
609.42 5317.39
3465.23
26.44
3.42
9640.96
1994- 95_____
879.82 2769.22
4579.24
19.62
8599.43
1995-96
793.07 2323.21
6408.71
90.99
9925.06
1996- 97
899.34
1052.60
6579.28
23.84
9010.74
1997- 98_____
983.97 2134.53 10273.67
35.10
14044.98
1998- 99 A/C
1017.85
1999.45 11541.58
24.80
15019.15
1999- 2000 -RE
1535.21 8346.08 11397.08
40.00
23064.98
2000- 01-BE
___________________
864.26 9577.24 12494.60
45.00
23755.66
Source : Finance Department, GOK
Table 11 .-Centrally sponsored schemes(revenue a/c(Rs. In Lakhs)-constant prices
Years
Deflator
M&PH 1
FW
WSS
SSW Nutrition
Total
1990- 91
88.94 426.47 3429.78 2326.14 125.02
7041.96
1991- 92
90.25 435.37 2116.31 2519.88 159.83
1.04
5723.04
1992- 93
94.33 658.95 4392.83 2386.11
26.28
20.15
7790.60
1993- 94
100.00 609.42 5317.39 3465.23
26.44
3.42
9640.96
1994- 95
106.98 822.42 2588.54 4280.46
18.34
8038.35
1995- 96
114.80 690.83 2023.70 5582.50
79.26
8645.52
1996- 97
123.43 728.62
852.79 5330.37
19.31
7300.28
1997- 98
129.62 759.12 1646.76 7925.99
27.08
10835.50
1998- 99
138.46 735.12 1444.06 8335.68
17.91
10847.28
Avg growth
6.24
-9.16
15.24 -19.42
4.92
Source : Finance Department, GOK
Under the centrally sponsored loans - revenue account (table 10 &
11) we see that the total moneys have increased over the period 1990-91 to
2000-01 under M&PH and WSS. There is however nothing allocated towards
nutrition under the head social security and welfare. Family welfare also
shows a gradual decrease in the same period. As far as family welfare is
concerned it is largely under the plan head. Health per se is still a small
portion of overall expenditure.
Table 12: Centrally sponsored schemes (capital a/c)
(Rs. in Lakhs)
Years
Current
Constant
M&PH
FW
TOTAL
Deflator M&PH
FW
TOTAL
1990- 91
1430.80 456.89
2059.95
88.94 1608.72
513.71
2316.11
1991- 92
239.39 214.68,
817.35
90.25
265.25
237.87
905.65
1992- 93
656.53
14.89
1245.70
94.33
695.99
15.79
1320.58
1993- 94
981.09
0.02
1887.55 100.00 981.09
0.02 1887.55
1994- 95
1021.21 ______0
2071.08 106.98 954.58
0.00 1935.95
1995- 96
1295,22 ______0
2187.29 114.80 1128.24
0.00 1905.30
1996- 97
741.47
20.51
1641.35 123.43 600.72
16.62 1329.78
1997- 98
6765.78 141,07
7786.66 129.62 5219.70
108.83 6007.30
1998- 99
8739.24 215.41
34523.72 138.46 6311.74
155.58 24934.07
Avg growth
16.40
-12.43
30.22
Source : Finance Department , GOK
d
Under the centrally sponsored schemes - capital account (table 12) we
see that the figures are fluctuating in the period 1990-91 to 2000-01. A large
increase is seen in 1997-98 and 1998-99 under M&PH.
Table 13: State sponsored schemes (revenue a/c) - current prices (Rs. In Lakhs)
Medical &
Family
Water
Social
Year
Public
Welfare
Supply
Security
Nutrition
Total
Health
& Sanitation
& Welfare
1990- 91
3663.64
466.17
2983.26
1297.04
733.34 16587.41
1991- 92
3433.61
3128.23
4145.16
1620.30
840.18 22028.22
1992- 93
4562.42
1353.96
5751.76
1842.24
890.39 27333.37
1993- 94
624.35
7232.65
5585.83
1796.39
884.43 34160.60
1994- 95
7766.58
673.75
11733.19
1875.89
1566.30 44290.85
1995-96
11072.93
661.21
13924.69
2699.10 2932.63 63113.59
1996- 97
13445.54
379.02
17277.52
4395.12 3535.42 75518.57
1997- 98
14669.23
521.78
3967.98 3431.69 73100.18
19978.18
1998- 99
13689.27
499.55
15118.31
3337.41
3290.68 69813.76
1999- 2000 -RE
489.11
14348.56
13904.32
4050,96 3392.51 70183.70
5340.65' 3634.84 83853.39
2000- 01-BE
16812.30
922.81
14669.66
Source : Finance Department, GOK
Table 14: State sponsored schemes (revenue a/c) - constant prices (Rs. in Lakhs)
Deflator Medical & Family
Water
Social
Year
Public
Welfare
Supply
Security Nutrition
Total
Health
&
& Welfare
Sanitation
1990- 91
88.94, 4119.23 524.14,
3354.24
1458.33
824.53
18650.11
1991-92
90.25 3804.55 3466.18
4592.98
1795.35
930.95
24408.00
1992-93
94.33 4836.66 1435.34
6097.49
1952.97
943.91
28976.33
1993- 94
100.00 5585.83 624.35
7232.65
1796.39
884.43
34160.60
1994- 95
106.98 7259.84 629.79 10967.65
1753.50 1464.11
41401.06
1995- 96
114.80 9645.41 575.97 12129.52
2351.13 2554.56
54976.99
1996- 97
123.43 10893.25 307.07 13997.83
3560.82 2864.31
61183.32
1997- 98
129.62 11317.10 402.55 15412.88
3061.24 2647.50
56395.76
1998- 99
138.46 9886.80 360.79 10918.90
2410.38 2376.63
50421.61
Avg growth
11.22
-4.06
14.01
5.74
12.48
11.68
Under the state sponsored schemes - revenue account (table 13 8514)
we once again see that the moneys expended are rising. However here MSsPH
shows a comparable rise with WSS. Family welfare has a smaller share as
compared to the centrally sponsored schemes. Nutrition has also an
increasing share over the years.
Year
Table 15: State sponsored schemes (capital a/c)
Current
M&PH
FW
WSS
Total
Deflator M&PH
Constant
FW
WSS
Total
1990- 91
1430.80i 456.89
0.00 2059.95
88.94 1608.72, 513.71,
0.00 2316.11
1991- 92
239.39 214,68
0.00
817,35
90.25 265.25 237.87
0.00
905.65
1992- 93
656.53
14.89
0.32 1245.70
94.33 695.99 15.79
0.34 1320.58
1993- 94
981.09
0.02
0.00 1887.55 100.00 981.09
0.00 1887.55
0.02
1994- 95
1021.21
0.00
0.00 2071.08 106.98 954.58
0.00
0.00 1935.95
1995- 96
1295.22
0.00
0.00 2187.29 114.80 1128.24
0.00 1905.30
0.00
1996- 97
741.47
20.51
0.00 1641.35 123.43 600.72 16.62
0.00 1329.78
1997- 98
6765.78
141.07
0.00 7786.66 129.62 5219.70 108.83
0.00 6007.30
1998- 99 A/C 8739.24
215.41 14792.79 34523.72 138.46 6311.74 155.58 10683.80 24934.07
1999- 00 -RE 7950.00
300.00 15990.00 24840.98
2000- 01-BE 5538.00
245.00 10789.00 16876.00
Avg growth
16.40 -12.43
30.22
Capital account figures for state sponsored schemes (table 15) again shows a
large rise in M&PH while smaller or negligible rises in FW and WSS.
Table 16: State sponsored schemes (loan a/c)
Years
Current
Constant______
WrSS
Total
Deflator _WSS_ Total
1990- 91 1361.05 1361.05
88.94
1530.30 1530.30
1991- 92 6847.00 6847.00
90.25 7586.70 7586.70
1992- 93 3696.02 3696.02
94.33 3918.18 3918.18
1993- 94 3376.00 3406.00 100.00 3376.00 3406.00
1994- 95 3288.00 3318.00 106.98 3073.47 3101.51
1995- 96 4452.00 4682.00 114.80 3878.05 4078.39
1996- 97 5897.00 5907.00 123.43 4777.60 4785.71
1997- 98 1682.96 1682.96 129.62 1298.38 1298.38
1998- 99 7843.86 7843.86 138.46 5665.07 5665.07
Source : Finance Department, GOK
The loans under state sponsored schemes (table 16) show that the
loans were allotted only towards WSS. It is likely that these were also
grants/loans to the GOT from agencies like the world Bank and other
bilateral donors. This can be followed up separately.
Table 17: Central plan schemes (Rs. In Crores)
Years
Current
____ Constant
wtss|m&ph Deflator WSS M&PH,FW
FW
1990- 91
2.00 1.49
88.94 2.25
1.68
3.00 1.30
1991- 92
90.25 3.32
1.44
1992- 93
3.00 1.26
94.33 3.18
1.34
1993- 94
3.00 0.82
100.00 3.00
0.82
1994- 95
5.00 43.61
106.98 4.67
40.76
1995- 96
0.00 58.71
114.80 0.00
51.14
1996- 97
0.00 61.65
123.43 0.00
49.95
1997- 98
0.00 81.22
129.62 0.00
62.66
0.00 60.75
1998- 99
138.46 0.00
43.88
Avg growth
43.74
Source : Finance Department, GOK
il
The central plan (table 17) also shows a similar feature with small
increase over the period till 1994-95 under M&PH head, and then shooting
up in the last five years from 1995-96 to 2000-01. WSS has had no moneys
expended under this scheme in the last five years while it is more or less
fluctuating and in smaller measure for MPH and FW.
These are funds made available through the budgets. This paper has
not gone into the issue of the efficacy of these allocations—that is an
important, but distinct question that must still be examined.
6. By Way of Conclusion
Such studies of local budgets are essential if the public is to take part
in informed debate on matters of health policy. But it is difficult because the
data are out of reach of the ordinary citizen. This is a study we had
undertaken for the GoK which set up the Task Force on Health and Family
Welfare. We were assured that the data required would be made available.
No one said that data would not be given. Yet, few were in a position
to actually give the data needed for the analysis. The state has passed a
Freedom of Information Act: thus our freedom to get this data is not an
issue. Yet, access is a big problem. Finance data, for example the past
budget documents of the state government, are not available on the website
[www.kar.nic.in], nor in any book shops. Even when they are supposed to
be priced publications—and few are—it is difficult to get them. The largest
percentage of our time in this study was in chasing the chimera called data.
One reason we could not get data was probably because it was not
available. This we found hard to believe in the beginning. But after a meeting
in the office of the Commissioner for Health and Family Welfare, attended by
concerned officials from the relevant departments, we had no option but to
accept this harsh reality. Much of the required data simply does not exist25.
Perhaps nobody outside had made a demand26 for it before!
It is therefore essential that databases on these matters be created, not
only in the concerned departments, but in research institutions as well.
This quick look at some aspects of the finances of the health sector in
Karnataka has shown that there has been an increase in expenditures on
allied sectors of health—water supply etc. This increase in health related
expenditures has taken place in the context of a relatively stable level of
expenditure of 6% of total expenditure on medical and public health. Is such
stability adequate given the requirements of the population for health
services? An analysis of finances alone cannot answer this question. To see if
25 How the department decides upon priorities in this situation remains a mystery
that needs to be clarified. Could we argue that decisions have been arbitrary? If that
is the working hypothesis, then how would the department go about refuting it?
26 Here Karnataka has much to learn from the way the Right to Information demand
has become a movement in Rajasthan—seen as a more backward state—through the
jan sunwais held there.
li
this level of expenditure is adequate, one needs an acceptable norm. This we
do not have.
The devolution of finances to local bodies needs to be examined as
well. The accounts we have seen do not take into account the local tier of
government following the 731^ and 74th amendments—because there are, in
any true sense, none. Today, there are expenditures in the district by the
state government agencies—but these are not expenditures of the local
governments—except perhaps in an accounting sense as these bodies may
have passed resolutions to incur the expenditure27.
Table 18: proportion of district outlays to state receipts (in % terms)
__________ Details_________ 1992-93 1993-94 1994-95 1995-96 1996-97 1997-98
Proportion of district outlays
12.36
12.54
13.92
12.88
12.65
12.85
to total revenue receipts of the
State_______________________
Proportion of district outlays
11.98
12.78
13.35
12.97
11.93
12.53
to total revenue expenditure of
the State___________________
Proportion of district outlays
9.08
8.27
9.32
10.38
9.33
10.81
to total receipts (capital and
revenue) of the State_________
Proportion of district health
35.78
39.71
34.04
26.87
21.50
17.21
allocations to total health
expenditure in the state
Source: compiled from Finance Accounts, GoK
We have calculated the proportions at constant prices for the district
outlays as given in the Link documents for the last six years. From the
second data set, giving data for the decade of 1990s, the revenue receipts,
revenue expenditures and total receipts of the state was taken.
It is seen from the above table that the proportion of total district
outlays to the total revenue receipts of the state is hovering around 12.3 to
13%, with no substantial rise over the years.
Similarly, the proportion of total district outlays to the total revenue
expenditures of the state also shows a figure of around 11 to 12%. As a
proportion of district outlays to total receipts of the state shows a lower
figure of around 9% over the years.
The more worrying figure comes with the proportions of district health
allocations to the total health expenditures made at the state level. It is seen
that a share of nearly 35% in 1992-93 has steadily fallen over the years to a
low of 17% in 1997-98. These were the years in which decentralisation was
supposed to be gaining momentum in the country. Where health is
27 When we look at the proportion of expenditure in the district to total departmental
expenditure, there is a big difference between the health and education
departments. A far larger share of education expenditure takes place at the district
level than in the health department. There is much scope to decentralise in the
health department.
^6
concerned, in Karnataka, these figures suggest that decentralisation was
being rolled back, if these numbers are any indication.
Considering that health as a proportion in total social services sector
has only a small share, as seen earlier, the above figures are to be taken
seriously to understand how much of the money is really flowing down to the
districts for the improvement of the health sector.
The priorities are not set by the local governments, and the power to
approve does not vest with them. They simply pass resolutions to justify
what the state government departments have decided to do. It is thus not
possible to make any statements about their relative efficiency or
effectiveness in the absence of actual experience of devolution of fiscal
responsibilities. But a system that keeps these bodies out of health care is
likely to be a system that will fail—and the existing top down one has failed.
Why not try a truly decentralised system?
Loans have been an increasing part of the financing of all programmes
in the state, not just health. The loan burden is increasing, but it has not
been possible to calculate the health sector’s exact share in this loan
burden.
The finance data also suggest that the state, in financial terms, is
becoming increasingly more susceptible to financial stress. The CAG’s civil
report no 3 of 1999 shows this clearly.
Much of this is tentative. In depth studies of the integrity of the
budget process—for example, to what extent do allocations differ from
expenditures, at what level and by what processes are decisions made and
so on, are essential for a deeper understanding of health—and other
developmental—finances.
And such a debate must involve large parts of our population—not
just bureaucrats and economists, but the people themselves. People’s
representatives, especially those from the depressed classes and women,
who now have a presence in these bodies, must be involved in such debates.
They have an electoral responsibility, and must be given all the support
needed to take part in this important debate. How this is to be made possible
will be an interesting question—and challenge.
The budget analysis presented in this monograph—tentative though it
is—presents a base for such discussion. It is when questions are asked,
when people demand answers and solutions, that such analysis can begin to
make an input to policy. Till then, it will remain in solitary and splendid
isolation from reality. What we can claim then, is to have made a beginning,
to have cut the Gordian knot where such debate is concerned. We look
forward to where this will take us.
u
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GOVERNMENT
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TASK FORCE ON HEALTH ANO FAMILY WELFARE
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A Commissioned Research Study
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PEOPLES PERCEPTION OF PUBLIC HEALTH CARE SYSTEM
IN KARNATAKA
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By
Dr. Ramesh Kanbargi
CENTRE FOR SOCIAL DEVELOPMENT
No.8? Shantishree, Nagarabhavi Post
Bangalore - 560 072.
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11
CONTENTS
Background
1
The National Health Policy
3
Disparities in Health Indicators
4
The Present Study
7
Objectives
8
The Sample
9
Data and Methodology
10
The Study Area : Some Insights
10
The Household Survey
22
Peoples Perception
28
The Focus Group Discussion and their Outcomes
31
In Gulbarga
32
In Tumkur
35
In Udupi
37
Summary of the Findings and Conclusions
38
Recommendations
41
ACKNOWLEDGEMENT
We were able to complete the present study in a short time because of the
co-operation given by the staff of the health department, respondents in the
selected districts, participants in focus group discussions. We gratefully thank
them.
Thanks are due to Dr. H. Sudarshan, Chairman, Task Force on Health
and Family Welfare, Government of Karnataka for giving us an opportunity to
work on this topic.
The research team of the Centre For Social Development worked hard to
collect and analyse data in a very short period and deserve all appreciation for
the good work.
It is hoped that the report would be found useful by all those interested in
improving Public Health Care Services in the State.
RAMESH KANBARGI
DIRECTOR
CENTRE FOR SOCIAL DEVELOPMENT
36®
PEOPLES PERCEPTION OF
PUBLIC HEALTH CARE SYSTEM
IN KARNATAKA
Ramesh Kanbargi
Centre for Social Development
Background
India had a rich traditional health care system during pre-colonial period
known as 'Ayurveda’. It enjoyed superiority over folk lore and tribal medicine due
to its scientific approach and research system. Ayurveda also dominated over
unani and homeopathy the two foreign medical systems that prevailed then
because of its wider societal acceptance.
The Unani system of medicine entered India along with the Moghuls and
enjoyed their royal patronage while homeopathy entered India through travellers
from Europe during pre-colonial period. Perhaps, there existed stable relation
between the local level investment in health care and the size of the local
community.
This investment was probably limited to training of skilled man
power to sustain the health care services profession to the future generations.
During the colonial period the British, the French and the Portuguese
brought with them new systems of medicine primarily for their own use. It was
the East India Company that first initiated the process of establishing the modern
Allopathic health care system in India by utilising the services of their army
doctors which also often catered to the needs of the native elites. Patronage and
promotion of Allopathy by the Britishers and then by the native rulers resulted in
gradual transformation of the attitude of the people who considered the imported
health care system accepted by the rulers as superior to indigenous medical
system. This attitudinal change among the people might have gradually
diminished the importance of Ayurveda in India. The States controlled by the
native rulers under the influence of the foreign powers or controlled by the foreign
powers themselves allocated increasing public resources to health care which
were mainly directed to Allopathy and Homeopathy.
This brought in the
transition from traditional indigenous system to modern imported system of
31
I
2
medicine. The transition, however, was mainly confined to urban area and better
off section within urban area.
Independent India essentially pursued the same policy of the colonial
rulers. The Allopathy system needs heavy investments in the buildings, medical-
surgical instruments, in pharmaceutical industry and in training of medical and
para medical personnel required. Since the focus of planning and development
of the modern health care system was concentrated on building of sophisticated
medical schools and hospitals, was of little help to revive Indian System of
Medicine. This has led to greater emphasis on curative-clinical services and their
concentration in urban areas.
The urban services are better equipped with
sophisticated technology and are mainly serving the better off sections.
The
globalisation process is gradually unfolding and is indicated by the state of the art
corporate hospitals that are being established mostly in the metros that further
increased the wide gap of accessibility to health care services to common man
particularly more in rural areas where about 70 per cent of population live. It is
sad reflection on the earlier policy not to bother about modernising and
mainstreaming Ayurveda, Unani or folklore practitioners who were serving the
vast rural population by licensing them.
There was profound impact of Chinese experiments with 'barefoot
doctors’ concept on Indian thinking. Srivastava Committee Report in 1975 laid
emphasis on rural public health.
It suggested the deployment of semi
professional health workers similar to Chinese barefoot doctors,
It also
suggested the development of a referral system through a hierarchical system of
urban specialised facilities catering to the needs of rural population on referral.
There was also pressure on the government to improve the health status of
largest segments of the population who are poor and are in rural areas. The key
indicators of health like Infant Mortality Rate (IMR) and Crude Death Rate (CDR)
clearly revealed the impact of this policy. For example, in 1970 the estimated
IMR (SRS) was about 130 for the country but it was higher in rural (136) as
compared to only 90 in urban areas. In 1978 IMR for India declined to 123 but
hovered around 130 in rural areas while urban area witnessed a sharp decline to
3
69. The IMR estimates for Karnataka at this period, were 90 for rural areas, 58
for urban and 82 for the State as a whole.
The World Assembly at Alma Ata in 1978 declared that health is a
fundamental human right and provision of Primary Health Care to all should be
the strategy to reach the goal 'Health For All by 2000 AD’. The declaration to
which India was a signatory gave new thrust to the process of health care
planning in India.
It became imperative to think of an alternative strategy to
ensure Health For All by 2000 AD.
I
The National Health Policy
The
National Health
Policy
1983
announced in this
background
recommended that IMR should be brought down from 120 to 60, CDR from 15 to
9 by the year 2000 AD. The policy statement talked about 'heritage’ but pulls the
rug from under by stating “however, the allopathic system of medicine, in a
relatively short time, has made a major impact on the entire approach to health
care and pattern of development of the health services infrastructure in the
country”.
Section 7 and 18 of the policy dealing with medical research and
education does not mention other systems of medicine. Similarly it also is silent
on the need to train and license the village medical practitioners of indigenous
system and the need for integrating traditional systems with modern.
However, it is noteworthy, that several health indicators after Alma-Ata
conference in 1978 have shown remarkable improvements. The disease specific
interventions have brought sharp fall in Crude Death Rate from an estimated 28
during 1941-51 to only 9 during late 90s. Planned development in the country
also made significant contribution towards reduction in death rate.
The
Expectation of Life at Birth, as a consequence of decline in CDR and IMR has
increased from about 40 years in fifties to over 60 in the nineties.
The
achievement, though impressive considering the level of other development
indicators like levels of living in the country, look pale compared to many other
less developed countries who started reforms in health sector along with India.
The World Assembly in 1978 was to basically address to the wide disparities
33;
4
observed between more developed and less developed countries and desired to
bridge them by 2000 AD when the goal Health For All was to be achieved.
Despite improvements in health indicators differentials have persisted. (Table 1).
Table 1 : Global Disparities in Health in Selected Countries: 1997
Country
Mean
population
growth
CBR per
1000
CDR per
1000
IMR
Life Exp. At
Birth (years)
M
F
(%)
China
Indonesia
Myanmar
Bangladesh
Pakistan
INDIA
1.0
1.7
1.9
2.0
2.8
1.9
17
24
31
31
39
29
7
8
12
11
11
10
31
66
49
77
91
75
69
62
56
55
59
60
72
64
62
58
61
59
Japan
Rep.of Korea
Thailand
Nepal
Sri Lanka
0.2
0.9
1.1
2.3
1.5
10
15
18
35
20
7
6
7
12
5
4
11
32
79
17
76
69
66
54
70
83
77
72
54
74
MDC
LDC
World
0.1
1.8
1.5
11
27
24
10
9
9
9
64
59
71
62
64
78
65
68
Source: Family Welfare Programme in India : Year Book, 1996-97.
Disparities in Health Indicators
The disparities observed among different countries indicate the extent of
success achieved in health sector. As mentioned, though there are remarkable
improvements in health in India over time, compared to many countries like
China, it looks less impressive. Within the country there are more pronounced
differentials in health indicators across the states (Table 2) and within each state
there are wide differentials by rural/urban residence by gender and social class
even though reliable estimates are difficult to obtain.
5
Table 2: Health Situation in India and Selected States
State
IMR 1996
CDR 1996
Maternal
mortality
ratio
1986
Sex
Ratio
1991
CBR
1996
India
R
77
U
46
T
72
R
9.7
U
6.5
T
9.0
580
927
27.5
AP
Karnataka
Kerala
Tamil Nadu
73
63
13
60
38
25
16
39
65
53
14
53
9.2
8.6
6.3
8.7
5.9
5.4
6.0
6.6
8.4
7.6
6.2
8.0
394
439
247
372
972
960
1036
974
22.8
23.0
18.0
19.5
UP
Rajasthan
MP
Bihar
Orissa
88
90
102
73
99
67
60
61
54
65
85
85
97
71
96
10.7
9.6
11.8
10.6
11.2
8.2
7.1
7.6
6.9
7.5
10.3
9.1
11.1
10.2
10.8
920
627
507
813
844
879
910
931
911
971
34.0
32.4
32.3
32.1
27.0
Maharashtra
Gujarat
58
68
31
46
48
61
8.7
8.3
5.4
6.2
7.4
7.6
439
373
934
934
23.4
25.7
Source: 1. Family Welfare Programme in India, 1996-97, Government of India.
2. Mari Bhat P.N., 1995.
However, estimates on IMR in Karnataka vary between 29 reported for
Dakshina Kannada to 79 for Bellary. The persisting disparities indicate that there
is enormous scope to improve accessibility to Primary Health Care among all
sections of the society at district level. Further improvements will be, to a large
extent, determined by the efforts made by the States to bring in equity in health
care services and enhance accessibility to these services.
The declining sex ratio observed in Karnataka is a more complex issue
entangled with social, economic and cultural factors in the society. But there are
broad indicators to suggest that they emerge from neglect of health care to
women in general, right from the infancy to old age. The latest data set available
35;
6
in National Family Health Survey - NFHS II reveal for example while IMR among
females is lower, under five mortality of girls is much higher than it is among boys
- 36.7 and 24.9 respectively. Maternal mortality is still unacceptably high in India
and Karnataka also and about 42 per cent of women suffer from anemia of
different kinds. Nutritional supplements - Iron and Folic Acid tablets (IFA) are
supplied for 3 months to all pregnant women in the state to improve their
nutritional level and improve the weight of the baby to be born. The NFHS II data
also show that about 70 per cent of Children aged 6-35 months suffer from
anemia of varied forms.
These few findings are distressing and raise the question of accessibility
of health care services and family welfare services provided by the state. There
is an impressive expansion in health infrastructure - there is a Primary Health
Centre for every 21,548 population in rural Karnataka and there is a Sub-Centre
manned by female health worker known as ANM for every 4,237 population, If
they are effectively catering to the public,
health status of rural women and
children who are primary targets should have been much better than what is
reflected in NFHS II survey. The findings reveal that about 83 per cent of women
respondents reported that no health or family planning worker had visited their
home during last year (12 months preceding the survey) that says a lot about
accessibility and the quality of health care that the state boasts of providing. It
also may indicate that female health workers may be concentrating their visits to
potential acceptors of contraception sterilisation, in particular.
In other words
health care services are biased towards contraceptive services.
In brief, what emerges from this background discussion so far is that over
the years allopathic system has become predominant system that has received
maximum support of public policy and resources. Though there is an effort to
revive the Indian System of Medicines not much is seriously done to improve its
outreach in rural areas where there is an urgent need. The disparities observed
across states in India, as noted, certainly indicate extent of efforts made to reach
the set goal in health sector. The disparities also loudly speak of the inadequate
outreach and perhaps also the quality of care provided.
36
7
Reliable health indicators at district levels in Karnataka as in many other
states are scarce. But available information suggest that Coastal Hilly districts
like Dakshina Kannada, Coorg and Uttara Kannada districts have performed
relatively better as compared to some of the Northern-Southern maidan districts
like Bellary, Gulbarga, Raichoor, Bidar, Kolar and Tumkur.
The recent Rapid
Household Survey conducted in Karnataka to improve understanding of
Reproductive and Child Health Survey at district level provide valuable insights
into the pattern of delivery of Public Health Care Services to the rural population
in particular. For example, the grass-root level health workers who are supposed
to visit every household in their allotted area to enquire/provide a variety of
services on a regular basis had visited only about 36 per cent of households in
the State (Kanbargi, et.al., 1998). In other words, a large majority of households
were deprived of these services.
An examination of this data by districts
revealed that in Gulbarga only 13 per cent, in Bidar 18 per cent and in Raichur
18.3 per cent of the households were able to receive the services of grassroot
health workers at their door steps and on the other hand it was 87 percent in
Kodagu, about 50 per cent in Dakshina Kannada and 60 percent in Mandya
districts.
The Present Study
Public Health Care Services in Karnataka are provided through a well
organised health Centres established in rural areas.
According to Human
Development Report, Karnataka - 1999, for every 21,548 population there is a
Primary health Centre (PHC). Each PHC has about 5-6 sub-centres and each
sub centre on an average caters to the needs of about 4237 population. In other
words there is a health worker for every 4000 population in rural areas who visits
all the households in her area (about 88 households) provide ante-natal, natal
and post-natal care to women, immunisation to the newly born against
preventable diseases, supplement the nutiritional status of pregnant women and
children which are designed to improve health status and survival of rural women
3^
8
and children.
She also provides some curative services to people for simple
ailments.
In addition to the female health workers (ANMs to LHVs) there are male
health workers, health Inspectors at PHC level who have to identify persons
suffering from fevers to check whether there is Malaria/Dengue, keep birth/death
records, participate in conducting school health programme, educate community
on epidemics and improve environment. Looking at the duties assigned to the
para medical staff one may wonder how many of the assigned responsibilities
are appropriately carried out by them. The RCH Survey conducted in Gulbarga
district reports that only about 27 per cent of all deliveries were conducted in
health institutions and among domiciliary births accounting for 73 per cent of
total, a great majority of them 71 per cent were conducted by either village
Sulagitti (Untrained Dai) or village elderly women.
On the other hand in
Dakshina Kannada 77 per cent of all deliveries were conducted in health
Institutions.
Among the home deliveries (23 per cent) only 33 percent were
attended by either untrained dai or some elderly woman of the village. Why this
variation in the delivery of health care services across the districts. Whether the
quality of care provided make differential demands or people in general do not
have much faith in public health care services? Is there any alternative such as
indigenous system of medicine that people prefer?
To understand widely,
differing utilisation of public health care services an effort is made here to assess
the peoples’ perception of Public Health Care Services and Indigenous System
of health care in Karnataka.
Objectives
The following are the main objectives of the study.
1. To study peoples’ perceptions regarding public health care services /
indigenous health care services available in rural setting.
2. To study the utilisation of health care service pattern among different
districts and different social class within district both in respect of public
and indigenous health care.
3«
9
3. To identify the inadequacies in the public health care services that
need to be rectified to make them more “people friendly” and more
acceptable by all sections of the society.
4. To identify causal factors for poor utilisation and suggest remedial
measures.
The Sample
The study was conducted in three districts of the state,
The sample
selection was based on the following factors:
D
Percent girls dropping out of school during 1st - to 7th standard.
2)
Literacy rate of females recorded in 1991 Census.
3)
Crude Birth Rate recorded in recent RCH Survey 1998.
4)
Infant mortality estimated by Registrar Generals Office.
5)
Crude Death Rate estimated for recent years reported in HDR, (K),
1999.
Based on these variables Udupi, Tumkur and Gulbarga Districts were
selected.
Table 3 : Sample Selection
SI
No
Variables
T
Udupi
State/Districts
Tumkur
Gulbarga
Percent girls dropping out
during
1-7
years
of
schooling
6.07
43.06
61.62
Rate
78.50
51.10
30.91
52.65
Karnataka
46.28
2
Literacy
1996
3
Crude Birth Rate (Rural)
21.4
24.7
31.9
24.4
4
Crude Death Rate ( R+U)
7.0
8.2
10.7
8.5
5
Infant Mortality Rate (R+U)
29
64
59
74
Source:
(females)
1,2, 4, 5 from Human Development Report, Karnataka, 1999.
3 from Reproductive and Child Health Survey, 1998.
39
10
Data and Methodology
Essentially such studies would be based on the data collected from focus
group discussion or a household survey covering adequate number of
households. Considering the short duration of time available, the present study
is based on both-data collected from focus group discussions and supplemented
by a representative household survey. In order to make the findings of the study
more meaningful relevant information was collected from several health
functionaries such as medical officers, para-medical staff and other health
authorities like DHO, Joint Directors posted at Divisional head quarters of the
State. Information was also collected from some knowledgeable persons like
Vice Chancellors of Universities, Academics and Political Leaders like Zilla
Panchayat Presidents.
Section I
The Study Area - Some Insights
The three selected districts are situated in three developmental phases one in advanced stage - Udupi, one in backward stage Gulbarga and one in
between these two - Tumkur.
It is often argued that regional imbalance in
development is a major problem that can be solved to a large extent by holistic
approach. Political power is said to play an important role in bridging the gap
between the two extremes of development.
Gulbarga district has remained
backward since the formation of the state despite being politically strong. In the
contemporary situation there are five ministers in the state government who hail
from Gulbarga and two of them may be considered as heavy weight politicians.
Health Minister himself is from this district. Earlier during formation years a Chief
Minister was from Gulbarga district who was widely known for his administrative
skills and his honesty. Despite such advantages the district has remained
educationally, socially and economically backward.
Our discussion with the Vice Chancellor of Gulbarga University and some
academicians revealed that one of the major factor for poor progress made in
Gulbarga and neighbouring districts - Bidar and Raichur is poor quality of
teo
11
education imparted which hinders progress in every field.
Even few brilliant
students would move out as soon as they complete their education and there is
hardly anything in this part that will attract outside talent. In fact, if any officer
from Bangalore is transferred to Gulbarga, it is considered as a punishment
posting.
Our prolonged discussion with Chief Executive Officer of Zilla Panchayat
revealed a different story. He reported that the district has some good staff in
health department. He often receives representations from public not to transfer
the person as he is good with the people and his shifting would cause
inconvenience to them.
Such representations certainly suggest the cordial
relation between the community and health care provider but they are
exceptions.
Udupi, on the other hand, presents a different scenario.
Educated
population with exposure to other cultures, particularly with Mumbai - financial
capital of the country has made remarkable impact on the district.
Several
studies have pointed out that its closeness to Kerala has made it different than
other districts in the state.
Excellent road and transport facilities, efficient
administration and well informed public make an ideal combination to be in the
forefront in the state in education, health and gender issues.
Most interesting
observation in the district is the contribution of private sector in two vital areas
education and health that have made the district unique.
Though the private
sector is often abused as governed by “profit motive” without any social
obligation, Udupi presents a different picture. Health and educational services of
private sector are accessible to all irrespective of the ability to pay.
Tumkur district presents a moderate picture - neither good nor very bad
but within the possible limits for improvement as fast as one wants. The district
has some very good health care institutions and some not good ones are
situated in the border area of Andhra Pradesh.
Nearness to Bangalore has
provided good choice to upper class/caste population to better health care
whereas majority of rural population 80-90 percent depend on the public health
care services.
The Medical College Hospital situated at the outskirts of the
12
District Town caters to people living in the vicinity of the college hospital as
revealed in our focus group discussions held in Gubbi Taluk. But in Madhugiri
and Kunigal Taluks none mentioned they ever had gone to this college hospital
or were adviced to go there by any service providers.
Gulbarga also has a
medical college but none of our focus group discussants and respondents in our
household survey, nor any medical officers/ANM/LHV mentioned of availing the
services or referring the sick to the Institution for treatment suggesting its limited
outreach.
The presence of private sector health care services and their accessibility
to general public at an affordable cost is an important factor in improving the
health status of people. The following table provides some idea on the utilisation
of private and public sector health care services in selected districts
in
Karnataka (Rural areas).
Table 4 :
SI
No
1
2
3
4
Private - Public Health Care Services Utilisation in
Selected Districts
Tumkur
Pvt.
Public
Dakshina
Kannada
Pvt. Public
47.8
50.0
67.0
Delivery
and
post
delivery
20.0
complications
49.2
51.3
with
Babies
64.1
pneumonia
Treatment
sought for
Pregnancy
complications
Babies
diarrhea
Gulbarga
Karnataka
Pvt.
Public
Pvt.
Public
34.0
54.9
39.2
56.8
39.5
68.5
25.9
56.2
37.5
54.5
34.3
20.8
50.0
25.0
60.8
19.5
55.4
21.3
28.2
72.3
23.4
56.5
26.0
70.4
21.6
with
Source: RCH Survey, 1998.
The information provided in Table 4 for selected three districts in
Karnataka show peoples’ preference for private sector services even in rural
13
areas.
It is widely known that private health care services are generally
concentrated in Towns and Cities and for utilising them one has to visit town or
City that will certainly prove more expensive. In addition to travel costs, private
health care services are relatively more expensive as they work with profit
motive. Even then, if the general public opt for them there must be something
wrong with the Public Health Care Services.
The description of some of the Institutions of Public Health Care Services
presented below provides a glimpse of the way they function in rural areas of
study area.
How Our PHCs Function
Gulbarga : “We visited a PHC according to pre planned schedule at 10.00
A.M. The PHC was locked. We were shocked to see the locked PHC
where it was prominently written - Working Hours - 8 to 12 morning and 3
to 5 evening.
After a wait for half an hour an ANM alighted from a jeep, came to
the PHC, took the key from the fixture of the Portico light and opened the
door. The whole building — newly built with vast vacant area around, was
stinking with smell of the toilet. We were told that the water supply to the
PHC has some problem since a week and even though the MO has
written to Panchayat office (which is responsible for water supply) no
repairs has been carried out. Later, when we met the Village Panchayat
Chairman and other members we learnt that they are not aware of it.
The Medical Officer was on leave as he was getting married.
Arrangements were made for a substitute to the MO to take care of
patients. He came around noon and reported that he is on a contract
basis appointment’ and as such has no control either over staff of his PHC
or over of the incharge PHC staff.
The ANM who opened the door reported that they were informed by
DHO about our arrival and the staff was asked to be present at PHC in the
morning. When asked at what time the PHC starts every day she said
around 10to11 o’clock as it is located at an inconvenient place and getting
public transport is very difficult. On an average about 10 to15 out patients
come for consultation when PHC remains open. Often people are not
sure whether PHC is open and prefer other sources for health care when
needed”.
The PHC is constructed at a distance of about two kilometers from the
village. It was constructed at this place because a resident of the village donated
this land for PHC. On completion of the construction the old PHC building in the
U-3
14
midst of the village was shifted to the new building and with this the problems
started for the people who needed health care services. The distance from the
village to PHC has to be covered by private jeeps that operate in the village. No
sick person would prefer to stay or no woman would like to deliver or undergo
sterilisation here because of insecure feeling. It is isolated building and scary at
night.
The community members reported that the old building was very
convenient and the then Medical Officer was staying in the village for long till he
was transferred. The new M.O. travels from Gulbarga a distance of about 30
kilometers and often he remains elusive.
The number of out patients visiting
PHC, as a result, has drastically come down. The location of the PHC is also
held responsible by the staff members to be irregular to their work and people
are not sure whether the Doctor has come or other para medical staff is present
in the hour of their need. Naturally they prefer private health care services that
are ensured any time. It was not surprising that during April 2000 to December
only 6 deliveries were conducted in the new building and the rest 300 were at
home.
The above noted observation is not an isolated case. Out visit to another
PHU in Gulbarga district and Community Health Centre and a PHC were similar
as depicted below:
The Research 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 sterilised women waiting (who had
come from different villages). One of them had developed complications
and was advised to go to Gulbarga for consultations by Head Quarters
ANM.
The Head Quarter ANM who is supposed to provide care to the
sterilised women had gone on leave as her husband seriously took ill and
she admitted him in a hospital in Sholapur. The MO had not come to the
PHC for a week without any reason nor informed any authority like Taluk
Medical Officer. He 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 expressed
15
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 appeared to be committed and honest also
expressed his helplessness regarding the verification of drugs in the PHU
as the Pharmacist never met him nor showed the stock during his last
three visits.
Our visit to another PHC situated at a distance of about 60 kilometers near
Maharashtra border was also disappointing. The PHC building was locked and
the only person present there was an Attender who could not explain why the
PHC was locked on a working day. The Research Team tried to contact the
Taluk Medical Officer on phone but the only phone in the vicinity was not working
because of power failure. The exchange functions only if there is power supply
as they do not have battery back-up.
The Research Team decided to visit a Community Health Centre situated
in a Taluka place about 20 kilometers from the PHC. The CHC was an apology to
a health centre. There was no water supply and no toilet. The Medical Officer
present reported that he lives in the Quarter of CHC but quarters also do not
have water supply nor toilets.
He uses the toilet in the inspection bungalow
situated near by.
Our prolonged discussion revealed that the CHC has several problems
indented drugs are not supplied. The new building constructed to improve the
facilities to the clients has remained unused during last five years because of
some legal problem. It was reported that there is lot of political interference in
posting of staff, their transfers, etc. which is hindering the functioning of CHC.
Can this CHC under such circumstances, be considered as first referral hospital?
The Research Team went to another PHU situated in a remote place.
One has to cover about 35 kilometers of which about 10 kms distance was to be
covered by jeep because of bad road. The PHU was locked and an Attender
was sitting outside with some tincture iodine and cotton to treat some wounds of
people (for a fee of course) who may visit the PHU. He opened the building - a
newly constructed one. The ANM had gone for a shandy to buy few necessities
but the Medical Officer had kept a leave letter in the attendance register of the
‘t-5’
16
PHU. In case some visitors like us come there they should know that he is on
leave. The MO travels from Gulbarga and naturally he would not like to take the
hazardous journey every day.
But the village residents told that the MO tells
them that he has several villages to visit and he cannot come to this village every
day naturally. The Medical Officer and other staff were informed well in advance
of our visit.
The poor impression that we had about the Public Health Care institutions
in Gulbarga was to some extent changed when the Research Team Visited
another PHC having two Lady Medical Officers and a male Medical Officer some
thing rare in the district. It was a husband-wife team and supported by another
LMO. The PHC was having child immunisation camp in the PHC on the day of
our visit - a weekly programme regularly followed.
There were some 10-15
children who had come from surrounding villages for immunisation.
The MO and his wife are from Mandya district working in the PHC for last
8 years. The staff position is excellent with only one or two vacancies. He has
been a committed officer that naturally has lot of impact on para-medical staff.
Every week the ANMs send blood smears for testing to the laboratory that keeps
the MO informed about their visit to the households in the allotted villages.
Surprisingly he was aware of high IMR in his PHC area and was systematically
collecting details of each infant death from the ANMs. Based on this information
we estimated IMR in the range of 60 - 70. Main reasons reported for IMR was
prematurity, pneumonia and low birth weight.
The average number of out
patients visiting the PHC was in the range of 50 - 60 every day. Since the MO
and his wife were residing in the quarters, their services were ensured for 24
hours to the needy people.
Our visit to 3 sub centres of this PHC was also
valuable as the ANMs were on their routine - one was attending a delivery,
another was conducting an Antenatal Care Camp (ANC) in the sub centre village
and the third had just returned to her sub centre quarter after completing
immunisation camp in a village. The decentralised way of functioning - ANMs
immunising children in their village, ANC camp in a sub-centre village itself with a
Lady Medical Officer present and attending a delivery case was very surprising in
‘t-G
17
the background of our experience in other health centres.
It reduced the
pressure on PHC resources and only emergency care was provided there.
There was a resemblance of quality of care and its access was ensured to all.
We were told that the local community served by the PHC is very poor and
depends only on Public Health Care services.
The PHC staff, under the
circumstances, thought that they have to discharge their responsibility to the best
of their abilities and it was visible.
But such PHCs are very few in Gulbarga
district.
An effort will be made here to highlight the way Public Health Care
Services are delivared in Udupi - an advanced district. Our visits to randomly
selected Primary Health Centres, Community Health Centres and Sub-Centres
were a contrast to our observation in Gulbarga district.
“We arrived at this PHC, without prior intimation, at 9.30 A.M. We
were surprised that the PHC was busy functioning - MO, Lab Technician
and other staff were attending the patients. On an average there are 40 50 patients a day. The young MO here is appointed on a contract basis
but is very regular to his work and fully committed.
The PHC building though old is very clean. The MO’s chamber had
privacy for patients. It had a clean wash-basin, running water, soap and a
clean towel. The toilet was also clean. All the records were up-to-date
and well maintained. There was telephone connection and it was working.
The PHC had displayed prominently at the entrance that if any visitor to
the PHC had any complaint on its functioning they can get a free post card
to write the complaint which they can mail to the concerned authorities
whose addresses were mentioned in bold letters.
The MO reported that the drugs supplied to him are of very good
quality and adequate. The drugs that private 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 that will enhance his
knowledge. For this, he goes to a Private Hospital in the night-not for
earning more money but to improve his understanding”.
18
The Research Team’s visit to a Community Health Centre in Udupi district
was equally pleasant.
“We reached this Community Health Centre by 10 A.M. The
Medical Officer, and his two colleagues LMOs were busy attending the
patients. The CHC building was old but well maintained. Regular water
supply, clean toilets, telephone and busy staff all indicated the good health
of the CHC. There was a solar water heater.
The Medical Officer had joined recently and he informed that as
soon as he joined he sent letters to all Panchayat officers in his jurisdiction
informing them that he has joined and is staying in the quarters of the
CHC and available for consultation 24 hours. Our visit coincided with
Christmas and some staff had taken leave for the festival. The M.O.
called them on phone and instructed them to reach CHC as soon as
possible to meet the visitors. To our surprise those on leave arrived within
half an hour indicating the command of respect the MO had on the staff
and their attitude to work”.
The number of out patients visiting CHC varies between 60-70 a day but
only 35 deliveries were conducted at CHC and 6 at home by ANMs during April
2000-December 2000. An important reason for this is plenty of Maternity Homes,
Mission Hospitals that have been established in rural areas and evenly
distributed in the Taluk that has improved accessibility enormously during last 7-8
years in the area. These services are available either free or at an affordable
price.
In order to have some insights in the delivery of Public Health Care
Services we visited a village by crossing a river just to see how effective is the
outreach services. When we visited the village most of the men folk had gone
out for fishing. We enquired with the women how they manage emergency
deliveries at night? We were surprised that just a telephone call to Manipal
Hospital will ensure an Ambulance, which will take the pregnant woman to their
maternity home for safe delivery. During last one year very time they had called
the number, had been ensured the service without any delay.
The choice of service and assured service have certainly made a big
difference to the health status of people of Udupi district as compared with
others.
The choice is judiciously made by the educated well-informed public
19
here.
The Public Health Care Services are confronted with the problem of
resources required to upgrade their technology to compete effectively with
private sector which they find it difficult. But certainly they are serving the poorer
sections given the constraints, to the best of their abilities, efficiency and
punctuality are part of the public health care services.
Our intensive discussion with ANMs revealed that general public is well
informed about health care. They reported that if there was power cut on the
previous day to the immunisation day,
few mothers would prefer to go to a
private doctor for immunising their children doubting the potency of the vaccine.
ANMs will have tough time to convince others that the potency of vaccine is well
assured in the new type of refrigerators that they have. On the other hand we
saw in Gulbarga, the thermometer showing the temperature of the refrigerator
was not working for several days, but the medical officer had recorded the
appropriate temperature in the diary every day. Neither the public was aware of
this nor the authority entrusted with the responsibility of ensuring potency of
vaccine bothered about it.
Public Health Care Services in Tumkur district presented a moderate
scenario - not comparable to Gulbarga or Udupi. Our visits to several institutions
in different parts - Madhugiri, Gubbi and Kunigal revealed the following.
“We reached this PHC in Tumkur by 9.30 A.M. 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, drunkards squatted in the
compound creating scare among inmates (Delivery cases).
All the female health workers complained that they are not supplied with
the eligible couple registers for several years, chlorination of wells,
spraying of DDT has been stopped since three years. The ointment and
paracetemol supplied to them is inadequate - does not last even for 4
months but people demand for at least these minimums during their
rounds to the village.
20
It was surprising with all the problems the PHC was still attracting patients
as seen by the large crowd of outpatients. There are 30-40 patients a day
on an average visiting the PHC for consultation and treatment”.
Our Research Team also visited a Community Health Centre where new
building is coming up under KHSDP at a huge cost. The Medical Officer was
busy attending patients.
His two colleagues Lady Medical Officers were also
equally busy in the old building. The CHC does not have a Gynecologist or a
Physician. About 40 - 50 deliveries take place and 20 per cent of babies born
there are reportedly under weight. CHC has facility to test blood for malaria only.
For hemoglobin and RH-ve patients are advised to go to Tumkur or to the
Medical College Hospital on way to Tumkur.
Rather than being a referral
hospital to other PHCs in the Taluk the CHC is just like any other PHCs in terms
of facilities, equipment etc. But the Medical Officers were working here for last
Housing facility to the staff is available.
Water supply is limited.
However, there was Telephone and it was working.
Tuberculosis is a major
10 years.
health problem followed by Asthma and half of the out-patients have been found
to being suffering from these two health problems.
The three scenarios presented above reveal several interesting features.
1)
People in Gulbarga are placed at a most disadvantaged situation, as they
have to depend mainly on public health care services for all their health needs.
But public health care services are most unreliable.
The doctor may not be
there, the PHC may not open the doors because of several factors and resources
spent by clients to reach the PHC/CHC - in terms of time and money may be a
waste.
The private sector is small, not very committed to serve the
disadvantaged section of the society (for example a well known private maternity
home charges Rs.5,000/- for very poor women for a delivery or for a complicated
delivery minimum of Rs. 15,000) and does not enjoy public confidence.
The
results are very clear the district has remained health poor.
2)
As a contrast Udupi district has efficient public health care services
though uncomparable with private sector in terms of resources, equipment,
technology and their social commitment. The community is highly educated and
50
21
can make informed choice.
The personnel of public health care institutions
regularly attend to their responsibilities to the best of their abilities within
constraints of the system in which they work.
Public is well aware of it and
perhaps it was only in Udupi district that we did not hear a single complaint
against public health personnel or institutions.
In this district people are very
fortunate to enjoy health care services of public/ private sector by choice.
3)
The public health care services in Tumkur district are not as efficient as in
Udupi nor as bad as in Gulbarga. Health care institutions function regularly and
provide services often at a price. As we proceed the role of corrupt practices in
the delivery of services will be clear.
People in rural parts of Tumkur were
unhappy with the way PHCs and the sub-centres are functioning that has lead to
Mushorroming of quacks every where to exploit the gullible public.
But still
people can avail some health care services from PHCs, at least prescriptions
though not medicines or treatment. Most of the ANMs regularly make rounds of
villages, take blood smears for testing and conduct home deliveries. The private
sector, though not very prominent in the interior parts of the district has made its
presence felt in Tumkur town and to a lesser extent smaller towns. A normal
delivery in a well established maternity home for a rural woman will cost about
Rs.3000 and a complicated delivery from scissarian section will cost about
Rs. 10,000 (considerably lower than charges of private nursing homes in
Gulbarga). A rough estimate of a normal delivery in Primary Health Centre would
cost about Rs.700-1000. Generally it is believed that public health care services
are free and the estimate given above was arrived by averaging costs reported
by a representative ANMs in the two districts viz. Gulbarga and Tumkur. In this
background we will present the outcomes that emerged from the data collected
through household. The household survey was conducted in 31 villages selected
from the villages covered by the sub-centres presented in Table 5.
22
Table 5 : Selection of Villages
District
Taluks
PHCs
SCs
FGDs
Udupi
2
8
26
6
No.of Village
covered in HH
Survey
15
Tumkur
3
6
41
5
8
Gulbarga
Total
3
8
8
22
20
87
5
16
8
31
Section II
The Household Survey
The household survey covered 82 households from 31 villages in 3
districts selected from different sections of the society focussing more on
deprived sections like Scheduled Castes Tribes or isolated houses situated on
the outskirts of the villages. The number of villages in Udupi is large compared
to other two districts because of the unique village settlement pattern in the area.
We also made special efforts to identify isolated areas within the jurisdiction of
PHC/SC like a village which can be reached by boat only from the nearest road
or a poor tribal belt not well connected by road transport etc.
The selected households for the survey of belong to (24 per cent)
advanced castes like Bunts, Gowdas, Lingayats, Reddys and one or two
Brahmins.
Scheduled Castes and Scheduled Tribes (40 percent) and other
Backward Castes (OBC) constituted about (27 percent). There were 5 percent
Muslim households and 4 percent of the sample belonged to Jains. 12 of these
82 households (15 percent) were headed by females (Table 6).
The questionnaire constructed for the household survey was quite
elaborate consisting of 36 questions.
It was designed to provide insights on
peoples’ preferences for different systems of medicine, their belief in village
quacks, witchcraft, worship of temple deity, “Harake”, Mantra-Tantra and extent
of practice in case, there was a reported episode of sickness. There was also
an effort made to understand how the preference for a particular system of
pH- ICO
'11051 PCI
23
medicine is justified or reasons for preference.
Whether the decentralised
system which is unfolding slowly in the state has tried to improve the health care
services? Whether the respondents were able to voice their grievances against
poor public health care services in the 'Grama Sabha’ meetings in their village
during last 5 years? Respondents’ views - suggestions to improve the health
care services, if any, were also elicited. The elaborate questionnaire took almost
an hour to administer to respondents.
Table 6 : The Socio-Economic Profile of Respondents
Variable
Advanced
OB Castes
SC/ST
Other Religions
Total
Owned land
Owned TV
Tap/piped water facility
Udupi
3
20
9
3
35
_____ Total
Districts
Tumkur Gulbarga
8
9
1
1
12
12
2
2
23
24
10
10
18
19
11
14
Number
20
22
33
07
15
14
15
Percent
82
24.4
26.8
40.2
8.6
100.0
44
35
47
54.0
43.0
57.3
System of Medicine Preferred for Treatment
The heads of the selected households were asked when there is an
episode of sickness in the family where do they generally go for treatment? The
responses are given below:
Table 7 : Preference for Treatment by System of Medicine
SI
N
o
1
2
3
4
5
6
Variable
Udupi
Allopathy - Govt.
Allopathy - Pvt.
Allopathy Govt + Pvt.
Quacks
Indian system of Medicine
Combinations of 1 to 5 and
witch craft, etc.___________
Total
9
7
10
District
Tumkur Gulbarg
a
4
2
2
9
5
2
4
5
_____ Total
Number Percent
11
4
1
7
6
09
18
17
09
12
17
35
23
24
82
5Z
11.0
22.0
21.0
11.0
14.6
20.4
1000
24
The contents of the Table 6 needs some clarification. SI.No. 1 shows on
exclusive dependence on allopathy medicine at public health care providers,
SI.No.2 on private practitioners of allopathic medicine and SI.No.3 indicate
dependence on allopathy - provided by public and private institutions. SI.No.4
indicates treatment by
unqualified persons in any system but practicing
allopathic system like giving pricks for any ailment and treating with other
medicines such as tablets or liquids. The patients reported that they are aware
that the 'Quacks’ are not qualified to practice but they are conveniently located
and their services are ensured round the clock at an affordable cost.
In case
there is a chronic disease or serious problem they will not take any risk with the
patients but advise them to go to a Private Clinic with which they are familiar or
often they may accompany them to the clinic.
Indeed not a single person in
either focus group discussion or in household survey reported any complaint
against the 'Quacks’ for contributing additional problem to the sick and suffering
by wrong treatment.
Looking at the small sample size of people availing the
services of these unqualified practitioners the outcome should be cautiously
interpreted. But what is surprising is the Medical Officers, para-medical staff of
Gulbarga and Tumkur districts are quite well aware of the presence of Quacks
around them. They just casually mentioned about their presence as if it is not an
issue of any consequence. In fact, presence of 'quacks’ around Public Health
Care Institutions itself is a strong indicator of poor accessibility of health care
services and also the poor quality of care provided by these institutions.
The data presented in Table 7 fully supports the earlier discussion on the
study area. It clearly brings out that 54 percent of the respondents exclusively
rely on modern allopathic system for relief when there is a sickness episode in
their household. Indian system of medicine which is showing some presence in
Metropolitan cities and large towns hardly has any presence in rural areas of the
state except in Udupi. It was reported that rural parts of Udupi still have some
practicing Ayurvedic Pundits widely known for their curative skills for even
chronic ailments. Homeopathy was not found in all the three districts.
25
The Table also brings out that only 11 percent of respondents reported to
have availed Public Health Care services reflecting strongly on the quality of care
provided by them.
Given the graphic description of how our Public Health
Institutions function the findings are not surprising. It also is to be noted here that
people in remote villages feel often 'resigned to their fate’ and resort to witch
craft, Yantra-Mantra because of poor accessibility to any health care whether
modern or traditional. This was more so in Gulbarga where public health care
services are very poor and private services are unreasonably expensive.
In
Udupi it was revealed that 'Bhoota’ belief is still prevailing in some pockets in
rural areas and after paying to Bhoots’ they go to a health care provider for
treatment hoping to be cured fast.
It should be mentioned here how an Ayurvedic Hospital in a village in
Kunigal taluk is functioning. It was placed in a rented room in the village and at
the time of our visit had remained closed for the last 7 months as the Doctor was
transferred and replacement never arrived. What will happen to some medicines
stored in the clinic? None in the village were aware. The historical approach to
indigenous system in policy and allocation of resources has not only lead to its
near disappearance but more importantly deprived the only choice the people in
rural areas would have had in times of their need. The late realisation of the loss
and urban elites’ experience with over drugging and abuse of anti-biotics is
reflected in the half hearted efforts made to revive the system. As an excellent
piece of research during early seventies showed, even the few indigenous
practitioners by then had almost switched over to modern allopathic system in
their mode of treatment. This is reflected in 60 percent of respondents saying
that modern allopathic system provides quick relief and appropriate diagnosis of
the disease, treatment is given by professionally trained personnel and higher
chances of relief and cure.
Those 40 percent who ‘otherwise’ reported that there are harmful side
effects and costs involved are high as such poor cannot afford thought that
modern health facilities are more easily accessible to rich people.
It was
interesting to observe this proportion of respondents was very high in Udupi (40
26
percent) and only 20 - 25 percent in Gulbarga and Tumkur districts.
When
specifically asked whether the modern health care facilities are within affordable
costs of rural poor only 44 percent reported that they are beyond their reach.
We tried to assess respondents’ views on indigenous system of medicine
specifically.
Do they still think it is popular these days?
An overwhelming
majority answered in negative as the diagnosis is not competent and therefore
people are loosing faith in the system.
It was also revealed that competent
practitioners of indigenous system are not available now.
In this background
whether the government should support indigenous system of medicine so that
rural poor will have accessibility to it?
Surprisingly 85 per cent of the
respondents said 'no'. Perhaps it is an indication that during last five decades
the society has enjoyed the modern system of health care - however inadequate
it is or inaccessible it is. People believe it is a good system though costly and
why rural poor should have indigenous system for them? Because it is cheaper?
How respondents perceive the role of village quacks? Do they think that
quacks are popular in rural areas? Not a single respondent in Udupi said that
there are quacks in their district or their vicinity. In Gulbarga 83 percent said that
the village quacks are very popular in their area as their services are ensured
round the clock, people can afford the cost of their treatment, diagnosis is based
on simple methods and the medicine is supplied by them or is available locally
and easily. Their diagnosis is based on their past experience.
The presence of Quacks in Gulbarga district is justified on several grounds
by the people and we believe the single most important ground is the failure of
the public health care services in rural areas where there is no alternative to
people in the hour of their need. So naturally they not only justify the presence of
Quacks but also appreciate their services.
Similarly in Tumkur 25 percent of respondents noted that Quacks are
popular in their area for mostly the same reasons reported in Gulbarga. These
views suggest clearly that quality care if made accessible to the public whether in
government institutions or in private sector institutions, as it was observed in
£6
27
Udupi will ensure elimination of Quacks in the area and people look forward
always for better services.
In the household survey 82 percent of the respondents reported that the
belief in ‘witchcraft’ is fast eroding while 6 percent said that it is still strong among
some section of population in the society and also is practiced by them.
But
undertaking a pilgrimage, arranging special pujas in the temples or practice of
‘harake’ as a way of getting relief from a health problem is still there in the society
as reported by 48 percent of the respondents. The rest 52 percent reported that
with the introduction of modern health care system such practices are slowly
disappearing. Few respondents said that such practices are becoming more and
more expensive and like health services only rich can afford them. Even a ‘puja’
in a nearby temple known for providing relief to people will cost minimum of
Rs.50 and travel and other cost if added, it becomes very expensive for poor
people. It was also revealed that the priests who perform the ‘pujas’ advise their
clients to seek health care services also for quick relief.
In other words, still
about half the population has faith in healing through worship or prayer and there
are indications that often they preceed resorting to modern health care services.
The data reveals peoples belief in worship, yantra or mantra in curing
neurological problems epilepsy and particularly childhood related diseases such
as Balagraha. Similarly it was widely reported that for ‘jaundice’ traditional herbal
medicines and for bone fractures the traditional bone setters are considered the
best as compared to the treatment in allopathic medicine.
It is often argued that the concept of germs and infections is still to
percolate among the populations in the traditional societies who widely believe
that diseases are the outcomes of curse of God or the sins that people commit.
Such a belief system often hinders the utilisation of modern health care services
or delays opting for them leading to more complications.
About 54 percent
respondents believed that chronic or incurable diseases afflicting a person are
result of his / her sins committed or curse of the God. Such strong beliefs can be
eliminated only with quality care made available to all particularly to the deprived
sections.
28
Peoples Perceptions of Public Health Care Services
Respondents were asked whether the female health worker ANM visits
their village regularly as per her schedule? Only 27 percent reported that she
visits their village once a week, 34 percent said she comes once a month or
twice a month and 30 percent reported that she never visits their village. About 9
percent reported that she comes occasionally and Enquirer how they are? The
general impression is that ANMs who are considered as back-bone of rural
health delivery system are not able to perform their job because of several
factors like inadequate housing facilities for them in the village, poor transport or
bad roads etc.
It would be in order to examine the role of these important
personnel to ensure full utilisation of their services to the benefit of rural
population.
If the ANM visits the village does she visit all households irrespective of
caste, community or prefers visiting selected households who are dominant in
the village? 55 percent of the households reported that generally she visits all
households indicating that there is preferential areas where she invariably pays a
visit and poorer sections like SC/ST dominant areas are visited occasionally.
The questionnaire had a list of services the ANM is supposed to provide to
the village people and respondents were asked to assess ANMs’ performance in
providing these services.
The data in Table 8 reveals very clearly what was discussed earlier
regarding the delivery of public health care services in the study area.
The
majority of respondents are either somewhat satisfied or not at all satisfied with
the poor quality of services. The response in Gulbarga is in conformity with the
description of PHCs/Tics presented earlier. Respondents in Udupi who are used
to avail private health care services, still think that public health care services
delivared through ANMs are rated relatively better than the other two districts.
29
Table 8 : Peoples Assessmen of ANMs Work : Fully Satisfied
SI
Services
Udupi Tumkur Gulbarga
Total
No
(No)
(No)
(No)
Number Per
cent
1
Pregnancy care
20
10
1
31
40.2
2
Attending delivery
17
7
2
26
33.8
3
Immunisation of children
20
12
3
35
45.4
4
Family Planning Services
11
11
1
23
30.0
5
Motivation for Family
Planning
5
6
1
12
15.6
6
Treating minor ailments
14
3
2
19
24.7
7
Attending
emergency
calls
14
4
1
19
24.7
8
Educating on hygiene
3
6
1
10
13.0
9
Treating diarrhea
3
4
08
1
10.4
10 Treating ROH problems
4
4
1
09
11.7
11 Educating on STI/AIDS
3
4
1
08
10.4
12 Referring to PHC/CHC
6
7
2
19.5
15
13 Giving simple medicines
15
4
1
20
26.0
like Aspirin____________
Total
32
21
24
77
The household survey was conducted in the villages served by the sub
centre. While sub-centre was located within a distance of 7-8 kilometers on an
average PHC was situated at a longer distance. The respondents were asked
whether they have easy accessibility to PHC in terms of its distance and
transport facilities? About 73 percent of all respondents reported that it is easily
accessible - 91 percent in Tumkur, 74 percent in Udupi and only 54 percent in
Gulbarga. As reported earlier our selection of tribal belt in Udupi with poor roads
and transport facilities and villages to be reached by boat around the coast are
the only places that have some problem in the district. But village surrounded by
water can call private health facilities on phone and reach the road by crossing
the water to avail the needed services. There is problem in Gulbarga with roads
and public transport that hinder accessibility.
During past 3 months to the survey 40 percent of households reported that
some one in their family had visited a public health care facility and 40 percent of
those visited were fully satisfied with the services. The proportion reporting fully
30
satisfied was 64 percent in Udupi 48 percent in Tumkur and only 4 percent in
Gulbarga.
The survey also tried to assess peoples satisfaction regarding the
functioning of the PHO situated nearest to their village specifically regarding
regular availability of Doctors, Para medical staff, availability of specialist
services and availability of drugs as presented in Table 9.
Tab e 9 : Assessment of Functioninc of PHCs: Percent Fully Satisfied
Udupi
Total
Tumkur Gulbarga
SI
Number
No
45.0
78.5
52.6
Regular availability of Doctors
1
Availability
of
infrastructure
2
5.6
10.5
7.1
facility
48.0
75.0
68.4
4.2
Staff co-operation
3
9.9
26.3
Specialist treatment availability
7.1
4
39.4
52.6
60.7
4.2
Treatment is effective
5
40.8
57.1
47.4
16.7
6
Privacy to patients
25.3
50.0
21.0
Attending
emergency
care
7
22.5
50.0
10.0
12.7
Adequate drugs available
8
The responses noted in Table 9 are self explaining. The proportion of
respondents fully satisfied with availability of Medical Officers’ services, effective
treatment, staff co-operation with patients, privacy to patients is relatively high in
Udupi as repeatedly pointed out earlier followed by Tumkur.
Not a single
respondent in Gulbarga reported the availability of Medical Officers’ services,
availability of specialists treatment and emergency care that needs serious
attention and fully supports the reported observations presented earlier.
It was surprising that 50 percent of respondents in Tumkur and Gulbarga
said that public health institutions staff expects money for any service they
provide particularly from poor people.
But in Udupi district not a single
respondent complained against the staff being corrupt on the other hand they
had sympathy towards them as they perform their job with several constraints to
the best of their abilities.
Go
31
Section III
The Focus Group Discussion and their Outcomes
The Focus Group Discussion (FGD) is a technique that is found valuable
in developing insights in any problem area where the survey methodology fails.
It helps in identifying existing social norms and practices because views
expressed openly and supported openly by majority is generally expected to be
more representative and legitimate from a public point of view than those
expressed in individual interviews.
collected through
FGD
However, it is to be noted that the data
need qualitative
analysis — a
characteristic of
anthropological methodology, in other words, it is mainly descriptive.
Generally FGD are conducted in sessions where a small number of
persons - 5 to 6 discuss about topics of relevance under the guidance of one or
more moderators.
Generally there will be a sheet of guidelines with the
moderator who will initiate and lead the discussion. In such situation one has to
ensure that one group does not dominate and force their view on other group not
so influential. The quality of analysis will depend heavily upon the unbiased use
of information and verbatim at appropriate places to highlight an important issue.
The present study was conducted in 3 districts of Karnataka.
Specific
data was collected from 22 primary health centres selected from the three
districts. For conducting FGDs it was decided to visit villages distributed in such
a way that half of them are situated closer to the PHO and other half at a longer
distance. Totally 16 FGDs were conducted. Our plan of having smaller selected
groups of women belonging to Scheduled Castes and other advanced castes to
elicit their views on the functioning of the Public health care system often met
with problems. Generally our FGDs soon turned out to be street corner meetings
and some time ‘mini gram Sabha’ attracting large crowds of 50 - 60 persons.
The major issues listed in the agenda was some societal factors related
with general health of the people — particularly age at marriage, early
motherhood, breast feeding habits particularly providing cholostrum milk to the
baby and taboos on food during pregnancy and why in the interest of their
daughter/daughter-in-laws’ health they should change the age old practices?
Gt
II
32
The societal factors are directly linked to the ANMs and PHCs function
that flow through IEC activities, mothers meetings, educating adolescent girls
and motivating for adopting spacing methods that by itself would improve
women’s health and survival and also the way people perceive the need for
rethinking based on their observations.
The last part was concerned with the delivery of health care services by
the pivotal institutions of public health care - PHC. Are they able to get relief in
their pains and sufferings in emergency?
The outcomes will be presented first by districts that have wide
differentials as shown earlier and their perceptions in the community that
emerged clearly during the FGDs.
FGDs in Gulbarga
There were five FGDs in one was exclusively arranged for Scheduled
Caste women in their colony which included 10 women and the rest were group
of men as large as 25-30 persons of different age groups and caste
compositions.
As noted marriage is a complex social and economic issue which is more
complicated by the arrival of dowry system. While marriages within kinship is
common in rural Karnataka, relationship has not helped to reduce the costs
involved in marriages.
People reported that even when the would be bride
groom is known, marriage will be pre-poned or postponed depending on the
harvest.
Even those who do not own any land will be economically relatively
better off during good harvest period. The least important factor in deciding the
marriage is the age of the girl.
It was revealed by all irrespective of caste
affiliations and for them marrying off the daughter is important. Only change that
has taken place is that most of the marriages now are post puberty marriages.
Very small proportion of people in Gulbarga are aware of the existing legal
provisions regarding marriage of girls or boys.
The marriage is consumated soon and the parents in-laws expect that
their daughter-in-law will soon bear a child to prove her fertility. If she fails for 2-3
33
years there will be talk of another marriage for the boy.
They have neither
resources for the medical examination of the boy or girl for their failure but easy
solution is ready to accept. There will be proposals. What about the health of the
young girl if she is mother at 16-17 years? The opinion was for generations it is
continuing and that itself is an indication of poor policy interventions.
Similarly there was strong opposition to give just born babies cholostrum
milk which the baby cannot digest easily and will develop ‘stomach problem’. If
breast milk is fed after 3 days babies will be growing healthy.
As reported by the ANMs they find it difficult to change the age old
-•
practices deeply entrenched in the society. But their efforts can be intensified to
be more effective. During the discussion there was interest among the group to
understand the intricate relation between marriage, pregnancy, child birth and
survival of woman and child. Generally ANMs talk to eligible women regarding
these issues but decisions are often taken by the elderly in the family or in the
neighbourhood who is well versed with traditional practices. There is, therefore
need to enhance the quality of IEC and direct it to the community as a whole
rather than only to eligible women-currently married in child bearing ages as it is
observed now.
The FGDs voiced their anguish at the way public health care service
delivery is carried out in their area. ANMs visits are very rare - on the contrary
they have to run after ANM requesting them to attend a delivery. There were
some good words also for them but were rare. Even the poorest of the poor try
to present something in return to the ANM on a birth in the family. But there is no
assured service that result in calling the village untrained dai who fortunately is
available any time. Why do they not go to PHO? People were surprised at the
question. There is no body in the evening or night and even during day we have
to visit a couple of times to consult the Doctor. They say that we have to bring
the medicine from a particular shop only that creates problem even if we have
arranged for the money. Our family will be dislocated if delivery is conducted
away in PHC. There seems to be a major problem to solve this riddle. The PHCs
63
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34
should be able to create confidence among the people that they can take care of
child birth to improve the situation.
The peoples’ perception regarding home visits to be carried out by the
ANM is worth noting. In a FGD a village Panchayat Chairman and a large group
of village residents were surprised when asked about their ANM visiting their
homes to enquire about health of members. It was revealed that ANM is also like
a Medical Officer and the needy have to meet her rather than she visiting every
household in her sub-centre jurisdiction.
The Village Panchayat Chairman, a
muslim woman, innocently asked “who should tell her about her responsibilities?
She thinks she is a big officer and we have to beg her if her services are required
and unless we pay she will not conduct any delivery.
But immunisation of
children is free and occasionally pregnant women get some injections”.
Scheduled Caste women had special grievance. They brought out during
the discussion that even when they request for injection (TT) or tablets (IFA) they
get if they are available with her.
Their request to the ANM often receives
arrogant stock answers like “I do not have now” or “come to PHC to meet the
Doctor”.
Gulbarga FGDs also brought out the irregular attendance of Doctors to
PHCs and PHUs. One FGD in a remote village which we could reach by a jeep
only resulted in collecting 6 patients suffering from jaundice which has become
endemic in the village. In the absence of Doctor and lack of resources to go to
Gulbarga for treatment, they have found a traditional cure for their problem. It is
reported that they “grind some herbs, put it in a Kambli (woolen rug) and make
the patient forcibly smell it for three days. It will result in sneezing for two days
and there will be green discharge through the nose. This should continue for 3
weeks. The patients will either get cured or will have to be admitted to hospital
because in 3 weeks any strong man will become week after continuous
sneezing. Similarly there is some medicine for snake bite and those lucky ones
will be cured with this herbal treatment”. The whole crowd looked sick to us. The
village had a PHU that opens occasionally and if there is stock of drugs patients
get treatment.
It was shocking that villagers consider the staff as 'Danda-
35
pindagalu’ title of a popular serial in a TV where the characters are a heavy
burden on parents.
The group expressed their unhappiness with the way immunisation
programme including 'pulse polio’ are conducted. Those who want can take their
children and many do not bother as there is hardly any effort to ensure
immunisation of all children.
The five FGDs in Gulbarga had simple suggestions to improve the health
care services which are complicated in implementing.
1)
Medical Officers should be regular to PHC during at least fixed
hours.
2)
There should be a Lady Medical Officer in some central PHC that
can cater to other PHCs.
3)
Drugs should be stored in PHC as there is no alternative but to
travel a long distance for a pharmacy, often to Gulbarga to get the
medicine prescribed.
4)
ANMs should be more active and provide them information.
Focus Group Discussions in Tumkur
The societal factors affecting the health of the women and children though
similar in Tumkur are not that intensive. The five FGDs were clearly divided in
two groups - one small that argued that if postponing the marriage of daughters
is going to help improve their health it should be postponed. The other group
arguing that as it is marriage of daughters is becoming more and more difficult
because of rising costs. The age at marriage is going up any way and may cross
even the legal age at marriage of boys and girls. It is observed that educated
girls are marrying late and as education increases automatically marriage age
will rise.
In order to reduce the risks associated with early mother hood the
discussion centred around their past experience. “So far we were told to have
two or three children and opt for female sterilisation. The health workers rarely
talk to our women about spacing methods and we are hearing the advantages
65
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36
first time”.
Community will accept good advise of ANMs if effectively
communicated.
But the problem arose when discussion reached the issue of PHC
functioning. The small groups initially participating sent a word to several people
who had some health problem and were not treated well even when they paid -
little less than what was demanded. One middle aged man who was suffering
from a wound reported that the PHC doctor took Rs.40/- for dressing it. He spent
during last week over Rs. 100/- but still not cured properly. The discussion also
brought out that the PHC Medical Officer is continuing here for the last 12 years.
The newly appointed Lady Medical Officer came for one day and disappeared
not to be seen as the MO ensures that no Lady Medical Officer joins here which
will reduce his income. He charges Rs.500 for his services to conduct a delivery
and additional Rs.500 for ‘drugs’. So a minimum of Rs. 1000/- is needed for a
delivery to be conducted in PHC.
The FGD also brought out the good things about Private practitioners in
the Taluka place. Dr R cured an old man of 70 years (brought during the
discussion) in just Rs.20/- which was not cured by PHC doctor who took Rs.400
and said that he is too old to cure and will die any way. The old man’s wife who
narrated this in the FGD said that “every house in the village has a terrible story
to tell about the MO of their PHC.
happily”.
Unless he is sent out people cannot live
The group also reported that Medical Officer prescribes more
medicines than needed and more expensive medicines that few can afford. He
also insists that medicines have to be purchased from only one shop that
charges more money from illiterates.
While many things discussed could not be verified for truth but it was felt
that participants were not trying to ‘make-believe-stories”.
They were serious
and looked honest in saying whatever they wanted to.
While the FGDs in
Gulbarga suggested with one voice every where that government ensure Medical
Officer in the PHC during fixed working hours Tumkur presented a totally
different scenario. Many Medical Officers were regular, staying in the quarters
but their services were accessible to only those who paid for it. The community
6£
H
37
was found helpless as the Medical Officers had very good relation with the
Chairman of the Village Panchayat and police as there are many medico-legal
cases and need full co-operation of each to benefit from them.
There were, however, 2 FGDs that appreciated the Medical Officers for his
social concern, his competence and co-operative nature.
On the whole there
was objective assessment by the people who said that their needs are simple
and government is spending resources which should be utilised properly. Who
should do it and how? Don’t they have responsibility? They were ignorant about
their rights and the avenues that exist for reddressal.
But Quacks who are found easily in every village were serving the
helpless poor who unfortunately have no access to public health care.
For example, ‘Shiva Shakti’ clinic which is in a village for last 6 years
provides health care services for just Rs.5/- and that too an ’injection’.
Many
Medical Officers insist that clients should bring their disposable needle and
injection and pay Rs. 10/- for his service charges. Compare this with the quacks’
service? Whether his care cures or creates more problem only time will tell. But
experience is that so far no untoward has happened either from Shiva Shakti or
two others in the same village.
Focus Group Discussions in Udupi
FGDs in Udupi did not attract large crowd like it was in Gulbarga and
Tumkur districts. But out comes of FGD were more appreciative of public health
services.
There was not a single complaint raised in any meeting as a total
contrast. On the other hand there were examples of Medical Officer of a PNC
taking a young tribal man who was suffering from TB to a well equipped special
hospital at his own cost and ensuring his full cure. The father of the boy reported
that “the Medical Officer must have spent about Rs.5,000 during last 6 months’.
People have realised that government has no resources to provide high-tech
health care services that private sector provides and they are available at
reasonable costs and poor can avail freely.
So why blame public health
services? They were happy that with all constraints the ANMs, MOs are doing
H
38
their best.
But the people would expect that PHCs should have X Ray facility,
services of specialists services like ENT, Physician and LMO / Gynecologists.
That would make the public health institutions more competent than what they
are now. Even if a person goes to PHO for treatment he may have to go to
private sector for some tests. So why not go to one place where you get fully
treated?
But the AIDs is spreading in the district very fast and there is need to
organise the services from private and public sector. The ANMs in Udupi and
districts like Dakshina Kannada, or Coorg where deliveries are mostly
institutional, should be trained to educate people in preventing the spread of
AIDs. The FGDs fully reflected these ideas.
Section IV
Summary of the Findings and Conclusions
The present study was conducted to understand peoples perceptions
regarding public health care services and indigenous health system in Karnataka.
For this three districts in the state viz., Udupi, Tumkur and Gulbarga that
represent three stages of development in peoples health - advanced, medium
and backward were selected. Further 8 taluks, 23 PHCs and 31 villages served
by those PHCs were selected for data collection.
The data was collected through a household survey in the selected 31
villages through a structured questionnaire. The hard data was supplemented by
qualitative data gathered in Focus Group Discussions conducted in the study
area. The analysis of the data is presented in three sections. The first, presents
the way our public health institutions function in the rural areas, second, the
findings from the household survey and last, the outcome of focus group
discussions. Before presenting the findings there is a brief background of the
health policy pressed in India since historical period.
Indigenous system of health care did not receive any attention during
colonial period. After independence India persued essentially the British policy
G2
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39
and the neglect of Indian system of medicine continued. But half-hearted efforts
to revive the Indian system and integrate them with modern system of medicine
are continuing.
The modern allopathic system of medicine brought in by the Britishers is
exorbitantly expensive by nature that many poor countries like India are finding it
difficult to manage financially. But the introduction of modern system of medicine
Allopathy has brought in enormous gains to the health of people in the beginning
the access to allopathic medicine was confined to urban elites and after
independence remarkable expansion has taken place to improve its accessibility.
The last five decades in India has witnessed impressive health gains as
measured by sharp decline in Crude Death Rates and Infant Mortality Rates.
The focus to the health of women and children in the strategy has proved
beneficial to them.
The wide differentials that exist in health indicators across states and
within states across districts by rural/urban residence, gender and social class
are alarming because despite all the efforts made to improve accessibility to
public health care services they are persisting.
The differentials and their
persistence raise the question of equity and accessibility.
The observed poor
indicators of health strongly suggest poor utilisation of public health care services
provided free. It can also suggest people are not utilising the public health care
services because they prefer other system of medicines provided by private
practitioners.
The findings of the present study are :
1)
The study area consisted a health poor district Gulbarga, a health rich
district Udupi and Tumkur district with medium health status.
2)
Public health care services in these three types of districts vary widely
and can be classified as good in Udupi, bad in Tumkur and worse in Gulbarga.
The graphic description presented provide good insights into the way the public
health care services are delivared in these districts and the outcomes measured
as Health Indicators.
st
40
3)
Poor quality of care and poor accessibility to care provided in public health
institutions explain to a large extent the existence and sustenance of Quacks unqualified health care providers who can cause enormous harm to the client
and legally they cannot continue their practice. In health poor districts like
Gulbarga and Tumkur they not only are thriving but also increasing in numbers
over time while in health rich districts they do not exist.
4)
The health policy persued for long has proved detrimental to the growth
and expansion of indigenous health care system in India. People in rural area
strongly believe that Allopathy system is better than other systems and prefer it.
They also think that “injections” cure faster and insist on it for any ailment.
5)
The encouragement given to Indian system of medicine looks is confined
to urban particularly in metropolitan cities and towns where the clients have a
choice of method. In the vast rural area public health sector is a major provider
and the choice is there for few with resources who can opt for private services.
6)
In the study area there was only one Ayurvedic Clinic which was closed
for past seven months before the survey team reached the remote place. The
villagers were not even aware whether it is going to be reopened soon or not.
They knew only that the Doctor was transferred and since then it is locked. But
people believe in indigenous system for certain types of health problems like
'Jaundice’ or
Balagraha’ etc.
systems are extremely rare.
However, reliable practitioners in indigenous
Udupi is the district where there is presence of
indigenous system of medicine. The Research Team heard several names of
Ayurved Pundits’ known for their extraordinary curing skills and abilities. In
health poor district like Gulbarga they are non-existent.
7)
Scheduled Castes and Tribes and population in isolated areas have
relatively more problems of accessibility even in health rich districts like Udupi.
In other districts the accessibility is still poorer for these populations.
8)
People perceive that public health care delivery system is inefficient and to
a large extent corrupt. The focus group discussion and the data collected in the
household survey bring out these issues clearly.
The focus group discussions
turned out to be something like 'Gram Sabhas’ where people vented out their
^0
J
41
anguish and sufferings. People who suffered at the hands of the public health
personnel were providing details of money demanded, etc. The meetings turned
out to be difficult to manage but strongly indicated the disenchantment of people
with public health institutions.
9)
The poor perception of people is reflected in poor utilisation of services
from Public Health Institutions in health poor districts.
10)
Public health care institutions suffer from poor infrastructure facilities in
health poor districts.
In Gulbarga and in Tumkur districts very few institutions
have water supply.
Toilets are unusably dirty.
Even maintenance of the
premises is extremely bad. The vast area surrounding PHO or CHC are full of
hazardous garbage like blood stained bandages, broken syringes, cotton etc.
11)
Health poor districts also have the problem of shortage of personnel at all
levels and those personnel who are in position large proportion of them are
irregular and have no commitment ultimately resulting in the public suffering.
Recommendations
The health indicators in Karnataka have shown remarkable improvements
over last five decades. But what is shocking is the wide differentials across the
districts that existed five decades back have sustained till today. Those districts
who were at the bottom have remained there. The persisting regional imbalance
reflects poorly on the functioning of the public health care service delivery system
in the state.
The study clearly brings out the urgent need for the following
interventions to set things right before it is too late.
1)
Health administration at district level needs to be improved. They should
be held responsible to play a pivotal role in improving public health by improving
health care service delivery and ensuring its equitable distribution.
2)
All public health institutions should work regularly during fixed hours and
any deviation should be seriously taken for punitive action.
3)
Uniform policy intervention and strategy in the state that have widely
varying health status is not going to bear results.
Tl
There is need to consider
J
42
districts by their achievements in health such as Health Rich, Health Poor and
Health Average districts for different strategies.
Health rich districts like Udupi need upgradation of quality of services to
make them competent as Private sector which may be an expensive proposition.
But the link that exists between private and public health care services have to
be strengthened.
In health poor districts there is an urgent need to make the services reach
people. ANMs should visit households, conduct deliveries and improve over the
current status in future. Medical Officer should attend PHC regularly and provide
service to the needy.
There is need to bring the concept of monitoring and
supervising the functioning of institutions and the work of personnel that is
missing now.
4)
The performance of district administrations should be linked with
improvement in health indicators and findings of service statistics.
5)
One of the important cause for not achieving the goal of “Health for all by
2000” was the casual approach to the concept of 'community participation in all
health programme. It should be reconsidered and serious efforts to be made to
ensure the same.
u
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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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0 FEASIBILITY AND MODALITIES OF APPLICATION OF PRINCIPLES OF
0
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HEALTH PROMOTION AND ITS INTEGRATION WITH
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HEALTH EDUCATION
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By
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Dr. K. Basappa
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Dr. G. Nanjappa
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International Union for Health Promotion and Education
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South East Asia Regional Bureau
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Karnataka Chapter, Bangalore
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000000000000000000000000000000gf/f0tf00ff
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CONTENTS
SI No.
1.
ACKNOWLEDGEMENTS
2.
PREFACE
1
3.
TOPIC
1
4.
THE PROCESS
1
5.
SECTION-I
2
6.
INTRODUCTION
2
7.
OBJECTIVES
2
8.
MATERIALS & METHODS
2
9.
SECTION-n
5
10.
NEED FOR HEALTH PROMOTION
5
11.
NEW CHALLENGES
5
12.
HEALTH PROMOTION
6
13.
OTTAWA CHARTER
6-9
14.
HEALTH EDUCATION
9-10
15.
ADVOCACY
11
16.
SOCIAL SUPPORT
11
17.
EMPOWERMENT
11
18.
FACTORS WHICH DETERMINE HEALTH STATUS
AND MAIN ACTORS RESPONSIBLE - AN
OVERVIEW
19.
PAGES
I
HEALTH PROMOTION & ITS BENEFITS FROM
CONTROL OF ENVIRONMENT.
11-12
13
20.
BENEFITS FROM BEHAVIOUR CHANGES
21.
SECTION -m
16
22.
HEALTH EDUCATION BUREAU
16
23.
INTRODUCTION
16
24.
STRUCTURE OF SECTION -1
17
25.
STRUCTURE OF SECTION - H
18
26.
FUNCTIONS OF SECTION -1
19-21
27.
FUNCTIONS OF SECTION - E
21-22
28.
SCHOOL HEALTH EDUCATION PROGRAMME
22
29.
GOALS AND OBJECTIVES
22
30.
ACTTVITTES
22-23
31.
PERFORMANCE
23- 24
32.
RECOMMENDATIONS
24-25
33.
SECTION-IV
34.
GRASS LEVEL ROOT WORKERS
35.
HEALTH SUPERVISERS
13-15
26
26-28
28
73
u
36.
HEALTH EDUCATORS
28-31
37.
MEDICAL OFFICERS OF HEALTH & SENIOR
HEALTH ADMINISTRATORS.
32-36
38.
RECOMMENDATIONS
37
39.
INTERACTION WITH OTHER HEALTH RELATED
DEPARTMENT
37
40.
INTERACTION
ORGANIZATION
NON-GOVERNMENT
37
41.
INTERACTION WITH PEOPLE
42.
SECTION-V
39
43.
VISION AND STRATEGY STATEMENT
39
44.
SUMMARY OF THE FINDINGS DISCUSSION AND
RECOMMENDATION
45.
SUMMARY
OF
RECOMMENDATIONS WITH
EXPLANATIONS
46.
EXISTING SCHOOL SYLLABUS ON HEALTH AND
COMMENTS ON THE SAME
47.
FffiALTH SERVICES AND
MODEL SCHOOL HEALTH
COMPREHENSIVE SCHOOL CURRICULA ON
HEALTH AT THE LEVEL OF PRIMARY AND
SECONDARY EDUCATION
■
THE NEED FOR COMPREHENSIVE
SCHOOL HEALTH SERVICE
OF
■
PRINCIPLES
AND
PRIORITIES
SCHOOL HEALTH SERVICE
HEALTH
■
FOCUS
ON
SCHOOL
EDUCATION
■
ECONOMICS OF SCHOOLS HEALTH
SERVICE
■
STRATEGIC PLANNING OF SCHOOL
HEALTH PROGRAMMES
■
TEACHERS TRAINING
48.
WITH
37-38
40 -44
IMPORTANT
REASONS AND
RECOMMENDED OUTLINE OF CURRICULUM ON
HEALTH FOR PRIMARY AND SECONDARY
SCHOOLS
GOALS AND OBJECTIVES
TOPICS AND AREAS OF
INCLUDED IN THE SYLLABUS
STANDARD-I
STANDARD -H
STANDARD-HI
STANDARD -IV
STANDARD-V
STANDARD - VI
STANDARD - VH
STANDARD- V1H
STANDARD-IX
STANDARD-X
74
STUDY
60-61
62
62-63
63
63-65
65
65-66
H
-i-
INTERNATIONAL UNION FOR HEALTH PROMOTION AND EDUCATION (IUHPE)
- SOUTH EAST ASIA REGIONAL BUREAU (SEARB) - KARNATAKA CHAPTER
ACKNOWLEDGEMENTS
International Union for Health Promotion and Education (IUHPE) - South East Asia Regional
Bureau (SEARB) - Karnataka Chapter Sincerely thanks and appreciates the gesture of Karnataka
Task Force on Health and Family Welfare for having invited the Chapter for conducting an action
Research Study on “the feasibility and modalities of application of principles of Health
Promotion and its integration with Health Education”. The Chapter thanks Dr. H. Sudarshan,
Chairman of the Task Force, Dr. C.M. Francis and other Members of the Task Force for their
suggestions and guidance in completing the Research Study.
Thanks are also due to the Project Administrator, Karnataka Health System Development Project
for providing necessary funds for the Research Study.
Thanks of the Karnataka Chapter are also due to Dr. G.V. Nagaraj, Director of Health and Family
Welfare Services, Dr. Kurthkoti, Additional Director (Health Education and Training) for their
help and cooperation for organising the field visits to Districts, Primary Health Centres and Sub
Centers.
Thanks are also due to the District Health and Family Welfare Officers and Technical Staff of the
Kolar, Bijapur, Bellary and Kodagu Districts for their participation in the Research Study.
The lUHPE-SEARB-Kamataka Chapter thanks Dr. K. Bassappa, Principal Investigator of the
Research Study and Professor, Community Medicine, Adichunchunagir Institute of Medical
Sciences, and Dr. G. Nanjappa, Member of the Research Team, Project Coordinator and
Professor Community Medicine, AIMS for their relentless field work, analysis and writing the
Project Report.
Tanks are also due to Dr. K. Ramachandra Sastry, Chairperson, Research Division, SEARB and
Retd. Chief of Research, Gandhigram Institute of Health and Family Welfare Trust, Mr. N.R.
Vaidyanathan, Chief, Budget and Finance, SEARB, and Retd. UNICEF Field Officer and Mr.
C.R. Premakumar, Member, Executive Committee, Kamantaka Chapter and retired Public Health
Executive Engineer for collection of information and interpretation from other developmental
sectors of the Government of Karnataka.
The Karnataka Chapter thanks Mr. Settappa, Joint Secretary of Karnataka Chapter SEARB for
having assisted the Investigators in the secretarial work and keeping the accounting work of the
project funds.
Dr. K. BASAPPA
President
Karnataka Chapter-SEARB-IUHPE
7^
J
PREFACE
Health promotion is defined as a process of enabling people to increase control over the determinants of
diseases and disability and improve their health by their own efforts.
The public policy and health policy in particular should be able to help people to acquire health and sustain
it for a long time, so that they remain productive for more number of years and do not add to the burden f
diseases and disability. Health promotional policy works in this direction.
The Task Force of Health and Family Welfare of Karnataka Government wanted to apply these principles
into the Karnataka State Health Care Service. A rapid assessment of the State of art Health Education
process was felt necessary and this report is related to the assessment of the extent and method of
implementation of health promotion in Karnataka State Health Care System and to find out the modalities
of application of the principles of health promotion with a view to integrate it with health education.
Topic
The topic is to study the “Feasibility and modalities of application of principles of Health Promotion and its
integration with Health Education”.
The Process
The Research Team after receiving the orders of assignment from the Karnataka Task force on health and Family
Welfare to take up rapid assessment of the existing situation with regard to the structure and functions of
Health Education Wing of the State Health Department prepared a research proposal and submitted to the
Task Force. After approval of the same, the rapid assessment was taken up. The assessment involved:
1. Literature review on health promotion.
2. Field visits to 16 Primary Health Centers in 4 districts to know the state of art of health education
activities and to assess the competencies of the health manpower at the district and Primary Health
Centre levels and the organization strengths and weaknesses.
Obtained
the views of senior health experts who were closely associated with the fimctioning of the
3.
Health Sector and present Health Education practitioners in and outside the State.
4. Some data were collected from the Health Directorate and District Health Officers about the structure
and performance of the health education wing.
5. The data were analysed and discussed in the Seminar Organised for the purpose.
6. This is the final report of the assignment.
LIST OF TABLES
1.
2.
3.
4.
5.
6.
Statement showing the Number of Respondents planned and contacted.
Number of I.E.C. Activities conducted from 1997 - 1999.
Number of School Health Education Activities - Target achieved.
Knowledge, Attitude & Practice of Grass root level Health Workers.
Knowledge, Attitude & Practice of Health Supervisor.
Knowledge, Attitude & Practice of Health Educators.
76
I
2
SECTION -1
A. INTRODUCTION
B. OBJECTIVES
C. METHODS & MATERIALS
Introduction and Objectives of the Study
A. INTRODUCTION
The Task Force on Health and Family Welfare, Government of Karnataka invited the Karnataka
Chapter of the South East Asia Regional Bureau of the International Union for Health Promotion and
Education to take up a rapid assessment of the “FEASIBILITY AND MODALITIES OF
APPLICATION OF PRINCIPLES OF HEALTH PROMOTION AND THEIR INTEGRATION
WITH HEALTH EDUCATION.”
The Karnataka Chapter accepted the assignment and conducted the study. The following is the report
of the study.
B. OBJECTIVES
1. To develop a vision and strategy statement on health promotion for the Karnataka State.
2. To examine the organizational structure and functions of Health Education Bureau of the
Directorate of Health and Family Welfare Services.
3. To Make a rapid assessment of capabilities of health staff to undertake health promotional
responsibilities with particular reference to competencies of grass root level health staff and their
supervisors, block level health educators. District Health Education Officers, Medical Officers of
Health of the Primary Health Centres and District Health and Family welfare officers.
4. To assess the existing inter-sectoral coordination related to health promotional activities amongst
the different development departments and non-governmental organizations at primary Health
Centre, District and State level.
C. MATERIALS AND METHODS
A qualitative assessment was decided upon because of the time constraint imposed by the task Force to
complete the study. Though this is a qualitative study and based on focus interviews and observations,
care has been taken to see that the interviews of relevant staff and observations have been made by the
experienced researchers themselves to ensure credibility and validity of the report.
1. Literature about health promotion published in the International and National journals and WHO
documents have been reviewed. It include global strategy for Health for All by the year 2000 and
Alma Ata Declaration of 1978 on Health for all (H F A) 2000 and primary health care published
by WHO and Ottawa Charter for health promotion (1986). And other documents and reports
Reviewed are Report of an International Meeting on public Health (New challenges) and Ninth
general Programme of work (9GPW) published by W H O.
2. Information about the structure and function of the Health Education Bureau were collected from
the Directorate of Health and Family Welfare Services and the District Health and Family Welfare
Offices of four District who are looking after planning and implementation of health programmes
in their district. These information have been tabulated and analysed.
3. Date were also collected by interviews and from focus group discussions and field observations of
the primary health centre and District Health staff regarding their competencies in health
promotional activities.
77
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3
Opinion of the health administrators, health researchers and health teachers on some aspects of
health promotion and practice, its importance and feasibility and the competencies and skills
required to implement health promotional strategies have been collected by open-ended
questionnaire and analysed. Experts from the State of Karnataka and outside the state were
included in the study.
5. For field study one district from each of the four revenue divisions of the State was selected.
Sixteen Primary Health Centres, 4 from each district were selected for observational study. The
district are kolar from Bangalore Division, Bijapur from Belgaum Division, Bellary from
Gulbarga Division and Kodagu from Mysore Division.
6. In order to know the existence and extent of intersectoral coordination and cooperation and
involvement, representatives of various development departments and non-government
organizations were also included in the study.
7. Criteria used for assessing the competencies and skill of the staff of implement health promotional
activities and opinion of Public Health Experts.
4.
Criteria Used
Rank Assigned
KNOWLEDGE
Has a clear perception of the meaning of health promotion.
His/her job responsibility and that of health department
1.
Has vague perception
Has no perception
2.
3.
High
Moderate
Low
ATTITUDE__________________________________
High
He/she is very eager to promote health promotion work.
He/she feels that it is worthwhile, but shows indifference and
not so enthusiastic about their job.
Moderate
He/she feels rather not concerned about his job responsibility
and about health promotion or health education
Low
OPINION ON STATEMENS
Consenses
Strongly Agree
Exist
Agree
Consenses
Agree with reservation
Does not exist
Disagree
1.
2.
3.
4.
STATEMENTS MADE ARE RELATED TO THE FOLLOWING.
1.
2.
3.
4.
5.
6.
7.
8.
9.
Need for health promotion and Education.
Methods of planning health promotional activities.
Importance of social mobilisation activities.
Need for involving people in the health programmes.
Need for inter-action with developmental departments and non-governmental organizations.
Need for further training of health staff.
Additional training for Medical Officers of Primary Health Centres.
Need for re-orientation of syllabus in Community Medicine in MBBS and MD courses.
Need for change in the attitude of policy makers towards public health and health promotion.
78
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4
TABLE- 1
STATEMENT SHOWING THE NUMBER OF RESPONDANTS WITH THEIR
DESIGNATION, PLANNED AND CONTACTED
SI.
No.
1,__
2.
Designation
7.
Director of Health and Family Welfare Service
Additional Directors of Health & FW Services______
Joint Directors of Health of FW Services
District Health and Family Welfare Services_____
District Health Education Officers
Dy. District Health Education Officers Block Level Health
Educates
Medical Officers of Health of Primaiy Health Centres
8.
9.
Health Supervisors, Male and Female______________
Health Workers Male and Female (ANMs & Jr. H. Asst.)
10.
Health experts and senior Health Administrators
11.
Non-Govt. Organizations____________
Other Government Sector representatives
1) Education
2) Public Health Engineering
3) Agriculture
4) Horticulture
5) Women and Child Welfare
6) Information and Publicity
3.
4.
5. __
6.
12.
73
Number
Planned
1
4
6
4
4
No.
Contacted
1
3
6
4
4
20
14
16
12
32
28
64
50
98
48
8
6
1
1
1
1
1
1
1
1
182
1
1
1
1
262
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5
SECTION - n
NEED FOR HEALTH PROMOTION
According to World Health Organization the definition of Health is “a state of complete physical mental
and social well-being and not merely the absence of disease”. Despite this definition and its widespread
usage, all over the world large majority of people view the health in the context of curative medicine, often
described perhaps presumptually - as “modem scientific medicine”. Apart from this, there is a pervasive
misconception among health planners in many countries especially in developing countries that good health
is primarily a result of medical intervention and hospital services and there has been a growing
morginalisation of public health.
NEW CHALLENGES
But the evidence available is quite the contrary. Mekeown’s research has shown that past improvement in
health has been due mainly to modification of behaviour and changes in the environment. For example,
Mekeown’s analysis of mortality trends in U.K. between 1801 - 1971 has shown that mortality from
infectious diseases such as Tuberculosis, Bronchitis, Pneumonia, Influenza etc., as well as from water
borne and food borne diseases had already begun to decline even before effective treatment became
available. (1)
(1) Mckeown suggests that communities and Government should look into factors (behavioural and
environment) to bring further advance in health status of their countries.
(2) Studies have also shown that extreme poverty of some 1/5* of the world population is the greatest
killer and largest cause of human suffering Disparity in health exists between nations and the gap
is increasing Healthier countries are becoming more healthier and poor health countries are
becoming poorer in health status. Just like rich countries becoming rich and poor countries
becoming poor due to imbalance in the economic development. (2)
(3) In addition, grave disparities in health condition remain within the countries, communities and
gender. For example poorer and less educated people suffer from higher mortality and morbidity
than those who are better educated and have higher income within the country and communities.
Women cany the triple risk of death and disease because of reproductive burden and gender
inequality and social injustice in all walks of life. Therefore, people who are relatively poorer, less
educated and women living in rural and semiurban and slums of big cities have less access to
health care system, suffer more from inequality and social injustice. (2)
(4) The emerging fourth challenge is the resurgence of old diseases like Malaria and Tuberculosis and
new diseases like HIV/AIDS and drug resistance of insects and bacteria are all adding to the
problem of health of developing countries. (2)
(5) The fifth challenge causing alarming situation both in developing and developed countries is the
increased cost of medical care due to social and commercialization of medicine, in the advent of
advanced diagnostic and technological knowledge. Inspite of these advances and costly treatment,
there has been no improvement of health of the people in relation to expenditure. (2)
(6) The 6th factor causing concern is related to alcoholism, drug addiction, tobacco smoking and
tobacco chewing.
In the face of these challenges, the approach and strategy for maintaining and improving the health of the
people should concentrate more on the root cause of illhealth and diseases. These root causes or
determinants of health and diseases are related to (1) income (2) Education (3) Employment (4) Nutrition
(5) Housing (6) Safe Water (7) Sanitation (8) Health environment (9) Health care infrastructure (10)
People’s participation (11) People’s awareness, and level of skill (12) Primary health care (13) Prompt
diagnostic and therapeutic services and (14) Rehabilitation services, these are the direct cause. The indirect
cause are many and they prevail in all walks of life of governance. Some of them, are public policy health
H
6
policy in particular, right to health, access to health care infrastructure and quality of health care providers,
equity and social justice etc.
In these circumstances people’s health can be improved and sustained only by comprehensive plan of
action that cuts all roots and rootlets that cause illhealth. For this to happen, all the people and the
concerned government organizations, voluntary organizations and religious organizations. Industries should
come together and work at all levels from the top policy makes (political, social and religious leaders) to
people’s representatives.
HEALTH PROMOTION
What is Health Promotion?
Health Promotion is defined broadly as a process of enabling people to increase control over the
determinants of illhealth and improve their health. In essence, health promotion is Social and Political
action. It seeks to empower people with knowledge and understanding of health (health education) and
creating conditions conducive to healthy living and healthy life style (social support). It reaches and
involves people through the context of their every day lives, such as homes, work places (Industries,
offices) learning (schools and colleges), and play ground recreation facilities, and eating establishment.
Health promotion takes a developmental approach to health, whereby health is considered as the goal and is
a result of the activities of all development sectors like housing, local governments, education, industry,
agriculture, transport services etc. Development approach promotes stronger health programmes
characterized by greater relevance to various development sectors such as school health, healthy cities,
healthy villages, and healthy food markets etc. (3)
In her opening address to the 5th global conference on health promotion in Mexico Dr. Gro Herlem
Brundtland, Director General, World Health Organization stated that “Promoting health is about enabling
people to keep their minds and bodies in optimal condition for as long as possible. That means, that people
know how to keep healthy. It means that they have the power to make healthy decision - within them
selves, community, local government and within the State. (4)
The UNICEF
“State of Health of World’s Children - 2000” (5) presents evidence to show that India is
not investing sufficiently in mother and child care despite the fact that infant mortality rate and under 5
mortality rate are not showing any decline in 2000 as compared to 1998-99.
IL OTTAWA CHARTER AND JAKARTA DECLARATION ON HEALTH PROMOTION
Significant features of the Charter
1.
2.
3.
4.
5.
6.
Ottawa charter define health promotion as a process of enabling people to increase control
over the determinants of illhealth and to improve their health.
Health is seen a resource for every day life and not objective of living.
Health promotion is not just securing of health, but goes beyond healthy life styles to well
being.
Pre-requisite for health are: (1) income (2) food (3)shelter (4) sustainable resources (5) social
justice (6) equity (7) water supply and sanitation(S) education. Improvement in health requires
a solid and secure foundation in all these basic needs.
Political, economic, social, cultural, environmental, behavioural and biological factors can all
favour health or may be harmful to it. Health promotion action aims at making these
conditions favourable to health through advocacy.
Health improvements require secure foundation in (1) a supportive environment (2) access to
information (3) development of life skills and opportunities for making healthy choices (4)
equal opportunities for all segment of the population with free access to health and related
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services irrespective of class, creed and gender difference. Health promotion aims at enabling
people to take control of those things which derermine health.
7. Health pre-requites and health supportive accessories cannot be ensured by health sector
alone. It demands coordinated action by all concerned, by governments, health and other
social and economic sectors, by non-governmental and voluntary organizations, by local
authorities, local communities, families and individuals. Health promotion action aims at
bringing coordination between various sections and media, between differing intersts in
society for the pursuit of health.
Based on the above principles, the Ottawa Charter suggested the following action.
1. Build Healthy Public Policy
The health promotion agenda of the makers in all sectors, at all levels of government and society
directs them to be aware of consequences of their decisions and accept their responsibility towards
health. Health promotion policy combines diverse, but complementary approaches like (1) legislation
(2) fiscal measures (3) taxation and (4) organizational changes. It is the coordinated action that
increases income, foster greater equity and social justice to individual family that counts to improve
health. The health promotion policy requires the identification of obstacles to the adoption of healthy
public policy in both health and non-health sectors and finds ways and means to remove them and thus
helps policy makers to make healthier choice.
2. Create supporitive environment
Creation of an environment supportive and sustainable is a prerequisite for health. Intricate links exist
between people’s health and their environment and this is the basis of socio-ecological approach to
health. While conservation of natural resources should be encouraged through out the world as a global
responsibility, the modification and creation of sustainable new resources for health should be the
responsibility of every nation and every conununity.
Supportive environment consists of two components. One is the physical environment and the second
is the social environment. As for as physical environment is concerned, that every person and family
must have work and minimum income to possess and utilize the infrastructure. The way society
organizes work would help to create a healthy environment. Health promotion should generate living
and working conditions that are safe, stimulating, satisfying and enjoyable.
Social environment is concerned with changing old behavior pattern or adoption of new behavior
pattern is of course possible only when man or woman is motivated and committed to behavior change.
But the process of motivation and commitment can be made easier and quicker by creating social
environment which creates critical mass in the community. That is tlie opinion of family, peer groups,
formal and informal leaders and religious groups should support a particular behaviour. It may be
about small family nonn, giving up tobacco and alcohol, extramarital sex or age at marriage ect.
These health promotion activities help to create and sustain such social pressure. The concept of
supportive environment implies that action is oriented towards determinants of the health of the
population. This is used to build bridges between sectors and professions, between theoretical
concepts and practical action for an improved countries.
Achieving supportive environment will require a new awareness of the possibilities for improving
health through environmental change. It will also require a strong future orientation that links public
health to sustainable development and consequently require a new emphasis on strategic planning and
development of management skills to facilitate cooperation between sectors.
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3. Strengthen community action
Community action play a very significant role in making people believe in what they do and how they
do and behave. It cements their belief. Therefore, community action programme, where they plan,
take decisions, implement them, mobilizing their own resources and take control over and won them
should be encouraged. Community development draws on existing human and material resources in
the conununity to enhance self help and social support and to develop flexible systems for
strengthening public participation and direction of health matters. This requires, full and continuous
access to information, learning opportunities for health as well as funding support.
4. Develop personal skills
Education for health and enhancing life skill development are important, because they increase the
options available for them to exercise more control over their own health and their environment, which
sustains health. Enabling people to learn through out their lives, to prepare them for all stages of life
and cope with the illness and injuries are essential. This has to be facilitated in schools (school health)
home, work place (occupational health) and conununity setting. Health promotional activities extends
to these areas through educational, professional commercial and voluntary bodies,
5.
Reorient health services
Health sector and health professionals remains the sheet anchor of health promotion, they must plan
efficient system of primary health care service through out the country from villages to metropolitan
cities. They must involve local governments and people to take control of them. They must move
increasingly in a health promotional direction beyond clinical and curative services. Health
sector and health professional need to embrace and expand the mandate winch is sensitive and respects
cultural needs. This mandate should support the needs of the individual and communities for a
healthier life and open channels of communication between the health sector and broader social,
political, economic and environment components. The health sector and other sector of government,
voluntaiy health organizations and other groups in the community must work together and contribute
to the pursuit of health.
Jakarta Declaration on Health Promotion into the 21st century.
The Jakarta Declaration on health promotion offers a vision and focus for health promotion into the 21st
centuiy. Its main emphasis is to tackle health determinants and for this, it draws upon widest range of
resources from all sides. The declaration recognizes that health promotion is an essential element for health
development. Health promotion, through its investments and actions on determinants of health, contributes
significantly for the reduction f inequalities in health, ensure human rights and build social capital which is
so important for health and well-being of people . The ultimate goal of health promotion, as envisaged in
the declaration is to increase in the health expectancy and to narrow the gap in health expectancy.
The Jakarta declaration endorses all the five Ottawa Charter Strategies
Charter strategies:
Build healthy public policy
Create supportive environment
Strengthen community action
Develop personal skills
Reorient health services
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In addition, the following five priorities for health promotion have been suggested.
•
•
•
•
•
Promote social responsibility for health of decision makers.
Increase investments for health development
Consolidate and expand partnership for health
Increase community' capacity and empower the individual
Secure an infrastructure for health promotion.
The Declaration calls for action to speed up progress towards health promotion giving priorities for the
following:
1.
2.
3.
4.
5.
6.
7.
Raising awareness about the changing determinants of health.
Supporting the development of collaboration and networks for health development.
Mobilisation of resources for health promotion.
Accumulating knowledge on best practices.
Enabling shared learning.
Promoting solidarity in action.
Festering transparency and public accountability in health promotion.
Jakarta declaration called on W.H.O. to take the lead in building a global health promotion alliance and
enabling its member States to implement the action programmes. A key part of this role is for W H O. to
engage governments, non-governmental organizations, development banks, U.N. agencies, inter-regional
bodies, bilateral agencies, the labour movement and cooperative as well as private sector in advancing the
action priorities for health promotion.
HL HEALTH EDUCATION
The widely used definition of health education is “Health Education is a process which affects change in
the health practices of people and in the knowledge and attitudes related to such changes”. (6). This
definition implies that health education is a process, it involves series of steps, it is concerned with
establishing changes in knowledge, attitude and behavior and also involves efforts by the people. Aims of
health education as formulated by W.H.O. (7) is to (1) ensure that health as a valued asset to the
community (2) equip people with skills, knowledge and attitude to enable them solve their health problems
by their own efforts and (3) to promote the development and proper use of health services.
Health education in the context of health promotion concept.
According to a position paper on health education jointly prepared by International Union for Hygiene
Education and division of health education W.H.O. Geneva - with support from Centre for communicable
diseases Control U.S.A. (8), health education is the combination of planned social action and learning
experiences designed to enable people to gain control over the determinants of health and health behaviors
and the health status of others.
Planning
Planning must be based on the consideration of relevant information. This information must
provide multiple factors that influence the behavior and health related outcomes of interest and
must account for the needs of interests of the target people.
2. The people who use this data must be knowledgeable in isolating those factors that affect health
and also must possess skills to determine the relative importance of these factors.
3. To ensure the needs and interest of the target population, they must be involved in the planning
process.
4. People’s participation assures that there is a rapport with people and a basis for pursuing mutual
efforts and partnership. It should be characterized as doing something “with” rather than “to” the
people.
1.
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5.
6.
Health programmes are more successful when target population perceive the problem and solution
in question to be the most important and appropriate respectively. People are found to act on
issues they judge to be important them.
Creating demand for health is an important responsibility of health education. For example, people
may not judge a given problem or issue to be important simply because they are unaware of its
magnitude or prospective and long-term effects.
Learning experiences
1.
Numerous factors influence the learning process including literacy, access to services and media
resources, readiness for change health beliefs, environmental and social barriers and social
reinforcement. Therefore, the health education programme planning must take into consideration
not only for technical education barriers such as illiteracy, but also for social and economic
barriers.
2. There are difference in the way people receive, process and act on information. So health
education programme must be prepared to offer a variety of learning methods and strategies to
maximize the probability of attaining die desired educational and behavioral outcomes and
necessary social change.
3. Combination of health education methods are important in effective communication. This
depends upon the characteristics of the target population, active involvement of collaborating
organizations and representatives of the community as partners, availability of resources and
competence of the persons conducting the health education programme.
4. There is no single model or method that holds universal superiority, health education specialists,
must understand a variety of educational, behavioral and social sciences theories.
5. Those who plan health education programmes must be capable of adopting educational strategies
for various sub populations of the community of the basis of characteristics that may be practically
identified, such as age, sex, neighborhood, ethnic and cultural identity
6. Therefore, the older concept of health education is not sufficient to meet the needs of health
promotional goals. It should strive to enable people to identify the determinants of health and take
action to nullify their effects on health and take control over the measures to protect, preserve and
promote health. The task of improving health is not only confined to health sector, health
professionals and health communicators, but to all developmental sectors of government and non
government organizations, religious leaders, traders, industrialists, politicians and all those
concerned with governance of the county and who matters for running the country towards
development, progress, and happiness.
Health sector, health professionals and health communicators have a special role to play. They should act
as coordinators, advocates and facilitators of health promotion.
Action required for individual countries or states with in the countries for health
promotion.
In order to provide action plan for promotion of health in developing countries, W.H.O. Working Group on
Health Promotion convened a meeting of senior health administrators in the region in 1989. The group
identified the following areas for action.
1. Enhancing health knowledge and understanding is the first essential step in health supportive
action by people.
2. Creating conditions - (social and environmental) that are conductive for health is another essential
requirement.
3. These can become a reality when there is high level of awareness for health among policy makers,
politicians, economic planners Health Researches, and the public people.
When the awareness is transferred into policies and legislative support, favorable resource allocation for
health would follow. Thus full mobilization of all social forces for health will be needed for health
promotion. In order lo achieve these goals, three fold strategies are recommended. They are (1) Advocacy
(2) Social and Environmental support for health and (3) Empowerment of people for health.
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Brief description of Advocacy Social Support and empowerment.
1. Advocacy:
Advocacy is the process of providing evidence based knowledge to people so that they become convinced
and committed and take appropriate decision in favor of the action required. Thus Advocacy is helpful in
generating public demand and bring about health issues in every day activities. It helps policy makers and
elected representatives to make right kind of decisions in the allocation of financial resources for
community health. It helps religious leaders to become more committed and convinced and help spread
scientific way of life to the people. It convinces political leaders to realize the need for support people’s
wishes and tiy to reorient health system. Advocacy to professional people helps in creating motivation and
interest in researching problems that affect people’s health and find scientifically based strategies to solve
health problems. Finally Advocacy helps create critical mass of interest and support positive health and
makes people to take healthier decisions.
Social support for health
Social support means creating and mobilizing favourable public opinion in favour of health behaviour. This
helps in legitimization of a particular action. It may be small family norm, giving up smoking or giving
unhealthy habits and take decision to build a sanitary latrine in the house. Public organizations and
institutions like. Youth Clubs, Mahila Madals, Panchayats and other social groups, are very usefiill in these
matter.
Building health infrastructure in villages and towns and cities is another social support system. Health
infrastructure like (1) protected water supply (2) sanitation and sewerage system (3) building health centers
and hospitals within the easy reach of the people and (4) provision of good roads and'transport etc.
Empowerment of people for better health
Empowerment of people means, providing health literacy and spread of knowledge to all and motivate and
create interest in them so that every body become self-supporting in health. Inculcation of knowledge and
helping people to develop required skill and capacity to acquire positive health and maintain it. It includes
suitable employment to every body equitable access to health, infrastructure and health advise and health
care services.
Thus favourable decisions of policy makers and those who allocate resources at the State and Central levels
are crucial. Followed by proper planning, strategy, development for health promotional activities at State
and District level are essential. Directorate of Public Health must have adequate manpower and resources
to implement the programmes effectively and monitor and evaluate and provide feedback to the programme
managers. In addition, the people should participate in planning, implementation and management of health
programmes at participate in planning, implementation and management of health programmes at grass
root level in every village, town and city if health promotion is to become a reality.
Factors which determine health status of the population and main actors responsible - An
Overview
1. Individuals, Family and the Communities.
2. Local, District and State level government health Organization.
3. Sectors other than health.
4. Central Government.
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HEALTH DETERMINANTS THAT NEED ATTENTION
1.
Individuals Family and Community
While genetics cannot be changed, the person’s awareness,
knowledge, skill life style play an important role. Family decides
the way of living, nutrition standards, home environment. Family
also decides about education, how many children are wanted,
handle family conflicts, how to care for disabled members. The
community influence the health of its members through safe
water supply, sanitation, education, shelter, handling violence
and un-employment.
2.
Health Ministry (State) Health System Services, Health
research conununity.
Health Ministry and health professionals are responsible for:
3.
Sectors other than health
1.
2.
Government Sector.
Non-Govt. Sectors.
a.
Health legislation.
b.
Health policies and budgeting.
C.
Health education.
d.
Provide primary and secondary health care.
e.
Make available minimum health care facility accessible for
all.
f.
Administer and manage health care facility so that the
services are actually rendered on day to day basis.
g.
Develop and maintain research health planning, monitoring
health programme, implementation and determining health
impact of health programmes and to provide needed
evidence to the policy makers and allocation of health
resources.
h.
Training and maintaining pool of medical and health
personal of various levels of expertise, health administration
etc.
Almost all sectors of economic activity have an impact on health
status of the community through national or regional policies and
decisions. For example Farm and Food Policies have a direct
impact on health so also water supply and sanitation and primary
education, environmental pollution and degradation due to
uncontrolled industrial pollution have indirect impact.
Social security system for working people and senior citizens,
level of employment, control of criminality and violence have
indirect effect.
Rural and urban development, housing industry, energy and
transport sectors have both direct and indirect effect on health the
effectiveness and efficiency of administration and also measures
to limit corruption have additional impact on community health.
4.
Central Government
Although Central Government is far away from health situation
of the individual, the macro economic policies of the government
and principles of good governance in general both have a direct
impact on health. Economic policies and the allocation of budget
between the various ministries, the degree of commitment of the
ministries for their missions, the efficiency and effectiveness of
administration and the research policies pursued by the
government have all impact on health problems.
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Health Promotion and its benefits
A. Benefits from the Control of ENVIRONMENT
Experience of the western countries is striking to demonstrate the vast benefits of health promotional
activities (action on the root causes) that accrue to mankind. These countries brought down infant mortality
rate from 200/1000 in 1880 to about 70 by 1930. The morbidity and morality due to gastro-intestinal
disease came down markedly during the same period 60 to 70% of these improvements are attributable to
safe water supply and provision of sanitation, good housing Nutrition, education and behaviour changes
like personal hygiene and practice of small family noun by majority of the people in those countries.
India missed Industrial Revolution so also Sanitary revolution that brought vast improvements in the
standards of health of Western Countries. India under the foreign rule for over 200 years, with its deep
entrenchment in tradition, superstition etc. is still even in the wake of 21st century and independence is
experiencing the vary high preventable mortality, morbidity and disability. This is because, very little
attempts have been made, to act on the root causes of illhealth. Even in the 21sf century, nearly 40 to 45%
of people do not have water supply (70% do not have safe water supply) 65% do not have toilet facilities,
40% of women between 15-49 years suffer from preventable anemia and 35 to 38% of women have body
mass index below 18.5 kg/m, and 44% of children under 3 years are underweight. These are the examples
to show how the country’s health system is neglecting the health promotion activities. The experience of
the western countries who are implementing some of the health promotional programmes in their
communities against chronic and behaviour related disease shown substantial improvements in health of the
population besides brining down the burden of disease and social costs.
The evidence that health promotional policies and actions yield substantial health benefits is being
accumulated.
B. Benefits from behaviour modifications
1. School Health
School health programmes for promoting better health show clear evidence of achieving higher literacy
levels, reductions in dropout rates, cassation of smoking, reduction in substance abuse, reduction in social
consequences of teenage pregnancy. School health promotional programmes can be effective in
transmitting knowledge, developing skill and supporting positive health choices. The evidence
indicate that greatest effectiveness lies when programmes are comprehensive and “holistic” liking the
school with health services, and where adequate attention is given for teachers training. Health promotion
in schools has emerged very strongly in the last decade in Europe and is spreading to the whole world as a
mechanism to combine a variety of elements achieving maximum health outcomes.
2.
Cardiovascular disease (CVD) and Cancer.
There is clear cut evidence that cardiovascular diseases came down significantly when health promotional
activities like campaign against smoking change in dietary habits, encouraging physical exercise are
implemented. For example in Finland, cardiovascular mortality has reduced by 73% since 1972 and all
causes mortality has been reduced by 50% in working age population over the same period. In a similar
way, North Caroline experienced 71% reduction in lung cancer mortality and 44% from all other cancers.
Other studies show that programmes aimed at changing lifestyle habits bring very positive health benefits.
For example, WHO collaborative study in Belgium for CVD prevention resulted in 25% reduction in CVD
mortality. Programmes aimed at lowering serum cholesterol through healthy diet produced an average
reduction of 15% serum levels of cholesterol among school children. 1% reduction in serum cholesterol
through dietary knowledge would bring a 2 to 3% reduction in coronary heart diseases. This was evident
Netherlands campaign launched by super markets.
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14
3.
Reduction of smoking benefits
The World Bank estimates that economic burden from smoking including health costs and loss of
productive capacity by disability or death is around 200 billion US $ annually. 50% of all smokers loose 20
years of life expectancy. Besides smokers pollute the atmosphere in their homes and public places.
Smoking habits can be brought down by variety of health promotional measures like pricing cigarettes and
legislation. There is evidence that 10% increase in the price of cigarettes (through taxation) leads on
average to a 5% decrease in the quantity smoked and the decrease in 15% among young people. Legislation
restricting smoking in working sites in Finland led 2.4% smokers quitting smoking and 14.3% reducing the
quantity consumed.
Further, smoking cessation programme in schools have resulted in 30 to 50% fewer smokers, especially in
peer groups. However, there is also evidence to show that without follow up with multiple strategies of
action, these rates do not hold. Smoking cessation programmes over a 20 year period have yielded 13% less
mortality from coronary heart diseases, 11% less from cancer mortality. Among pregnant women smokers
cessation of smoking has resulted in lowering tlie risk of low birth weight and reduction of obstetric
complications. Smoking cessation is found to most cost effective programme. The cost per life year gained
from such programmes ranged from 2000 to 5700 US $, where as the cost per year gained from treatment
for mild hypertension is up to 8600, and the cost of extensive drug treatment per life year gained is more
than 192,000 US $.
4. Mental Health and health promotional activities.
There is significant evidence to show that mental health promotion strategies have reduced depression,
reduced suicide rates and reduced behavioural problems. Swedish Educational Programme have shown
vety positive results. For example, there was reduction of suicide rates for 19.7 cases/100000 population to
7.1 cases after 3 years of programme implementation. Besides there was economic benefit, the number of
inpatient days reduced by 70% and there was also savings in the amount of tranquilizers and anti
depressant drugs used. Other mental health promotional programmes have reduced teenage pregnancy HIV
infections, 75% reduction in pre-term delivery, reduction in low birth weight babies and babies with brain
damage.
5.
Healthy Ageing
The real key to healthy ageing is to begin health promotion early in life. However, there is evidence to
show that application of health promotional activities like, physical activity even at the age of 50 can bring
down substantially cardiovascular mortality and risk of falls and enhances cognitive function of the mind.
The impact on society is seen in keeping the elderly population active and therefore productive for a longer
period, reducing health and social costs. The available evidence show that maintaining healthy life styles in
old age is directly associated with health gain.
6.
Healthy Equity
Equity in health is gaining ground in recent years. WHO describes equity as a fair opportunity provided for
all people to enjoy health to their fullest potential. It does not mean equal health status for evety one, but it
means reduction of differences between people’s health as much as possible through equal opportunity for
health.
There is evidence to show that socio-economic conditions related to income, education and employment are
at the root causes of illhealth. Even in Europe, substantial number of people (57 million in 1993) lived in 23
million poor households. Even in rich countries, people with means live several years longer and have
fewer diseases and disability than people without resources.
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15
Relative deprivation has show to have profound effect on healthy rather than absolute poverty. Relative
deprivation can have poorer education, low skill development, higher unemployment and lower capacity to
deal with information and lower material resources. There is strong evidence to show that relative poverty
is closely linked to poorer health. Many equity interventions for health are found to have impact at
community level. People can gain increases ability to solve their problems at every stage of participation or
involvement at the local community level.
Healthy cities concept of WHO’s Health for All strategy with hundreds of people participating provides a
strong multi-agency framework for development. Such programmes have sliown evidence of effectiveness
including generating increased income, through work opportunities improved community support with
counseling services and better community involvement etc.
Data also show that health and education are most important and powerful forces for economic
development in poorer countries. Basic investment in health and education can produce positive economic
outcomes. This kind of investment in Trinidad, Cuba, Chile and Cost Rica has reduced poverty to less than
10% of the population.
References:
1. McKeown T - The role of Medicine - Dream, Mirage, Lodon Nyffield Provincial Hospital Trust 1976.
2. New challenges for Public Health - Report of an inter-regional meeting, Geneva, 27-30 November
1995 (Page 7 & 8) from World Health Report 1995.
3. Ottawa Charter for Health Promotion.
4. Opening address of 5th Global Conference on Health Promotion - Mexico - 2000. Promotion and
Education Quarterly, 2000, Vol. VIII/3, Page - 15.
5. UNICEF State of World Children -.2000.
6. Society of Public Health Education (1966) Health Education Monographs No. 21, New York.
7. W.H.O. (1954) Tech. Rep. Ser. No. 89.
8. Extract from meeting Global Challenges - published IUHPE Board Meeting Souvenir - April 200
Page 23.
9. Development of Competency - based on University Health Promotion courses by P. Howat, et al Journal of Promotion and Education Vol. VII/1, 2000 Pages 34-35.
10. A Practical Frame work for setting priorities in Health Research.
11. Human Development - South Asia’s Educational Renaisance - UNESCO.
12. Health Promotion in Action - Voluntary Health Association of India.
13. Health Promotion - Dr. H. Nakajima, Director - General (Retd) W.H.O.
14. Malnutrition - A South Asia Enigma - Dr. Ramalingaswamy & Jonson & J. Rhode.
15. A call for action - promotion Health in Developing countries - W.H.O.
16
SECTION - in
Health Education Bureau
Introduction and objectives
Structure of Section I
Structure of Section II
Functions of Section I
Functions of Section II
6. Recommendations
1.
2.
3.
4.
5.
L HEALTH EDUCATION BUREAU
1.
Introduction and objectives
The State Health Education Bureau (SHEB) was started in the Directorates of Health and Family Welfare
Services in the year 1930. The Bureau was reorganised in 1965 with the assistance of Government of India,
W.H.O., UNICEF, and Dr. V. Ramakrishna and others played a significant role in bringing about the
establishment of the SHEB in the Department of Public Health in the Mysore State. It was nurtured and
enriched by many eminent Directors of Public Health of Mysore State and latter Karnataka State ever since.
World Health Organization, Rocke-feller Foundation and other International Health Organisations also
helped the growth of the State Health Education Bureau.
The Bureau developed a sound health education policy for the state and exerted its influence in improving
the health status THROUGH HEALTH EDUCATION. The Bureau laid down long term and short term
objectives, structure and fimetions needed to reach those objectives.
A. Long term objectives
a. To help people to achieve health by their own actions and efforts.
b. To obtain people’s active support and participation for public health programmes and policies.
c. To assist people to shoulder the responsibility for health.
d. To encourage people to demand more and better health services.
B. Short term ob jectives
a. To collect baseline data of the prevailing health conditions, health attitude, beliefs and values etc.
b. To educate the people on health matters by various methods and evaluate the relative effectiveness
of the methods and channels of communication.
c. To provide in-service training in health education for all categories of health staff.
d. To produce health education materials and reproduce them wherever needed.
To reach the above objectives, the Bureau laid down the following activities.
1.
2.
3.
4.
5.
6.
7.
Planning, organising and directing State-wide health education activities.
Conducting studies regarding baseline data, health educational needs, resources, priorities etc.
Determine the appropriate channels of communication and develop effective methods and
materials for their use.
Training of the personnel of health and family Welfare Department on health education methods.
Assisting, organising and conducting of seminars conferences, family group teaching etc.
Fostering cordial intra and inter-departmental coordination and building group relationship with
non-governmental organizations.
Dissemination of scientific information for people, through various channels of communication.
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STRUCTURE AND FUNCTIONS
A. STRUCTURE OF THE HEALTH BUREAU-1
The State Health Education Bureau consists of two Divisions. First Division is headed by the Project
Director, Reproductive and Child Health Services and Second Division is headed by the Additional
Director, Health Education and Training. Functionally also the first Division is concentrating on health and
family welfare and the second Division is concentrating on School Health, Training Nutrition etc.
SI. No.
Categories
Sanctioned
Working
At State Level
1.
Joint Director
1
1
2.
Deputy Director
2
1
3.
Field Publicity Officer
1
4.
Editor
1
5.
Assistant Editors
2
6.
Health Education Officer
1
7.
Health Educator
1
8.
Social Scientist
1
1
1
At the District Level
1.
District Primary Health Centre Level
31
7
2.
Dy. Dist. Health Education Officers
104
78
782
517
At the Primary Health Centre Level
1.
Block Health Educators
Health Educators with Diploma in Health Education (DHE)
No. with DHE
No. without DHE
Total
10
State Level
10
District Level
130
5
135
Piy. Health Centre
51
466
517
Teaching Staff
26
Total
26
471
217
688
Comments
The strength of the staff and their qualifications at the State Level is adequate, but the vacant posts should
be filled up.
9,
IS
At the district level, 104 posts have been sanctioned for 27 districts at the rate of more than 3 per district.
Whereas, only 782 posts of Block level Health Educators have been sanctioned for 1685 Primary Health
Centres. At the rate of one Block Level Health Educator per primaiy Health Centre, still 903 posts are to be
created. This is very difficult to achieve in the near future, because, it involves heavy expenditure and no
trained and qualified Health Educators are available for recruitment.
Besides, taluka level health officer posts are sanctioned recently to strengthen the administration and
management of health programmes in rural areas. This is a good development and this taluk level health
office should be strengthened with posts of Health educators. Therefore, there is need to reorganise the
distribution of available Block Level Health Educators between talukas and PHCs.
STRUCTURE OF THE HEALTH EDUCATION BUREAU - II
This action of State Health Education Bureau consists of the following staff.
SI No.
Category
1.
3.
4.
1
1
1
1
1
1
v
Training Officer
Health Supervisor
Student Health Education Unit
1.
2.
3.
Deputy Director
Assistant Director
Dist. Nursing Officer
1
1
1
Audio-Visual Unit
1.
2.
3.
4.
5.
6.
7.
Technical Officer
Artist cum-photographer
Artist
Sub-Editor
Projectionist
Craftsman
Silk-Screen Technician
1
1
1
V
1
1
1
v
V
1
1
V
V
1
Field Study & Demonstration Unit
1.
2.
3.
4.
5.
6.
7.
1
(vacant)
1
Training Unit
1.
2.
6.
Working
1
Additional Director
Joint Director
2.
5.
Sanctioned
Technical Officer
Health Supervisor
Public Health Nurse
Home Science Assistant
Social Scientist
Teacher
1
v
1
1
1
1
V
1
1
1
1
1
Exhibition Unit
1.
Technical Officer
1
v
19
FUNCTIONS
A. INTRODUCTION
The main function of the Division I of Health Education Bureau is to plan, implement and monitor health
education activities pertaining to family welfare in rural areas of the State. These activities are implemented
and monitored through the District Health and Family Welfare Officer at the District level and Medical
Officers of Health at the Primary Health Centre level under the over all supervision and control of
respective Zilla Panchayats. The bulk of the work is carried out by the grass root level workers and Health
Supervisers. Block level local non-govemment organisations and public people. He also guides Health
Workers and Supervisers and monitors the health education activities.
At the district level, the District Health Education Officer prepares a district plan of IEC activities. He
supervises and monitors all health education activities throughout the district. He under takes tours and
meet and discuss the health education issues with other developmental sectors of the government and local
non-govemment organizations. He is also resource person for local Non-Govemment Organisations for
health education activities.
B. OBJECTIVES, STRATEGIES AND METHODS USED FOR THE IEC ACTIVITIES.
a.
Objectives:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Promotion of higher age at marriage.
Promotion of spacing methods.
Promotion of terminal methods for those who are having more than two children.
Involving people in IEC activities.
Motivating people to demand Reproductive and child health services.
Encouraging people’s participation.
Discouraging gender discrimination with respect to conception and child care.
Encouraging 100% ante-natal registration and care.
Motivating and encouraging parents to care for infants and under 5 children especially in the
matter of nutrition and immunization.
b. Strategies used for EEC activities
Most of the IEC activities are 100% centrally funded and sponsored. They are planned at the State level as
per guidelines given by the Government of India and given to the districts for implementation, monitoring
and reporting. The number of activities and methods to be used are fixed depending upon the total grants
received. At the district level, the number of IEC activities are divided among several Primary Health
Centres in the district and given to the Medical Officers of Health for implementation.
c.
Method used
All the standard methods of health education are used. They are:
a.
b.
c.
d.
e.
Mass media, Door Darshan, Radio, Press, Video Films.
Folk media - Dramas and street plays.
Exhibition.
Personal communication by grass root level workers.
Group discussions:
Mother Swasthya Sangha (MSS)
Atte Sose Samvada
Village Health Committee
4. Village Panchayat
5. Local S.H.G. and youth and Yuvathi Mandals
1.
2.
3.
^4
20
TABLE- 2
Number of IEC activities by conducted in the last 3 years
Targeted & achievement during the last 3 years 1997, 1998 &
1999
SI No.
IEC activity
Target
Achievement
% of achievement
1.
Film Shows
14400
6198
43
2.
Film Strips
40500
40204
99
3.
TV & VCB
4050
2500
99
4.
Folk media programme
2700
2500
90
5.
Multi-media campign
-Nil-
169
6.
Press advertisements
-Nil-
979
7.
Press release
-Nil-
4273
8.
Exhibition - major
14400
5390
9.
Dramas
10.
Healthy Baby shows
10735
9222
86
11.
Mahila Vichara Vinimaya
12615
9770
77
12.
Mother-in-law and Daughter-inlaw program
8545
6921
81
13.
Mahila Dinacharini
6320
5073
80
14.
MSS Workshops: Taluka
175
160
90
District
9
9
100
15.
Folk Artist Workshop (1997)
19
8
16.
Village level MSS Tmg.
programme (1997)
3215
2920
37.3
32
90
C. BUDGET MADE AVAILABLE FOR IEC ACTIVITIES
SI No.
Year
1.
1997- 98
2.
3.
1998- 99
1990-200
Budget
75.01 lakhs
90.86 lakhs
61.48 lakhs
D. REMARKS OF THE DIRECTOR, R.C.H.
Though EEC is the base for creating demand generation for Family Welfare and Maternity and Child Health
Services, the inadequacy of funds has become a major barrier in the implementation of IEC strategy. On an
average, Rs. 70 lakhs are being spent on IEC per year under FW & MCH for a population of more than 5
crores in the State. This is a veiy meagre amount. However, there are various thrust areas under FW &
MCH which are not effectively covered.
With the introduction of Panchayathraj System in Karnataka, implementation of EEC at district level has
become very difficult. It is observed that a major portion of amount earmarked for district levels activities
21
remains unspent as the amount is either released very late or not released to District Health and Family
Welfare Officer by Zilla Panchayats.
Many posts of health education personnel are remaining vacant al all levels. Many Primary Health Centres
do not have sanctioned post of Block Health Educators and even sanctioned, posts are not filled. 255 posts
are vacant for 782 sanctioned posts of Block Health Educators. With all these constraints, IEC activities
have played a vital role in popularising FW & MCH programme in Karnataka.
Inference on the data presented above and on the remarks of the Director.
IEC activities are planned depending upon the budget made available for health education by the Central
and State Governments. The budget allotted is too small compared to the need. With so many eligible
couple living in 27066 villages spread over 1.92 lakh square kilometers it is impossible to reach them and
create awareness and motivate them. In fact, the progress made under RCH care especially in promoting
spacing methods is very low and so also increasing the age at marriage. Percentage achieved under film
show and exhibition is only 43% and 37% respectively. This is not encouraging.
The progress achieved so far in brining down birth rate and increasing the couple protection rate (58.6%)
cannot be attributed solely for these IEC activities. Most of the awareness about family limitation may be
cumulative effect of all the formal and informal health education activities and public opinion and social
pressure that were going on in the State over the years. The people in the State seems to have realised that
small family norm is best for their well-being and women in particular are coming forward for permanent
method even with one girl child. However, the present progress in couple protection rate is entirely due to
permanent method, that too female sterilization. Therefore, efforts should be made to remove the unmet
needs of nearly 11.5% of eligible couples and popularise and motivate people to accept spacing methods to
improve their health as well as reducing the infant and under 5 years childrens morbidity and mortality.
This will also help to bring down maternal mortality and morbidity. The male participation is also
important in the community. Another crucial and important health promotional measure is increasing the
age at marriage of girls. This is important in the long run. Both these measures are necessary to bring about
sustainable behaviour of people for small family norm.
Further, progress in RCH is possible only by health promotional strategies of advocacy, social support and
empowerment. Therefore, the State Health Education Bureau should gear up to the task in coming years.
Functions of H.E.B. II
The functioning of this section of Health Education Bureau is very important to reach the long term goals
set by the Bureau. However, the functioning of this section is not very satisfactory. This Section consists of
5 State level units with technical and non-technical staff. These units are (1) Audio-visual Unit (2) Field
Study and Demonstration Unit (3) School Health Unit (4) Exhibition unit and (5) Training Unit. Some units
are not working because of posts sanctioned are vacant for a long time and sufficient grants are not made
available for effective functioning. Each of these have a definite fimction to perform.
For example (1) The Audio-visual unit is concerned with (a) training different categories of health
personnel in audio-visual education and preparation of A.V. aids (b) Designing, production and
procurement of A.V. aids and other educational materials of use in the field (c) assisting in the evaluation
of A.V. aids produced in the Bureau. This section is not functioning because most of the key posts are
vacant for a long time.
(2) Functions of Field Study and Demonstration units are (a) To find out most suitable, and cost-effective
methods and media of health education (b) planning, organising and implementing and demonstrating
research-cum-action programmes (c) investigation of various health education issues that may arise from
time to time and assist in solving them. Thus this unit is very essential for supporting health education
activities. This unit also is not functioning because of the absence of the key staff for a veiy long time. The
^6’
22
existing staff do carry out some in the field demonstration unit, but it is negligible and not based on
scientifically planned studies.
Therefore, the staff for both these units should be found as early as possible and these units should be
energized. Both these units are very important to plan and bring out scientifically based evidence for health
promotional activities and materials they produce and use and also to bring out relative cost effectiveness
of several media they use.
(3)Exhibition unit which is very important for planning health exhibitions for the State. It is not functioning properly
because of the absence of the key staff over a long time.
(4) Student School Health Education Unit and Training Units are however functioning. Their performance
is given below.
SCHOOL HEALTH EDUCATION PROGRAMME
School health programme is a State plan scheme and started in the 3rd 5 year plan period. The objectives
and goals were laid down as per recommendations of Smt. Renuka Ray Committee Report in 1965. The
school health progranune first covered 30 primary Health Centres in 1965 and extended gradually to cover
35 Primary Health Centres in 1969, 103 Primary Health Centres in 1973, additional 300 Primary Health
Centres in 1980, 90 Primmy Health Centres in 1985, 100 Primary Health Centres in 1985, 122 Primary
Health Cnetres in 1987, 465 Primary Health Centres in 1998 and thus by 1989, 1245 Primary Health
Centres, out of the present 1686.
Goals and objectives.
Goals:
To enhance and Promote health education of school children in every possible manner to
enable them to adopt measures to achieve and remain healthy and develop in them a self
reliance and social responsibility and better quality of life not only as children of today,
but also as adults of tomorrow.
Objectives
1.
2.
3.
4.
5.
Promotion of positive health.
Prevention of diseases.
Early diagnosis, treatment and follow up of defects.
Awakening health consciousness in children.
Provision of healthful school environment.
Activities
To reach the above goals and objectives, the following activities were planned to be implemented.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Health appraisal of school children.
Remedial resources and following up.
Prevention of communicable diseases including vaccine preventable diseases.
Healthful school environment.
Nutritional services.
Mental Health and Dental Health and Eye Health.
Health Education.
Health Education of the handicapped Children.
Teachers training.
Proper maintenance and use of school health record.
23
Organisation for implementing the school health scheme
School health service is one of the basic responsibility of State Health services and it is incorporated in the
functioning of primary health Centre throughout the State. Therefore, the entire State health organization
from sub-eentre at the grass root level to the head of the Health Education Section at the State level are
responsible for implementing the scheme. The primary health centre staff plan and implement the school
health programme in their areas, district health supervisory staff (District Nursing superviser) and give
guidance and monitors the progress.
The District Health and Family Welfare Officer reports to the head of the Health Education and Training
section of the State Health Education Bureau at the State level. The District Health Education Officer plans
and implements the health education activity through the Block Level Health Educator. The Medical
Officer of Health of the Primary Health Centre is responsible for medical examination and follow up of the
health of the school children with the help and assistance of Health Workers under his/her control.
Performance.
Activities
Extent of Coverage
1.
Health appraisal
Only medical examination is carried out.
2.
Remedial measures and follow up
Done very superficially
3. ' Prevention of communicable diseases Only immunization services given to 1, 4, 7th standard
children. No other communicable diseases is detected
including vaccine preventable diseases
or treated.
4.
Nutritional services
No programme.
5.
Health Education
Not carried out systematically
6.
Teacher training
Carried out, but not sufficient.
7.
Maintenance of school health record
Not done systematically
8.
School environment, water supply and Nothing is done
sanitation
As shown above, the performance is patchy and all activities are not carried out except the medical
examination and immunisation of 1, 4 7th standard children Teachers training is also not sufficient and the
progress is not satisfactory. No attempt is made to take up any activity under school environment and
sanitation in schools. The follow up service is very unsatisfactory. Only activity that is carried out under the
school health service is medical examination and teachers training which is given below.
24
TABLE - 3
Showing performance is some activities of school health service during
1999-2000
Activities
1.
Percentage of target achieved 1999, 2000
T
Medical examination of school children
80%
2.
Immunisation
>
1st standard
83%
>
7th standard
100%
>
10th standard
73.54%
3.
Teachers training
69.55%
4.
Medical defective found
17.63%
L
As per the records furnished by the Health Education and Training (HET) of the Stale Health Education
Bureau, only school medical examination, teachers training and immunization services are monitored at the
State level. The performance of each district is scrutinised and progress noted. The district which lag
behind are noted and remarks sent to the respective District Health and Family Welfare Officers. Though
the physical targets achieved are above 80%, the quality of service appears to be very poor. During out visit
to about 8 Primary Health Centres in 4 districts, we had a chance to look into the school health records and
to discuss the matter with school head masters. Medical examination is done mostly by Health Assistants
and not by the Medical Officers except in Kodagu District. There is no follow up services. The quality of
training of teachers is not satisfactory according to most of the teachers. Teachers also feel that it is an
additional job and many of them are burdened with other school regular curricular activities. Health
education in schools is not carried out regularly and it is very unsatisfactory.
Recommendations
School health service is one of the most important health promotional activity. Though it is a regular
activity of the Health Department and Medical Officer of Health of Primaiy Health Centre is responsible
for a least medical examination of school children, it is not done properly.
Medical Officers of Health should be activated to take up school medical examinations seriously and the
performance monitored by the District Health and Family Welfare Officers and the MOHs who are lagging
behind should be reprimanded.
Health Education activity should be planned and every school in the Primary Health Centre area should be
covered. The Health Supervisers at the PHC level must be made responsible and the District Nursing
Supervisor and the District Health Education Officers should monitor the programme and report to the
District Health and Family Welfare Officers.
There is no attempt to improve school environment Water supply and toilet facilities should be provided to
every school. This should be taken up as a priority. This involves substantial investment and efforts should
be made to raise donations in the villages by giving equal contribution from the Government. This may be
taken up a phased manner.
Teacher training should be intensified and quality of training improved. There should be at least one trained
teacher in every school in the State by the end of 2002.
The furniture, flooring in most of the schools is veiy poor and should be improved.
39
25
Though this programme a combined responsibility of Health and Education Departments, the Education
Deptt., is not evincing sufficient interest in the programme. District Health and Family Welfare Officers
must start advocacy programme for District Education Officers and Zilla Panchayat President and the
District Executive Officer. The Additional Director of Health and Family Welfare Services should meet his
counter part at the State level and bring pressure on the District Education Officers. The District School
Health Councils and State Health Councils should meet periodically and hold discussion on the
performance of school health activities.
The government and Zilla Panchayats should be persuaded to invest in providing toilet facilities in all
schools in the State.
The vacant posts in Field Study and Demonstration Unit, Audio-Visual Unit, Exhibition Unit should be
filled up urgently and these units should be made functional and energised.
Question of brining all IEC activities under the Health Education Bureau should be closely examined
because the health education work in there programmes should not suffer when it is most needed. The
programme directors know when they should launch health education campaign and where. It is his
responsibility to achieve completion of the control programme. (Disease/Epidemic).
The routine health education programme covering all the areas of public health should be the responsibility
of State Health Education Bureau and special health education campaign should be left to the respective
programme Directors.
Recommendations on repositioning of Health Educators.
Ideally every PHC should have one Health Educator. Due to financial stringency this may not be possible
for the next few years. There fore one Health Educator may be attached two PHC and stationed at taluka
Health Office under the supervision guidnes and control of taluka Health Officer
All the BLHEs should be deputed to acquire DHE qualification at the rate of at least 50 every year.
At the District level one District Health Education Officer and one Deputy District Health Education
Officer may be retained.
At the Taluka level there is need for one senior Health Educator to coordinate the work of PHC level
Health Educators. This will strengthen the taluka level health organization and enables them to plan and
carry out effectively IEC activities
The Health Task Force may suggest to the Govt, to allocate at least 5 to 10% of the health budget for health
education purposes as approved by Central Health Council.
Joe
26
SECTION -IV
1. Grass Root Level Workers
2. Health supervisors
3. Health Educators
4. Interaction with other Health Related Departments
5. Interaction with Non-Govemment Organisations
6.
Interaction with people
1. GRASS ROOT LEVEL WORKERS
Total of 50 workers from 4 Districts posted to 16 Primary Health Centers were interviewed and
they were questioned about their knowledge and practice of health education and observed their
attitude towards the subject of health education.
Competency
Most of them are aware of their responsibility (80%) and felt that health education is one of their
most important and frequently undertaken job. most of them (85%) showed strong positive
attitude towards the job. in fact many expressed, they are able to do tlieir job because of their
health knowledge and their ability to talk to them and convince them about the health benefits of
their action. About 75% of them know various methods of health education and social
mobilization techniques. However , they are not making any efforts to get the cooperation of the
Village Health Committee and local people. The people’s participation in conducting health
programme at the grass root level is not much appreciated by the field workers and their efforts to
involve them is almost absent. Participation by members of the Mother Swasthya Sangha (MSS)
is however appreciated by all the workers. Most of the m are expressed they must have frequent
meeting involving mother-in-laws and daughter-in-laws and other elders, where they can discuss
common health problems and remove some doubts and misunderstanding, superstition about
child birth and child care.
Interaction with other Sectors
Grass root level workers get the maximum cooperation and help from the Community
Development Departments through Anganwadi workers. Inter-sectoral cooperation from other
sectors is not appreciable except Revenue Department from whom they get pregnancy allowance
sanctioned to their clients.
27
TABLE - 4
Grass root level workers, their level of knowledge and attitude on various aspects of Health
Promotion and Education Interviewed
Percentage
SI
No.
1.
Awareness
responsibility
High
Moderate
Low
Total Number
Responded
80
16
4
50
job
of
2.
Knowledge
80
12
4
50
3.
Attitude
75
14
6
50
4.
Need assessment capacity
76
14
10
50
80
12
8
50
60
30
10
50
70
10
20
50
80
16
4
50
20
40
40
50
10
30
60
50
10
20
70
50
5.
6.
7.
8.
9.
Knowledge about health
Education method
Social mobilisation tactics
Knowledge about the State
of people and N.G.O
participation
Need for Inter-sectoral
Coordination
Methods to be used in
Health promotion
Advocacy
Social support
Empowerment
Inference and recommendations
The knowledge, attitude and practice of grass root level workers with regard to health education as one of
their prime duties and its importance in implementing any health programme is satisfactory. However, they
are not in a position to appreciate and involve the local people in their planning or implementing health
programme in the villages. Though they understands the need and advantage of involving local leaders in
conducting health programmes, they do not have the skill to do so. Therefore, there is a great need for
training the grass root level workers in development of skill as to how to involve the local people in the
health programme. People participation in health activities under the primary health care strategy is one of
'r
■LIBRARY
library
ANO
o f
INFORMATION
CENTRE
y-
11C51
pH' \ 00
28
the main function of the Primary Health Centre as recommended by the Alma Ata Declaration. It has also
been realized throughout the world both in developed and developing countries that people’s participation
is sine qua non for the success of any health programme, and it (people’s participation) should assumes
greater significance in health promotion strategy.
Mother Swasthya Sangha (M.S.S) activities were appreciated by all. This progrmme should be
strengthened and frequently arranged, but such programmes will have to be monitored and supervised by
the Health supervisors. These meetings and contacts are conducted only once in a way or whenever the
money for it is released. This should not be the case. The programme should be a routine duty of health
workers. Health Workers male and female in eveiy sub-centre should plan their contact meeting every
month in every village.
EEC activities in each village should be planned and conducted by making use of local school children,
teachers, retired people and other public spirited social workers. Both male and female people should be
encouraged to participate. Organised community activities have better impact in creating awareness.
2. Health Supervisers
A total of 28 health superviser staff from 4 districts were interviewed. As shown in table 5 all of them are
aware of their over all responsibilities and they know that health education is one of their duties.
Conversation with them revealed that they have good knowledge about supervision and guidance. They
undertake frequent tours of their area and help the grass root, health workers is difficult cases of refusals of
advice and resistant cases towards family limitation. Their knowledge of supervision and guidance is only
with reference to normal, routine personal health education to the individuals. However, they also
participate in group education like M.S.S activities and jathas and video shows and baby shows. In many
places. Health Supervisors are resource personal for local NGO for their education campaign. However
they need training in health promotion strategies.
Problems of Health Supervisors
Many of them are quite senior people with 15 to 20 years of service. They do not have promotional
opportunities, because only few of them get a district Supervisory position. This aspect has led them to feel
frustrated and have become less enthusiastic in their job. This should be halted by appropriate remedy.
Most of the health work at the grass root level is carried out by the grass root level workers and their
supervisors. The department is illoffered to neglect their services, especially in the field of health
education. In fact, in many PHCs, it is the senior health supervisor who manages the PHC activities
because the Medical Officer of Health is either absent or attends only to clinical work.
49:7
29
TABLE - 5
Health Supervisors, their level of knowledge ,attitude on various aspects of health
promotion.
SI
No.
Percentage
1.
Awareness ofjob responsibility
High
Moderate
Low
Total Number
Responded
80
15
5
28
2.
Knowledge
70
20
2
28
3.
Attitude
80
16
4
28
4.
Knowledge and ability in need
assessment
80
10
10
28
78
12
10
28
75
15
10
28
80
18
2
28
65
15
20
28
20
60
20
28
18
70
12
28
15
60
25
28
5.
Ability to supervise and guide
6.
Social mobilisation capacity
7.
Knowledge about the need and
role of peoples participation
8.
Inter-sectoral Coordination
9.
Knowledge
on
promotional strategies
Advocacy
Social support
Empowerment
Health
Inference
Though Health Supervisors are important at PHCs level, for health education programmes , there seem to
be complacency in their attitude and practice. This may be due to the (1) presence of Block Level Health
Educator, who is responsible for implementing the organized health education or EEC activities at the PHC
level and (2) also the Medical Officers of Health are not taking any interest in administrative affairs of the
PHC and leave everything to the Health Supervisors. Health Education as an activity at PHC level is
suffering from these two constraints. Both these Constraints must be attended to by Medical Officers. They
must be made to take more interest in administration and management of health programmes including
health education at the PHC level.
There is need for proper supervision and monitoring of PHC performance from the District Health Officers
•47^
30
Recommendations
The Health Supervisors must be made responsible for all health education activities at the PHC level. The
administration should activate these people more particularly the Medical Officer of health must be made to
take interest in administration and management. This is possible by frequents visit of the District Health
and Family Welfare Officers to the PHCs and arranging seminars and symposium at District level for all
Medical Officers of health.
Block level Health Educators, District Health Education Officers and Deputy District Health
Education Officers
14 Block level Health Educators working at the Primary Health Centres, 4 districts Health Education
Officers and 4 Deputy District Health Education Officers working at District level were interviewed and
participated in focus group discussions.
Competency
Health Educator is a facilitator for Health Promotion at grass root level. He lias to plan and organize Health
promotion programmes and implement them through the grass root level workers.
As shown in table 6 most of them aware of their job responsibilities and know the job well. They have the
right kind of attitude and appeared enthusiastic in their job. They have sufficient skill to develop education
programmes. However, they are not making use of their skill in social mobilisation work and involving
people in health education activities. For Example, 90% of them have sufficient knowledge about the need
for inter-sectoral co-ordination and N.G.O involvement, but only 30% of them are making efforts. When
asked why it was so, many of them expressed that they are neglected lot. There contribution is not
recognized by superior officers. Only 50% of them have right kind of communication skill and 40% of
them are capable of talking to people on any subject. Their knowledge about advocacy is satisfactory, but
their ability to practice is doubtful. They do not have sufficient knowledge about social support and
empowerment. Except few District Health Education Officers, all others need intensive training in the
principles and strategies of health promotion.
Recommendations
Long Term
The Health Educator at the taluk and primary Health Centre Level and the district Health Education
Officers and the Deputy District Health Education Officers at the District level are the key persons for
planning and implementing IEC activities. They should have sufficient knowledge about the community
and community leaders and should be enthusiastic and committed for the task of spreading scientific
knowledge to people and involve them in health programme. In fact part of the reason for tardy progress of
health programmes is attributable to non-involvement and half hearted participation of people. This is the
case in all health programmes. It may be improper Malaria eradication, poor Tuberculosis control low
couple protection rate etc. Therefore, training and retraining of the health educators in social mobilisation
methods and in various modem communication technology is urgently required. Most of them take their
job very casually and do things very slowly. This may be due to lack of administrative pressure from
districts, which may be strengthen.
Short term
Immediately, there is a great need to arrange training programme for all health Educators on health
Promotion. A programme of reorientation for District Health Education Officers and Deputy District health
Education Officers and those possessing DHE qualification may be organized at the slate level in two or
three batches. The course may be of one week duration.
31
For those BLHEs without DHE qualification, a two week training progranune may be organized at the
Divisional level so that all the Health Educators are trained and equipped with skills to plan and implement
IEC activities under health promotion strategies as recommended by the Ottawa Conference on Health
promotion. More specifically they need training in group dynamics, motivation, communication,
interpersonal relationship, intersectoral coordination and social mobilization. They should also be
trained in modern electronic media and utilization of computers.
TABLE - 6
Block Level Health Educators. District Health Education Officers and the Deputy District Health
Education Officers their level of knowledge and attitude and ability
Percentages
SI.
No.
High
Low
Medium
1.
Awareness ofjob responsibility
80
15
5
2.
Knowledge
90
7
3
3.
Attitude
95
4
1
4.
skill of collecting and analyzing health need
assessment
65
20
15
5.
Knowledge of health education methods
80
10
10
6.
Social mobilisation tactics
70
20
10
7.
Knowledge about the local leaders , religious
groups and need to involve them in health
education activities
60
25
15
Knowledge
90
5
5
Practice
30
30
40
9.
Communication ability
50
25
40
10.
Ability to write, press release and talk to lay
people
40
40
20
11.
Knowledge about health promotional activities
40
40
20
12.
Knowledge about advocacy
40
45
15
Practice of advocacy
20
20
60
Knowledge about social support practice of
social support
60
30
10
20
30
50
40
30
30
20
40
40
8.
13.
14.
Need for inter-sectoral co-operation and NGO
involvement
Knowledge about empowerment practice of
empowerment measures
JO6
32
MEDICAL OFFICERS OF HEALTH
Twelve Medical officers of Health from 4 Districts participated in the discussions. Opinion and their
response to various issues is given below. Many of them know the importance of health education and
the need for extensive health education efforts. They also know that health education is one of their
duties, but they did not show any enthusiasm and interest in health education activities. Those who do
not have much clinical practice do well in all health programme including health education and those
having good clinical work say that they do not have enough time to do so much of non clinical work
including health education, in fact, medical officers who have good clinical practice take help of health
workers to assist him. Doing clinical work is good for the people, because many patient need not go for
distant places for primary medical care. Therefore, the clinical practice should not be disturbed, the
principle of integrating clinical practice with non clinical work like administrating and
management of health programme has been a failure. Now Taluk Health Offices have been
established and Taluka Health Officers must be made Administrator of Health service in the
Taluk and all the Health Workers including Medical Officers of PHCs should come under his
administrative control.
33
THE MEDICAL OFFICERS WERE QUESTIONED AND THEIR OPINION WAS
COLLECTED. THE RESULTS OF THE ANALYSIS IS AS FOLLOWS
SI No.
AREAS EXAMINED
REMARKS
1.
THE NEED FOR HEALTH PROMOTION.
2.
METHODS
OF
PLANNING
PROMOTIONAL ACTIVITIES
3.
IMPORTANCE OF SOCIAL MOBILISATION
4.
NEED FOR INVOLVING PEOPLE IN HEALTH 50% AGREED, BUT ANOTHER
PROGRAMMES
50% SAID PEOPLE DO NOT
COOPERATE.
5.
NEED FOR FURTHER
HEALTH STAFF
6.
QUALIFICATION REQUIRED FOR HEALTH ALL AGREED THAT THEY
EDUCATORS
SHOULD
HAVE
DHE
QUALIFICATION
7.
ADDITIONAL TRAINING FOR MEDICAL MAY BE USE FULL. ONCE IN 3
OFFICERS OF HEALTH
YEARS FOR UPDATING THE
RECENT ADVANCES
8.
NEED FOR ORIENTATION OF SYLLABUS
OF COMMUNITY MEDICINE IN MBBS
COURSE
9.
NEED FOR CHANGE IN THE ATTITUDE OF THEY AGREED THAT PUBLIC
POLICY-MAKERS
TOWARDS
PUBLIC HEALTH WORK IS NOT
HEALTH
APPRECIATED
BY MANY
DOCTORS IT IS RARELY
THAT
GOOD
HEALTH
WORKER
(DOCTOR)
IS
APPRECIATED, WHERE AS
GOOD
CLINICIAN
IS
APPRECIATED
BY
ADMINISTRATORS
AND
POLITICAL LEADERS, ALIKE
VERY
HEALTH ALL AGREED, BUT THEY DO
NOT WANT TO TAKE PART,
IN PLANNING PROGRAMMES
TRAINING
yes
ALL
AGREED
STRONGLY.
OF
MANY DO NOT HAVE ANY
IDEA
OF
SOCIAL
MOBILISATION STRATEGY
ALL AGREED THAT HEALTH
WORKERS
SHOULD
BE
TRAINED
AND
NOT
THEMSELVES.
ALL AGREED THAT THEY
MUST BE EXPOSED MORE
AND
MORE
THE
TO
ALL
COMMUNITY.
AND
NATIONAL
HEALTH
PROGRAMMES SHOULD BE
DEMONSTRATED TO THEM
IN MORE DETAIL.
34
OPINIONS OF PUBLIC HEALTH EXPERTS ON SOME ISSUES OF HEALTH PROMOTION
Health promotion is a part and parcel of public health. In fact the goal of public health is to create the
environment conducive, and mould the behaviour of all people favorable to positive health. Health
promotion comes even before the primary level of prevention. It is also called primordial prevention.
Therefore Health promotion is not something different from the main stream of public Health philosophy
and public health Actions
Opinion of public Health experts was sought about some aspect of health promotion. 98 people were
approached in and out of the state and 48 people responded. Their opinion is given below. Opinion
expressed by experts is overwhelmingly in favour of application of principles of Health Promotion in the
Public Health Action Programmes. Most of them also express that public health in recent years in being
neglected by policy makers and due status is not given to the Public Health & Public Health experts.
This will have to be over come by appropriate advocacy programme for top-level policy makers.
35
OPINION OF PUBLIC HEALTH EXPERTS
AGREED OR NOT (PERCENTAGE)
SL
No.
STATEMENTS RELATED TO
STRONGLY AGREED DISAGREED
THE
NEED
FOR
HEALTH
PROMOTIONAL STRATEGIES AND
THE
RATIONALE
AND
POSSIBILITIES
OF
IMPLEMENTING IN DEVELOPING
COUNTRIES
20
80
-NIL-
2.
METHODS OF PLANNING AND
IMPLEMENTATION
10
90
-NIL-
3.
IMPORTANCE
MOBILIZATION
5
90
5
4.
NEED FOR INVOLVING PEOPLE IN
HEALTH
PROMOTION
PROGRAMME
3
90
7
10
90
-NIL-
5
90
5
3
90
7
3
95
2
1.
5.
6.
7.
8.
OF
SOCIAL
NEED
FOR TRAINING
FOR
MEDICAL OFFICERS OF HEALTH,
&
DISTRICT HEALTH AND
FAMILY WELFARE OFFICERS ON
HEALTH PROMOTION
OF
DHE
DESIRABILITY
QUALIFICATION FOR HEALTH
DPH
AND
EDUCATOR
QUALIFICATION FOR HEALTH
&FAMILY WELFARE OFFICERS
NEED
FOR STRENGTHENING
SYLLABUS
IN
COMMUNITY
MEDICINE FOR MBBS AND DPH
NEED FOR CHANGE IN THE
ATTITUDE OF POLICY MAKERS,
POLITICIANS TOWARDS PUBLIC
HEALTH
JJO
36
OPINION ON SOME OF THE IMPORTANT STATEMENTS ON PUBLIC HEALTH
POLICY
SI
No.
1.
2.
3.
4.
5.
6.
7.
8.
9.
PERCENTAGES
STATEMENTS
AGREED
DISAGREED
THE CONCEPT, PRACTICE AND IMPORTANCE GIVEN FOR
PUBLIC HEALTH BY HIGHEST DECISION MAKING
PEOPLE ARE FOR IMPLEMENTATION OF HEALTH
PROMOTIONAL STRATEGIES.
100%
-NIL-
ONE OF THE MAJOR BARRIERS FOR IMPLEMENTING OF
THE HEALTH PROMOTIONAL STRATEGIES IS THE LACK
OF PROPERLY TRAINED PUBLIC HEALTH EXPERTS AT
THE HIGHEST DECISION MAKING LEVEL AND AT THE
MIDDLE PLANNING AND IMPLEMENTING LEVEL
98%
2%
PUBLIC HEALTH RESERCH IS NOT MAKING THE
NECESSARY CONTRIBUTION TO PUBLIC POLICY,
BECAUSE OF ITS TENDANCY TO WANT TO BE SEEN AS
EXCELLENT RATHER THAN ANY RELEVANCE TO THE
NEEDS OF PUBLIC POLICY
70%
30%
MOST PUBLIC HEALTH PROFESSIONAL AND CLINICAL
PROFESSIONALS
WORKING IN PUBLIC HEALTH
POSITIONS IN THE COUNTRYHAVE LITTLE TRAINING IN
WIDER ASPECTS OF HEALTH. THEIR EXPOSURE TO
RELEVANT SOCIAL SCIENCES AND HAVE HAD LITTLE
OPPORTUNITY TO LEARN FROM ROLE MODEL HOW TO
ADDRESS THE SOCIAL, ECONOMIC AND POLITICAL
FORCES AFFECTING HEALTH
60%
40%
POLICY MAKERS IN PUBLIC HEALTH AND HEALTH
PROFESSIONAL SHOULD MEET REGULARLY TO REVIEW
THE HEALTH PROBLEMS AND RESERCH EVIDENCE
AVAILABLE FOR THEIR DECISION MAKING
100%
-NIL-
90%
10%
100%
-NIL-
RESOURCE ALLOCATION FOR PUBLIC HEALTH MUST BE
MORE
EQUITABLE
CONSISTENT
WITH
ITS
CONTRIBUTION TO SOCIAL DEVELOPMENT AND NEW
RESOURCES SHOULD BE MOBILIZED
100%
-NIL-
THE GOVERNMENT SHOULD FIND WAYS AND MEANS
TO ENHANCE THE STATUS AND IMAGE OF PUBLIC
HEALTH CARE PROFESSIONALS CONSISTENT WITH
[ THEIR CRUCIAL ROLE IN HEALTH OF THE NATION.
100%
-NIL-
IN ADDITION, THE PUBLIC HEALTH SPECIALIST NEEDS
SKILLS IN COMMUNICATION, PUBLIC POLICY ANALYSIS
AND DEVELOPMENT
SOCIAL PROGRAMMES (THIS INCLUDING HEALTH) ARE
OPERATING UNDER EVER TIGHTER RESOURCE
CONSTRAINTS. THEREFORE, THE CONTRIBUTION OF
GOOD HEALTH TO SOCIO-ECONOMIC DEVELOPMENT
MUST
BE
CONVINCINGLY DEMONSTRATED
IF
ADEQUATE AND SUSTAINABLE RESOURCES ARE TO
FLOW TO THE HEALTH SECTOR
///
37
Recommendations
First of all there is need to educate other departments to impress on them, that health of the people is their
concern also and if there is cooperation and coordination, the health promotional programme can be
implemented smoothly and quickly. Moreover, the proper and successful implementation of health
programmes would also help other non health related programme substainlly, because people take more
and keen interest if the progranune is health related. Therefore, there is need for organizing advocacy
programme for managers and policy makers of other development departments at the State level, they
should be identified and educated. A programme for people can be effectively and efficiently implemented,
if all departments extends support and participate for example, the success of family Welfare programme to
some extent is due to the extensive intersectoral coordination and cooperation. The benefits that flow from
intersectoral coordination is much more than the benefits that accrue when departments work separately.
This is the fruit of interaction and this does not cost any thing more ‘instead’ strengthens interpersonal
bonds and Interdepartmental bonds and help cohesion and purpose in government institutions. This is very
important because people are loosing confidence in government run programme.
4. Interaction with other health related departments
Findings
Intersectoral coordination of all development departments of the government is important for speedier and
effective implementation of health promotional programme. In this connection, the representatives of the
following departments were contacted and information collected by using structured questionnaire. They
are Education, public Health Engineering, Information and broadcasting. Agriculture and Horticulture
departments. Most of them agreed that there is need for cooperation and coordination between health
Departments, and their departments but expect that the health department to take initiative in the
matter because health is the business and concern of health sector. Many of them arc not happy
about the attitude of doctors towards them.
5. Interaction with Non-Governmental Organisations
Eight non-govemment organization in 4 districts implementing some health education activities were
contacted. All of them are very much enthusiastic to do health work and help people to improve their
health. But most of them are dependent on government for funds and projects. The projects managed by the
NGOs are better organized and people are satisfied by the services. Some of them engage full time staff.
These workers seem to be more serious about their responsibility and duty and they have better rapport
with the local people performance of NGO seems to better than government organization but the budget of
NGO seems to be better than government organization.
In the long run it may be better to involve more and more NGOs and try to encourage them. Unless socially
spirited people come forward to manage non-govemment organization and if they are allowed to work only
with full time employees and work like any other profit oriented organizations, they would become very
soon as government run institutions. Therefore carefull verification of non-govemment organization and
the staff composition and the background of people who run such organisationis required before entrusting
any health related projects to them.
6. Interaction with the people
It was possible to meet some people in village in all the 8 primary Health Centres of 4 Districts Both men
and women in their homes and in public places were interacted to understand whether they know the health
education and other health programmes and whether they are getting adequate information about health.
Z/^
38
Findings
Most of the respondents showed indifference to our questions on Probing further, they reveled that the
health worker come and talk to them on health matters sometimes on family priming and antenatal care.
Mothers expressed that ANMs are advising them on diet and child care. They are not aware of any other
Health Education Campaign on other Health activities Except Aids/HIVs.
Many village are not satisfied by the services they receive when they go for the Primary Health Centre for
Treatment, except immunization services.
Nevertheless, it is surprising to know that many of the villagers have understood the rationale of small
family norm and they do not have much gender discrimination and coming to sterilization camps even with
one girl child. But many are not for male sterilization.
Most people want water supply at their doors through taps and some of them are also willing to bear the
expenditure on it, but they do not know why they want piped water supply. They do not know the
importance of sanitation and are not interest to have toilet facilities in their homes.
Recommendations
Therefore, there is need to launch health education programme systematically and continuously by the
government. The television media and radio should be used more frequently to reach large number of
needy people. The messages should be transmitted instead of scholarly talks through media. Prime time
should be chosen for telecasting messages and slogans. These programmes should be supplemented by
health workers in the field by way of clarification etc.
I
yj3
u
39
SECTION - V
1. Vision and Strategy Statement
2. Summary of the findings discussion and recommendations.
1. A vision strategy statement for improving the health status of Karnataka State in
21st Century
India including Kamataka State is facing a triple burden of diseases and disability even after 50 years of
development after attaining political independence. The first burden is that many preventable disease and
disability still persist as public health problems. This is due to partly, to administrative and technical
problems in the control of infectious and nutritional diseases and partly due to failure in public health
policy.
In addition, due to demographic transition and increase in expectation of life, people are surviving longer.
Unfortunately they survive to suffer from costly diagnostic facilities, costly drugs and longer hospital stay.
Relatively, more health budget is being spent on elderly people than young and working people. This is the
2nd burden.
The third burden is the emergence of new diseases like HIV/AIDS, Alcoholism, and Drug abuse.
These challenges together with higher infant mortality rate (70/1000), higher proportion, low birth weight
babies (30%) and higher mortality among under 5 children all pose a formidable disease burden to the state
In the face of these challenges, the health care system in the state is not that efficient as revealed by slowing
down of decline of IMR and under 5 year mortality (1999-2000). In recent years incidence of malaria,
tuberculosis and HIV/ACDS have also shown increasing tendency.
Therefore, there is a clear indication that the present and past public health policies and strategies are not
sufficient to lesson the burden of disease and disability in kamataka. This situation has lead the state to
spend more and more for curative services and get less and less in terms of health gain to the population.
The experiences of western countries from 1801 to 1971 has shown a similar trend.
Ottawa charter after considering all the above factors, has suggested to all countries to apply the principles
of health Promotion in their health policy. The Karnataka State would do well to implement these strategies
to achieve the maximum benefits in terms of improved health. These strategies would help the people and
government to reach the determinants of illhealth and destroy the roots. Even though this is a long, arduous
and expensive task, it is the only way left for reducing the burden of disease and disability, and to promote
the health of the state.
The 5 strategies suggested by the Character are:
1.
Build healthy public policy
2.
Create supportive environment
3.
Strengthen community action
4.
Develop personal skills
5.
Reorient health services
u
40
Major areas of concern that should be adequately addressed are:
❖ Development of human resource
❖ Sustained action to build supportive environment for all people
❖ Fostering intersectoral action for health
❖ Forging partnership between non-govemment organisation and government health sector.
With the application of principles of health promotion and hopefully improved, health administration, the
state may hope to improve health status of people of Karnataka, sufficient enough to live a healthy, useful
and procedure lives at least by 2015 in 21st century.
2. Summary of the Findings, Discussion and Recommendations.
The study reveals that the Karnataka state Health Department has required organizational infrastructure,
manpower and skill to launch Health promotional activities in the direction as suggested by the world
health Organization’s 9th General programme of work. However, some minor deficiencies and week
linkages have been found in the study and they are discussed below and remedial measures suggested in the
way of recommendations.
A. ORGANIZATIONAL STRUCTURE
The existing organizational structure in the state to take up the health promotional activities at the State,
District, Taluka and primary Health care center level is adequate and no additions or modifications are
required. The name of the state Healtii Education Bureau. Should be changed as Health Promotion and
Education Bureau. All the Health Education staff may be brought under one division.
B. MANPOWER
State level
Some posts of Technical Officers of the Health education Bureau at the state level are vacant for a long
time. This has led to the disfunctioning of these units and State health Education Bureau is very much
handicapped without these Units. For Example, the Audio visual Unit is essential for pre-testing all EEC
materials before they are produced in large numbers to be cost effective. Likewise die field study and
demonstration Unit is essential because the health promotional activities are field tested for their
applicability to the population and the cost effectiveness is determined before they are applied to a larger
area.
Therefore the vacant posts in Audio-visual, field demonstration and Exhibition units may be filled up
urgently.
District level
At the district level, no addition is required. The posts of the District Health Education officer and one
Deputy District Health Education officer may be continued.
Both of them should have DHE qualification (the state has sufficient number of DHE qualified Health
Educators). Their designation may be changed as District Health promotion and Education Officer and
Deputy District Health Promotion and Education Officer.
7/3"
41
Taluka Level
At Taluka level, there is no Health educator post are sanctioned at present. Therefore, one Health Educator
post may be sanctioned for every taluka. The State has sufficient number of health educator for 175 talukas
these post must be filled with D.H.E qualified Health Educators.
Primary Health Centre Level
The State has 1685 Primary Health Centres (this may go up also) and there are 782 Health Educators.
Therefore, there is shortage of nearly 900 posts. It is very necessary that each Primary Health Centre should
have one Health Educator and therefore additional posts may be created in a phased manner at the rate of
200 per year for the next 5 years.
C. TRAINING AND PROFESSIONAL EDUCATION
Training
The Study reveals that the Health Educators and Medical Officers need training in the health promotional
aspect. Short term training courses may be arranged for District Health Education Officers, Deputy District
Health Education Officers and the Medical Officers of health of all Primary Health Centres at the State
level and at Divisional level. The training may be of one week duration.
The Health Educators, without DHE qualification may be sent for acquiring DHE qualification at
Gandhigram in a phased manner.
Professional Education
The Medical Offices of Health of Primary Health Centre or Health Administrators at District and State
level should have right kind of attitude and interest in health promotion, because they are the kingpins in
health care delivery system. Therefore, their attitude and interest in health promotional activities are
important and essentional.
Since the medical students are molded in the philosophy of medical and health practice and service at
graduate level and it is here they form attitude and learn and develop skills, for right kind of attitude and
practices. The syllabus in Community Medicine in MBBS and DPH and MD courses must be adjusted to
include Health Promotional aspect of health care in a substantial way. The Community Medicine
Department must have infrastructure to demonstrate the operational aspect of Health Promotional activities.
The Rajeev Gandhi University of Health Sciences may be requested at issue guidelines and modify the
syllabus in Community Medicine for both at undergraduate, diploma and degree courses.
FUNCTIONS
IEC activities
Information, Education and Communication activities are very important and essential for creating
awareness of health and its importance in the minds of people. This is the 1st essential step in any health
education programme to enable people to take control of determinants of illhealth in the community. At the
present moment, there are no sufficient routine IEC activities in the State except centrally funded
programmes. The State health sector should plan and carryout Health Education Programmes as a routine
function of the Department and sufficient resources sould be earmarked for this in the annual health budget.
Sponsored programmes are also very few and they will not reach the people and their impact is negligible.
1J6
42
School Health Programmes
This programme is very important in inculcating the health knowledge, moulding childrens health attitude
and develop right kind of healthy life style favorable for healthy living. A comprehensive health
programme which is already in existence should be implemented in all schools in the State. Therefore, the
Government may be requested to issue orders to activate interdepartmental committee and implement
comprehensive school health programme. This programme should include (1) health appraisal and follow
up including medical examination (2) teachers training (3) providing good, clean and well ventilated class
rooms (4) safe drinking water and toilet facilities to all schools and colleges in the state.
Further a comprehensive health education curriculum may be framed and taught covering all aspects of
health promotion in a graded manner to the 1st Standard to X Standard students as is being done in
Europe, Australia and USA. The curriculum should include environment, air pollution, green house gases,
which are causes of illhealth. Healthy life style, population elements, family welfare and sex education
HIV/AIDS etc. Health promotional measures required to be cultivated and practiced by the individual,
family and community. Their social responsibility towards the health of others is very essential, for health
promotion of the population.
The Subject of health promotion may be made a compulsory curricular subject in schools and appropriate
educational material may be produced by State Health Education Bureau in collaboration with Health,
Health Education and Educational Experts.
D. ETHICS, ADVOCACY, HEALTH RESEARCH AND PARTNERSHIP FOR HEALTH
PROMOTION.
a. Ethics
Bioethics cannot be limited to medical practice and organ transplant. Bioethics is, in broader sense,
includes all interventions upon human being whether in a group setting or individual. Health Promotion
and Health Education are to produce a undoubtedly a type of intervention, to produce a modified life style,
attitudes, and desires, wishes and way of life. Health promotion also covers inequity and injustice meted
out to some section of society. In fact the rationale of application of health promotional measures is to
uphold the dignity of human being, affirmation of human right and the freedom to empower himself to
protect and promote health. So ethically also the health promotional principles are sound and the human
right demands the application of these measures in civil society.
b. Advocacy:
For successful implementation of health promotional policies and activities, the health sector should
develop strategies for Advocacy at various levels. It should be armed with solid evidence that health
promotion works and is worthwile. The health department should have a strong support and useful
partnership with industry and other non-govemment organizations.
Advocacy is required at all levels of governance. At the top level to policy makers, legislature and decision
makers (specially resource allocators). Health administrators at the top level must be able to take strong
leadership and plead with policy makers and exert pressure on them to change the directions of policy
wherever it is not favourable for health promotion. For this to succeed, the health administrators should
have solid and convincing evidence.
c. Health Research and Partnership
How and where convincing evidence is available? The scientific evidence can come only by health
research. The State has vast potential for collaborative research in health field. There are 23 medical
colleges with well equipped fully staffed, community medicine departments. The Government should
foster partnership between Medical Colleges and the District Health Administrators for producing scientific
>-/7
i
43
evidence about the benefits of health. Promotional activities. Collaborative action research is chapter and
more useful! because it gives feed back to the health programme manager to change the directions it
required. This is a highly potential area to develop and the Government can insist upon this while handing
over 3 PHCs to the Medical Colleges as contemplated recently.
d. Funds
The funds for IEC activities. Advocacy programmes and social mobilisation programmes should be granted
by the Government. It should be remembered that money spent on health promotion activities can bring 10
times more dividend than the money spent on drugs and purchase of sophisticated equipment. The
Government should proceed in the direction of allocating more and more taxfunds for attacking root
causes of diseases than treating diseases for cosmetic purposes.
The Central Health Council has already given guidelines to allot 5 to 10% of health budget for health
promotion. This should exclude the investment on water supply and sanitation.
E. Intersectoral coordination
It is very clear and apparent from the literature and a decade of experience that health promotional areas
overlap between many developmental departments. And the health promotion is possible only by
developmental approach. Moreover, health promotion is essentially a social and political action and
therefore, the health promotion goes beyond health sector and embraces all other developmental sector of
Government. Therefore, intersectoral cooperation and coordination between departments becomes very
necessary and crucial for successfull implementation of health promotional activities. Many case studies
and opinion of experts show that comprehensive multi-disciplinary health promotional programme yield
better results than programmes by single sector.
The study reveals that there is no strong linkage between health sector and other development sectors both
at the top and at the bottom levels. Therefore, modalities should be found out and experimented to secure
firm coordination and cooperation amongst all developmental departments at the Ministerial, Secretary,
Directors level at the District level and at the grass root level. Health promotional committee may be
formed with the State Health Council with the Chief Secretary as the Chairman to oversee the policy
directions, and matters of intersectoral cooperation between various sectors. Developmental sectors which
are very important and whose activities comprises many health promotional components are the following:
•
•
•
•
•
•
•
Education Department.
Infonnation and Broadcasting Department.
Community Development Department.
Agriculture Department.
Department of Industry.
Social Welfare Department and
Public Health Engineering Department.
1. Education Department
The study reveals that there is no strong linkage between Health and Education Departments in the State. A
close liaison is veiy much needed between these two Departments because one of the most important health
promotional programme in the long run is the School Health Programme (SHP). For successful
implementation of School Health Programm very close collaboration is essential. Already existing
committees at state & District levels may be given sufficient responsibility & powers and resources.
44
2. Information & Broadcasting Department
This sector is very much relevant to day than ever before. Because of the explosion of information on
health promotion and multitude of media telecasting such information. Many TV Stations in their
enthusiasm to make T. V. shows attractive especially to the youths include scenes and actions that actually
convey unhealthy life styles Therefore, there must be a Watchdog Committee to watch out such shows
and bring it to the notice of controlling authority in the State. Such a Committee should include
public people also.
For purposes of telecasting health promotional activities by the governmental media, a plan of telecasts has
to be prepared by the Information and Broadcasting Department and the health experts either from the
Department of Health or from non-government organizations doing health promotion work to be consulted
before telecasting.
Health Promotion and Education Bureau should prepare their own TV scripts and request the Information
and Broadcasting Department to telecast periodically. Details may be worked out jointly by the two
Departments. The Health Department should gather public opinions about the television shows that have
health implications and bring the telecasts that gives mis information, wrong information if any to the
notice of the information and broadcasting department. Health Department through its health promotion
and education wing should identify the health promotional elements in the programmes of these sectors and
discuss with the respective authorities.
Similarly, the directions by the Government may be issued to all development oriented Departments to
have a close liaison with the Health Sector.
3. Collaboration with non-government organisation
Health promotional activities are carried out mostly at the level of people, in the families, community,
villages and slums. Proper understanding and cooperation of local non-government organizations are
very useful and essential. At present there is no formal collaboration with the Non-Govemment
Organizations. The Government may issue directions to the health sector to establish firm and sustainable
relationship with local non-government organizations for implementation of health promotional activities.
These organizations are very essential for social mobilisation, people’s contact and people’s participation in
the programme.
7Z9
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45
SUMMARY OF RECOMMENDATIONS WITH REASONS AND
EXPLANATIONS
Recommendation -1
It is recommended to change the name of the Health Education Bureau as “Health
Promotion and Education Bureau”.
Reason:
First of all to conform with the recent advances in the international Health forum and
secondly to add additional importance of health promotional efforts of public health. Because the
health promotion incorporates other two fields of action in addition to health education. They are
social support and empowerment of people for better health. Therefore, the organization that
deals with health promotion should have the appropriate name as “Health Promotion and
Education Bureau”.
Action:
Ministry of Health and Family Welfare can issue an executive order to this effect.
Recommendation - 2
The existing two divisions of Health Education Bureau should be merged and all the
health education staff at the Primary Health Centre, District level and at the State level should be
brought under the newly named division of “Health Promotion and Education Bureau.” This
division should be headed by an Additional Director of Health and Family Welfare Services, who
will work directly under the Director of Health and Family Welfare Services. However, the
District Health Education Officer and Health Educators at Primary Health Centre will work under
the control of District Health and Family Welfare Officer, Taluka Health Officers and Medical
Officer of Health of Primary Health Centres.
Reason:
Health promotion and education activities need special efforts and attention of the health
department. Health promotional strategies and activities will have to be planned, executed and
monitored at the State level, District level, Taluka level and Primary Health Centre levels. Unless
there are designated personnel at various levels, the programmes cannot be effectively
implemented. Secondly, the health promotion and education is becoming a specialised field in
view of advances in communication and multi media. Therefore, communication specialists and
well trained and skilled specialists are required to understand and interpret various behaviour
changes taken place in the community as a result of health promotion and education activities.
Further, if all specially trained and qualified staff are working under one direction and control,
they would perform better and will be more efficient and more productive because of their
combined talents and expertise.
Action:
Ministry of Health and Family Welfare can issue an executive order merging the two
divisions of Health Education Bureau into one division of “Health Promotion and Education
Bureau”.
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46
Recommendation - 3
Every newly created Taluka Health Office should have atleast one qualified Health
Educator. His designation should be Taluka Health Promotion and Education Officer. He has to
work under the control of Taluka Health Officer and under the technical control of District Health
Promotion and Education Officer. He is responsible for planning, implementation and monitoring
of all health promotional activities with the help of Health Educators of PHC and grass root level
workers and their supervisors at the Primary Health Centre.
Reason:
In the context of supervision and guidance of health promotion and education activities,
the existing District Health Education Officer is not efficient because, of the vastness of the
district and very large population to be served. Therefore, a supervisory and guidance staff at
Taluka level will be good and can be more effective because he can contact the field staff more
frequently and the area he has to cover is reduced markedly. He can guide and supervise all the
activities in all the PHCs of the Taluka and report to the District Health Education Officer (See
also page 39 of the report) These officers will have to be mobile because his/her activity involves
mostly touring and therefore they should be given traveling allowance and loan to purchase two
wheelers.
Action:
Regular Government order will have to be issued after obtaining clearance from the
Finance Department for the creation of 175 Taluka level Health Promotion and Education
Officers. Along with this order, the loan for these officers for purchase of two wheelers should
also be sanctioned.
Recommendation - 4
Ideally, there must be one Health Promoter and Educator for every PHC. This requires
more than 1600 Health Promoters for the whole State. But there are only 782 Health Educators in
the state at present. To cover all PHCs with Health Promoters, it is recommended to attach two
PHCs per every Health Promoter and Educator. But, he has to be attached to Taluka Health
Office and made to work under the control of Taluka Health Promotion and Education Officer.
And additional 273 Health Promoters post may be sanctioned to cover all PHCs. This will ensures
one Health Promoters or every two PHCs.
Reason -1:
Now there are 782 sanctioned posts of Health Educators in the State. Of these, 688
people are working and 94 posts are vacant. Of 688 persons who are working, 217 people have
DHE qualification and the remaining 471 people do not have DHE qualification. These people
may be posted as Health Promoter and Educator and two PHCs may be attached to each person,
thus 942 PHCs can have Health Educators. The vacant posts of 94 may be filled up as soon as
possible, so that another 198 PHCs can be covered. Still 545 PHCs will go without Health
Promoter and Educator and to cover these PHCs 273 additional posts required to be sanctioned.
Reason - 2:
All India staffing pattern for PHC includes Health Educator. In addition, there must be
some person at the grass root level to initiate and take leadership in a very vital area of public
22 J
47
health. Health promotion is a process of enabling people to increase their control over the Health
determinants. It involves people and host of other public persons. He/she should be in constant
touch with village formal and informal leaders to secure their co-operation and use their influence
in order to bring about critical social pressure on general public to change their behaviour. People
will have to participate in a big and sustainable way to bring about this revolutionary change in
the human health behaviour and practice. He is a grass root level worker at the PHC in health
promotion and education and a facilitator and an organizer. Unless there is one person with
sociology background with mass communication skill, all efforts made from the top in the field of
health promotion and education will be of no avail. Therefore, one Health Promoter and Educator
per Primary Health Centre is a must and this staffing pattern should be continued and additional
posts may be sanctioned, in a phased manner.
Qualification for Health Promoter and Educator
He/she must have a basic (BA or MA) University Degree in sociology and should have
undergone training in health promotion and education. (A six weeks training programme may be
arranged for all those who have no DHE qualification and for new recruits before they are posted
as Health Promoter and Educator)
Recommendation - 5
All vacant posts in Field Study and Demonstration Units, Audiovisual Unit, Exhibition
and Student Health Education Unit should be filled up immediately and the above units should be
made functional and energized.
Reason:
These units are essential for any health promotion and education organization. It is in
these units innovative action programmes are tested before they are employed on a large scale.
They act as field laboratory for pre-testing IEC materials and they are research-cum-action units
to give feed back in concurrent and terminal evaluation of an educational activity. Therefore, all
these units may be retained and vacant posts may be filled up. These units are also important for
planning, monitoring and evaluation of health promotion and education activities (see also page
34-35 and 53 of the report for further justification)
Action:
Director of Health and Family Welfare Services in consultation with the Health
Commissioner can fill-up all the vacant posts.
Recommendation - 6
Now, the IEC activities are organized by several division like RCH, IPP IX, AIDS,
Tuberculosis and Leprosy. It is recommended that all IEC activities should come under the
responsibility and control of the Health Promotion and Education Division. This division should
implement and monitor all IEC activities.
Reason:
Health promotion and health education is a team activity with special input by Health
Promoter both at the implementation level and planning and monitoring level. The division of
health promotion and education is staffed with people who have the skill to organise mass
J?#
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48
education campaigns and group education programmes involving people and there are
Administrators at the taluka and district level to over see all IEC activities and give appropriate
guidance. Therefore, all IEC activities of all divisions should be entrusted to the division of
Health Promotion and Education to improve efficiency (see also page 55 of the report)
Action:
An executive order from the Health Commissioner is required. Because all programme
Directors will have to surrender the funds from their budget to this division for implementation of
the health education activities.
Recommendation - 7
Routine health promotion and education programmes should be organized in eveiy PHC
covering all villages. All the grass root level workers and their supervisors must be responsible
for implementing these activities. These activities must be planned, organised and monitored by
the PHC Health Promoter and Educator and supervised by Taluka Health Promotion and
Education Officers. Atleast Rs. 5000/- per PHC per annum may be budgeted for health promotion
and education.
Reason:
At present there is no organised routine health education activity to perform either by the
Health Educator or grass root level health workers except personnel communication to pregnant
mothers by ANM and sponsored IEC programmes which are funded by Central or State funds.
This is not correct. This appears to be the reason why Health Educator at PHC are used for other
odd jobs by the Medical Officers because he has no routine job to do till a sponsored programme
is sanctioned and funds released. The health promotion and education should be a routine Primary
Health Centre function. It is the duty of Health Promoter and Educator to plan social mobilization
programme, group education programme in eveiy village in the PHC and implement the plan
with the help of local grass root level workers and their supervisors. Some funds must be made
available for the PHC for health promotion and education activities. The Health Promoter at the
PHC may be allowed to raise funds from philanthropists for the programmes. But the State should
provide some seed money for the purpose. The programmes like M.S.S. and self-help groups,
jathas by school children should become a routine activity in every village. Whenever there is a
sponsored programmes, it should also be implemented as and when there are sanctioned by the
state and central governments.
Action:
The Director of Health and Family Welfare Services should send the proposal to Finance
Ministry with the concurrence of Health Commissioner and plead with the budget allocators to
make provision of atleast Rs. 5000/- per PHC per annum.
The Director of Health and Family Welfare Services should also issue executive order to
make IEC activity as a function of the Primary Health Centre and the planning, implementation
and monitoring should be the responsibility of Health Promotion and Education Division. Of
course the District Health and Family Welfare Officer and Medical Officers of Health are
responsible in their jurisdiction for implementing these IEC activities (see also page 55 of the
report for justification)
723
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49
Recommendation - 8
5 to 10% of the Health Budget of the State may be earmarked for 1EC and associated
activities in the annual budget. This has been already agreed upon by the Central Health Council
a few years ago.
Reason:
IEC activities which involves awareness programme. Advocacy programmes require
funds for organization and implementation. These programmes are essential to implement the
following suggestions envisaged in the Ottawa and Jakarta Declarations. They are:
1. Raising awareness among the general public about the determinants of diseases and
illhealth.
2. Promotion of social responsibility of people about the health of others.
3. Encourage people to participate and take control over the root causes of illhealth.
4. Secure infrastructure for health promotion by motivating people to help build health
infrastructure in all villages and towns.
5. Mobilization of resources and public opinion required for health promotion in all
cities, towns and villages.
6. Increase community capacity and empower the individual about health promotion
and others.
Apart from the above, the health promotional activity involves large number of people and
groups and not merely individuals. The health promotional activities are aimed at and deal
with apparently healthy people with a view to help them to gain better health and become less
susceptible for diseases and thus saving lives, lessen the burden of diseases, and increases
productivity. This in the long run help communities to improve their health status, to stabiles
the population size by adopting small family norm.
Action:
Health Minister and Health Ministry of the State may be requested to take initiative by
putting the proposal before the cabinet and then to Finance Ministry for concurrence.
Recommendation - 9
Advocacy programmes on Health Promotion and Education may be organized throughout
the State at various levels. The actors and clienteles is given below. These programmes should be
conducted periodically and should become a annual or bi-annual feature of the Health & Family
Welfare Department.
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50
They should deal with appropriate health promotion.
Level
State Level
Actors
Clienteles
1. Director of Health & F.W. Services.
1. Policy makers
2. Additional Director of Health & FW 2. Legislatators
Services of Health Promotion and
3. Finance Ministry Officials
Education Division.
3. Joint Director of Health Promotion 4. Top level Bureaucrats
and Education Dvn.
5. State level religious leaders
4. Deputy Director, IEC
6. Health Professionals
7. Health Researchers
District Level
1. Dist. Health and FW Officers.
2. Dist. Health Promotion and Edn.
Officers
3. Dy, Dist. Health
Education Officers.
Taluka Level
Promotion
1. Zilla Panchayat President and
Members.
2. Chief Executive Officer.
& 3. Local Religious Leaders.
4. Local Legislators and MPs.
1. Taluka Health Officers.
2. Taluka
Health
Promotion
Education Officers.
3. Health Supervisors.
and
1. Taluk Panchayat President
and Members.
2. Taluka MLA.
3. Religious Leaders.
4. Local Formal Leaders.
5. Local NGO.
Primary
Health
Centre Level
1. Medical Officer of Health.
2. Health Promoter and Educator.
1. Village Panchayat President
& Members.
2. Local Teachers.
3. Health Supervisor.
3. Local NGOs.
4. Self help Group.
5. Village Health Committee.
Reason:
Advocacy and lobbying have become useful mechanisms for motivation and convincing
policy makers and decision makers to take rationalistic view and right decision. These
programmes are also needed at implementation level (see pages 16-17 and 49 of the report.)
Action:
Health Commissioner should issue direction to Health Department.
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Recommendation - 10
A comprehensive School Health programme should be implemented in all primary and
secondary schools in the State.
Reason:
Now primary and secondary education is compulsory till the age of 14 for both boys and
girls. Therefore there is every possibility of reaching 90 to 95% of children (upto the age of 14) in
the schools. School health programme has become one of the most beneficial health promotion
activity not only for the present generation of children, but also for the next generation of parents.
Many case studies all over the world have accumulated evidence, to show that school health
programme is the most cost effective method of health promotion activity. To be effective, it
should be comprehensive and cover 90 to 95% of the target groups, (see also pages 17-18 of the
report)
Action:
Government order may be issued directing the Health Department to draw up a plan of
action for implementing a comprehensive school health programme in consultation with the
Education Department. Necessary funds may also be made available. There is no need for special
staff for the Health Department for school Health services. The existing staff at the PHC or
Taluka level is sufficient. However some more Funds are required for building toilets and water
supply facilities in every school, which may be sanctioned by Zilla Panchayat.
The existing State level and District level School Health Review Committees may be
activated or fresh Committees may be constituted with Education Commissioner as Chairman at
the State level and the Deputy Director as Chairman at the district level. The education
department is ready to collaborate, but the Health Department is not responding sufficiently to
plan and implement a comprehensive school health programme. Medical officers must be made
responsible to implement school health programme.
Recommendation - 11
The syllabus for primary and secondary school education may incorporate health
knowledge and health practices topics in the curriculum, so as to include all aspects of health,
environment, air pollution, population problem etc., and social responsibility of the individual and
of the society for community health, and the need to take into account the equity and social
justice to all sections of people.
Reason:
There is great need to add health topics in school curriculum in a graded way from 1st
standard to 10th or 12th standards. The knowledge learnt here is important and essential for proper
healthy behaviour and develop healthy life style for the entire life span of the individual. It helps
children to adopt good health habits and discard bad health habits and practices. Many bad health
habits are cultivated in childhood without knowing fully there effects on health. Educated person
should know desirable health habits, behaviour and practice them by himself and educate his
family. He must be a model to others. Moreover, many personal habits and behaviour associated
with good health are formed during childhood, the neglect of which may be the causes of illhealth
in adult life or old age.
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52
Therefore, scientific information and rationale behind good healthy life style should be
made available to every student then and there, and from the early age. Environment of schools
should also be healthfull.
Action:
Education Ministry should give direction to curriculum committees to involve Health
promotion and Education Director while making reversion of curriculum for primary and
secondary education from 1st to 10th standard. Out line of the proposed curriculum is given in the
annexture
Recommendation - 12
Training for District Health and Family welfare Officers and Taluka Health Officers and
Medical Officers of Health in health promotion and education may be organised at different
levels as follows:
State level
Dvnl. level
3. District level
Dist. Health & Family welfare Officers
Taluka Health Officers
Primary Health Centres doctors
1.
2.
Duration:
State level
Divisional level
District level
2 days
1 week
11/2 week
The topics should include all the elements of health promotion and education and rationale behind
this movement.
Reason:
District Health and Family Welfare Officers and Medical Officers are the kingpins in the
implementation of any public health programmes. Unless they are motivated and takes
professional interest in the matter, these programmes cannot be implemented. Therefore, the
training of these personnel are very important.
Action:
Health Ministry should issue Government Order and direct the Health Department to plan
and implement the training programme as early as possible.
Recommendation - 13
The Government may be recommended to bring about intersectoral coordination and
cooperation among all Developmental Sectors of the Government.
Reason:
Health promotion and education is a developmental approach to achieve better health for
the people. All developmental programmes have the same goal of achieving better standards of
living to all people. Therefore, intersectoral coordination is an essential strategy to achieve health
promotion. Further, when more sectors of Government are involved in health programmes the
J2 7
53
health message spreads and reaches more people and the programme is more likely to succeed
than when it is done by one sector.
How it could be done
A Coordinator preferably Joint Director of Health Promotion and Education may be
appointed for this purpose. He will have to identify the areas for discussion and coordination
needed in implementing a particular development programme, involving health component. He
will then arrange a discussion with the respective Departments and the Additional Director of
Health Promotion and Education and other public health experts, (see also page 57-58 of the
report)
Recommendation - 14
Government may involve non-govemment organizations in health promotion and
education programmes at all levels
Reason:
Non-Govemment organizations are another organizational resources available to the
government to bring about health promotion of people. The health promotional programmes
involves active participation of people, ultimateltely they are the beneficiary of any health
programme. The local NGO know the local people better and they can raise additional resources
needed for the programme.
Action:
Health Ministry may direct the Health Departments to involve local non-Govemment
organizations to participate in all health programmes in a substantial way.
How it can be done
The concerned Health Department official should give preference to non-govemment
organizations to preside over a function or to inaugurate a group discussion and allow them to
talk and discuss the issues and thus encourage them to participate in awareness programmes or
advocacy programmes. There must be equal partnership between NGO and government sector
and the management of the programmes must be transparent and open. The NGO also will be
helpfill to raise additional resources whenever needed.
However entrusting, the sole responsibility to NGO for implementation of an health
programme without proper control and check may be counter productive in the long run.
Recommendation -15
Recommended to the government to make public health qualification like DPH or MD
(CM) mandatory qualification for appointment as District Health & Family Welfare Officer.
Reason:
Health promotion is a public health activity. It involves people. It is a social and political
action. It envisages a planned activity. The health promotional programmes have to be planned,
monitored and evaluated scientifically. Besides, the public health expert should be able to exhibit
54
leadership qualities and should be an efficient manager. To acquire all this knowledge and
develop skill one has to undergo additional training and education. A physician after his MBBS
degree or with clinical postgraduate degree will have no chance to acquire proper attitude, skill
and theoretical knowledge needed to become a technical administrator. Therefore, a public health
administrator should have public health qualification.
Action:
Government can change the cadre rules and incorporate the DPH or MD (CM) to be
promoted as District Health and Family Welfare Officer.
Recommendation -16
The syllabus for MBBS course, DPH and MD(CM) may be modified so as to include all
the essential principles, strategies and action programme of health promotion and education, so
that these professionals should be capable of being community leaders in order to mobilize
community participation.
Reason:
The new ideas and new developments in public health and preventive medicine are many
and they are increasing every decade. People in the academic field are not so well versed about
what is actually happening in the field or commumty. Community medicine is changing much
more than other fields of medicine. Hence, there is need to incorporate these principles in the
curriculum of basic doctors and public health experts.
Action:
Rajeev Gandhi University of Medical Sciences Vice Chancellor can direct the
Curriculum Committee of the university to consider and incorporate the principles and practicing
of health promotion and education in MBBS., MD and DPH courses.
Recommendation -17
Training for State, District, Taluka and PHC level health education staff should be
organized at various levels.
SI
No.
1.
2.
State Level
District Level
3.
District Level
Level
Cadres
All State level and District level staff.
All Health Educators in the District with
DHE qualification._____________ _____
For Health Educator without DHE
I qualification.
Duration
3 Days
1 Week
6 weeks
Reason:
Health promotion and education process involves more than mere education. The social
support and empowerment are additional action programmes that these people will have to
undertake to implement health promotion strategies.
.1
55
Action:
Director of Health and Family Welfare Services can issue order for training of these key
officials for health promotion and education.
Recommendation -18
Health Promotion and Education Division should have the staffing pattern and the top
level staff should have qualification and experience as follows:
1.
Additional Director of Health and Family
Welfare Service
•
Number of posts
One
Status
•
2.
Qualification
One
Qualification
MBBS., DPH., or MD (CM) should
have worked atleast 10 years as Health
Administrator at the District or State
level. Qualification in Communication
is desirable.
Joint Director of Health Promotion and
Education.
One
Number of Posts
•
of Health
MBBS., DPH., or MD (CM) should
have worked atleast 15-20 years as
Health Administrator at the District or
State
level.
Qualification
in
Communication is desirable.
Joint Director of Health and Family
Welfare services.
•
3.
Head of the Division
Promotion & Education.
Appointment should be promotion by
selection from among the District
Health Promotion and Education
Cadre. Seniority should be the criteria
unless a person has an outstanding
achievement in the field.
BA or MA in Sociology, DHE and
Degree or Diploma in Communication
and should have had 10-15 years of
experience
as
District
Health
Promotion and Education Officer or
equivalent post in the Division of
Qualification
7^0
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56
Health Promotion and Education.
4.
Deputy Director of Health Promotion and
Education.
Number Of Posts
4
One for RCH Training
One for School Health
One for Non-Communicable diseases
&AIDS
One for Communicable Diseases &
Research
•
5.
BA or MA in Sociology and DHE and
should have not less than 10 years of
field experience as District Health
Promotion and Education Officer.
Diploma or Degree in Communication
may be given preference.
Qualification
District Health Promotion and Education
Officers
Number of Posts
27 or as many as number of Districts in
the State.
By promotion among the District
Deputy Health Promotion & Education
Officers.
•
6.
BA or MA in Sociology and DHE and
should have had atleast 5 years of
experience as District Officers. Degree
or Diploma in Communication may be
preferred.
Qualifications
Deputy District Health Promotion &
Education Officers
Number of Post
27 or as many as number of District in
the State
Appointment by promotion from
among Taluka Health Promotion and
Education Officers.
•
BA or MA in Sociology and DHE and
atleast 5 years as Taluka Health
Promotion and Education Officers
Qualifications
/3l
57
7.
Taluka Health Promotion and Education
Officers
Number of Posts
175 or as many as number of Taluks in
the State
Appointment by promotion from
among the Health Promoters and
Educators
•
8.
BA or MA in Sociology and DHE and
atleast 5 years of experience as Health
Promoter and Educator
Qualifications
Health Promoter and Educator
1635 or as many as number of PHCs in
the State
Number of Posts
Appointment by fresh recruitment from
among the applicants.
•
BA or MA in Sociology, DHE
qualification or a Diploma or degree in
communication may be preferred.
Candidates should possess:
Qualifications
> Good knowledge in Kannada
9.
Technical Officers
3
Number of Posts
139-
good
>
Should
possess
communication
>
Should posses good leadership
quality
>
Should have good knowledge
about the community, group
dynamics. Lobbying, negations
etc.
>
Preference may be given to
people who are living in
villages of the respective
Districts. The existing Health
Educators may be absorbed as
Health Promoters & Health
Educators and the rest may be
recruited
58
One for Audiovisual Unit
One for Field Study & Demonstration
Unit
One for Exhibition Unit
10.
Health Supervisors
2
One of Training Unit
One for field Study & Demonstration
Unit
11.
Nursing Officers/Public Health Nurse
2
One for Training Unit
One for Field Study & Demonstration
Unit
12.
Home Science Asstt.
One FS & DU
13.
Social Scientist
One FS & DU
14
Teacher
One FS & DU
15
Artist-cum-photographer
One
16.
Artist
One
17.
Sub-Editor
One
18.
Projectionist
One
19.
Craftsman
One
20.
Silk-screen Technician
One
Qualification and experience required for the above posts are already existing in the
Department, the same may be applied.
The following recommendations have been made to National Governments by a W.H.O.
international meeting held in Geneva - 27 - 30 November 1995. They may be considered by the
Task Force wherever they are applicable.
•
Resource allocation for therapeutic medicine and for public health must be more
equitable, and new resources should be mobilized for public health.
•
Government should promote, facilitate and support voluntary public health action and
community participation in policy development.
•
Governments should promote and facilitate intersectoral cooperation in public health. In
order to achieve an effective and coherent public health policy, health ministries must
recruit the partnership of other departments such as trade, industry, agriculture, housing.
)3S
59
public works and so on, all of which have key roles in the development of the new public
health.
•
Governments should find ways and means to enhance the status and image of public
health care professionals consistent with their crucial role in the health of a nation; such
status and image should not be less than that of professionals offering predominantly
curative care.
Governments must seek an integrated approach to health, the environment and
socioeconomic development and, in the words of the Saitama declaration, “improve
solidarity in a global approach to generate, distribute and utilize public resources for
sustainable development, promotion of health and protection of the environment.”
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60
EXISTING SYLLABUS ON HEALTH IN PRIMARY AND SECONDARY EDUCATION
IN THE STATE
3Rd Standard
4Th Standard
5Th Standard
6th Standard
7th Standard
8th Standard
Chapter 1.
Parts of the Human Body - Sense Organs - Care of the Sense Organs
- Teeth - Types, Growth - Brushing - Bad Breath - Tooth Decay
Chapter 2.
Food - Common Food Items - Nutrients found in food - Growth
and Food - Protective Food - Milk - Complete Food - Cooked Food
- Food Eaten Raw - Cooked and Uncooked Food - Washing Cleaning - Vegetables and Fruits.
Chapter
Human Body - Nutrients and Health.
2.1
Functions briefly on respiration and circulation
2.2
Our Food different Nutrients, sprouted seeds
2.3
Digestion of food - Digestive Juices - Teeth
2.4
Food Preservation - Canned Food - Improper serving and spilling
result in wastage - Over cooking destroyed certain nutrients
2.5
Food and Health - Contamination of Food by flies - Food exposed
to dust - Food preserved low temperature
2.6
Water and Health - Drinking water should be free from floating
matter and germs - Water should be purified by filtration and
storage of water - Wastage of Water should be avoided
2.7
Health and Hygiene - Surround should be kept clean - Unclean
surrounding cause diseases there should be clean drinking water and
toilet facility in houses and schools - Breeding of Mosquitoes
Chapter 6.
Human Skeleton
Chapter 7.
Physical exercise and good postures
Chapter 8.
Our Food - Carbohydrates - Proteins - Fats - Vitamins - Minerals Water - Vitamin deficiencies - Storage of Food - Fried Food Sprouting Seeds.
Chapter 9.
Infectious diseases - Communicable diseases - Food Borne - Vector
Borne - Prevention Inoculation — Clean Food — Clean Environment
Chapter 13.
Environment and Pollution - Housing.
Chapter 19.
Prevent Water and Air Pollution
Chapter 8.
Digestive System - Respiratory - Sense Organs.
Chapter 10.
Water Pollution
Chapter 13.
Man and Environment Pollution
Chapter 9.
Water Pollution
Chapter 10.
Air Pollution
Chapter 11.
Human Body
Chapter 12.
Food Health and disease - Nutritious Food - Food habits - Food
preservation - Adulterated Food - Habits - Smoking - Drug
Addiction - Personal hygiene
Part -II
Transmission of microbes from one person to another person Transmission through water and food - Cholera - Tuberculosis Tetanus - First Aid - Transmission - Through Animals - Rabies Immunisation - Pregnant Mother - Infant - Preservation of Food -
Unit-I
i3<
61
Food Poisoning
9lh Standard
Unit-III
Hormonal plants - Asthma
Part - I
Unit -1: Ways of living
Chapter 14.
Human eye
Chapter 15.
Defects of eye
Chapter 16.
Colour vision
Part-II
Unit-I
Chapter 4.
Life Processes - Digestion in man - Respiration - Transport Excretion - Reproduction
Unit - II
The Story of Man - Evolution in Man
10th Standard
Part-II
Unit - II
Chapter 5.
Environmental Pollution
Chapter 6.
Constituents of Food C/F/MV/P/F - Mineral Salt deficiency disease
- Anaemia - Goitre - Balanced diet - Food Adultration.
Chapter 10.
Factors affecting human health - Malfuctiong of Body Parts Genetic Factors - Hormoal Imbalanced - Allergy - Malnutrion Pathogens - Viruses - AIDS - Leprosy - Malaria - Kala azar
COMMENTS ON THE EXISTING SYLLABUS AND NEED FOR A CHANGE
The existing syllabus starts from 3rd Standard to 10th Standard. First Two standards are left out. This is not
correct. Students when they are admitted to First Standard are already 6 Years old and they are capable of
understanding some elementary aspects of human body and environment. More over important aspects of
living style should be introduced as early as possible so that scientific information is available to the
student before he had any chance of imbibing unscientific view of life style. There fore awareness about
health should be started from the 1st Standard itself.
The existing syllabus though includes some aspects of health information the health matter is not sufficient
and not scientifically arranged from 1st Standard to 10th Standard and the syllabus is not comprehensive.
Syllabus do not emphasize the acquisition of skills, it is not sequentially developed and do not reflect the
interdependence of students, peers, the family, and the community. Promotion of health and well-being is
not adequately treated. Classroom activities are not supplemented by activities and projects at home and in
the community that enhance students understanding of the family and social underpinnings of health.
Further the syllabus do not include any thing about the individual, family, and community responsibility for
creating health facilities and maintaining community health which is crucial for learning life skills and
acquiring healthy habits.
The principles of education is to arrange syllabus from simple things to complicated things gradually and in
increasing sophistication. The subject matter must be repeated at periodical intervals. The syllabus must be
taught over an extended period of time and it should be incorporated into the daily life activates of the
community. The existing syllabus do not conform to the educational principles. Hence there is need for a
thorough change in the syllabus.
REFERENCE:
Report of a WHO Expert Committee. WHO Technical Report Series - 870.
13 G
62
THE NEED FOR COMPREHENSIVE SCHOOL
HEALTH SERVICE.
EXPERIENCE OF U.S.A.
U.S.A, is implementing comprehensive School Health Education Curricula and they have found by large
scale evaluation studies the following benefits over the years.
1.
2.
3.
4.
School Health Education Increases students knowledge of healthy behaviour and risk behaviour.
Teacher training in health education has a significant effort on successful achievement of health
out - comes for children.
“Booster Shots” of health education is necessaiy every 2-3 years.
Significant gains in students knowledge can be achieved after 50 hours of instruction and
moderate improvement in students health related behaviour can be achieved after 30 hours of
instruction in a topic.
Reference:
W.H.O. Technical Report Series 870.
PRINCIPLES AND PRIORITIES OF SCHOOL
HEALTH SERVICES
Every school should provide a safe learning environment for students and a safe workplace
for staff:
To often the school environment itself can threaten physical and emotional health. The school environment
should:
•
•
•
•
provide safe water and sanitary facilities;
protect students from infectious diseases;
protect students from discrimination, harassment, abuse, and violence;
reject the use of tobacco, alcohol, and illicit drugs.
Every school should enable children and adolescents at all levels to learn critical health and
life skills:
•
•
•
focused, developmentally appropriate, skills-based health education in topics such as infectious
diseases, nutrition, preventive health care, and reproductive health;
comprehensive, integrated, life-skills education that can enable young people to make healthy choices
and adopt healthy behaviour throughout their lives;
health education that enables young people to protect the well-being of the families for which they will
eventually become responsible and the communities in which they reside.
Every school should more effectively serve as an entry point for health promotion and a
location for health interventions:
•
•
•
•
•
provide safe and nutritious food and micronutrients to combat hunger, prevent disease, and foster
growth and development;
establish prevention programmes to reduce the use of tobacco, alcohol, and illicit drugs, as well as
behaviour that promotes the spread of HIV infection;
treat, when possible, helminth, malarial, skin, and respiratory infections, as well as other infectious
diseases;
identify and treat, when possible, oral health, vision, and hearing problems;
identify psychological problems and refer those affected for appropriate treatment.
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63
The community and the schools should work together to support health and education:
Families, community members, health service agencies, and other institutions have an important role to
play improving the health of young people. At the same time, the school can play an important role in
improving the health of the community as a whole. Such roles include:
•
•
•
advocacy and support by the community for the development of the school as a healthy organization;
active consultation and collaboration between families, the community, and the school to improve the
health of children and adolescents who attend school, as well as those who do not;
active participation by the school and its students in programmes to improve the health and
development of the entire community.
School health programmes should be well designed, monitored, and evaluated to ensure
their successful implementation and their desired outcomes:
•
•
•
developing or adopting in each Member State the most appropriate and affordable methods to collect
data about children’s healtli, education, and living conditions, by age-group and sex;
emphasizing, whenever possible, research that draws on the knowledge and skills of local educators,
students, families, and community members;
developing methods for the rapid analysis, dissemination, and utilization of data at the local level, where they can
have the greatest impact.
FOCUS ON SCHOOL HEALTH EDUCATION
1. School Health Education (S.H.E.) will Focus on behaviour and conditions that promote health.
2. Help Children to develop life skills needed to adopt healthy behaviour.
3. Inculcates knowledge, attitudes, believes and values related to the development of healthy
behaviour and health promoting conditions.
4. It will provide learning experience that allow students to practice skills and model behaviour.
ECONOMICS OF SCHOOL HEALTH SERVICE
There is ample evidence that school health expenditures result in substantial savings:
•
•
•
A study in the USA estimated that every US $1.00 invested in schools on effective tobacco education
saves US$ 18.80 in the costs of addressing health and non-health problems caused by smoking. The
study further estimated that the benefit of every US$ 1.00 spent on education for alcohol and other
drug abuse prevention saves US$ 5.69. Furthermore, each US$ 1.00 spent on education to prevent
early and unprotected sexual behaviour saves USS 5.10. On average, the money saved by society for
each USS 1.00 spent on these three forms of health education is approximately USS 14 (1).
Spending money on school health programmes can be justified on purely economic grounds; schooling
pays off in higher incomes and a healthier workforce. (2).
A 1993 World Bank analysis (2) estimated that most regions of the world could greatly benefit by
implementing an “essential public health package” consisting of the following five central elements:
> an expanded programme on immunization;
> school health programmes to treat worm infections and micronutrient deficiencies and to provide
health education;
> programmes to increase public knowledge about family planning and nutrition, about self-care or
indications for seeking care, and about vector control and disease surveillance activities;
> programmes to reduce consumption of tobacco, alcohol, and other drugs;
> AIDS-preveniion programmes with a strong component on other sexually transmitted diseases.
64
Although school health programmes are explicitly mentioned in only one of the above elements, for a large
portion of the world’s population, schools could efficiently provide all five elements of the recommended
package.
There is ample evidence that better health improves academic performance:
Throughout the world, there are many examples of the school-based treatment of medical problems
resulting in improved academic performance. In one, Jamaican children who were treated for moderate
whipworm infections raised their test scores, which had lagged by 15% up to the level of uninfected
children (2). School food programmes also have a marked effect on attendance and school performance (3).
There is ample evidence that school-based programmes can reach very large populations of
school-age children:
•
•
•
Schools can reach about one billion students worldwide and, through them, their families and
communities. As previously noted, “the formal education system is . . . the developing world’s
broadest and deepest channel for putting information at the disposal of its citizens” (4).
School health programmes have improved the health of large populations when implemented on a
national scale. In the Republic of Korea, for example, the prevalence of intestinal helminthes among
children was reduced from 80% to 0.2% over 30 years through a school-community chemotherapy,
health education, and sanitation programme.
Teachers can have an immense impact on young people’s health. As reported by UNESCO, there are
almost 43 million teachers around the world at the primary and secondary levels (23.9, primary; 18.8,
secondary) (2). The size alone of the teacher population is of public health significance.
There is ample evidence that health education and services have far-reaching effects:
•
•
•
•
Studies in the USA have documented that carefully designed and implemented comprehensive health
education curricula can prevent certain adverse behaviour, including tobacco use, illicit drug use,
dietary practices that cause disease, unsafe sexual behaviour, and physical inactivity. Further, such
curricula reduce school absences by reducing the impact of disease and drug and alcohol abuse, and
the number of injuries and unintended pregnancies; they also improve cognitive performance through
proper diet, exercise, sleep, and stress reduction (5).
Healthy habits learned during early years (e.g. safe food handling) will be applied throughout life (6).
School-based clinics show evidence of improving students’ knowledge about how to be effective
consumers of health services, reducing substance abuse, and lowering hospitalization rates (7).
Health promotion for school staff, one of the least visible elements of school health programmes but
one of the most critical, can decrease teachers’ absenteeism and improve their morale and the quality
of classroom instruction (8). One programme for school staff in the USA demonstrated reductions in
body weight, resting pulse rate, serum cholesterol level, and blood pressure (9).
REFERENCE:
1.
2.
3.
4.
5.
6.
Rothman M et al. Is school health education cost effective? An exploratory analysis of selected
exemplary components. American journal of health promotion (in press).
World development report, 1993. Investing in health. New York, Oxford University Press,
1993:33-34.
Levinger B. Nutrition, health and education for all. Newton, MA, Education Development Center
and United Nations Development Programme, 1994.
The state of the world’s children, 1988. New York, Oxford University Press (for UNICEF), 1988.
Allensworth D, Kolbe L, eds. The comprehensive school health programme: exploring an
expended concept. Journal of school health, 1987, 57:409-473.
Motaijemi Y, Kaferstein FK. Food safety in the school setting. Geneva, World Health
Organization, 1995 (unpublished document available on request from Programme of Food Safety
and Food Aid, World Health Organization, 1211 Geneva 27, Switzerland).
13°}
65
Dryfoos J. School-based social and health services for at-risk students. Urban education, 1991,
26(1): 118-137.
8. Jamison J. Health education in schools: a survey of policy and implementation. Health education
journal, 1993, 52(2):59-62.
9. Bishop N et al. The school district for health promotion. Health values, 1988, 1292):41-45.
7.
Strategic Planning of School Health Programmes - from problems to action
Published research on how schools change and accommodate innovation provides convincing evidence
that producing change in schools and communities is a long, necessarily local, and evolutionary process
that must involve the entire system. So-called “quick fixes” do not work; the implementation and
institutionalization of refonns often take 20 years. According to new international study of the process of
change in educational reform, successfill reform has three main ingredients:
•
•
•
a well planned and evolving national commitment, made concrete through appropriate management
practices and institutional support, sustained over at least 10 years:
strong local capacity;
coherent linkages between central, district, and local school levels, by means of information,
assistance, pressure, and rewards.
The Strategies are:
•
•
•
•
•
To promote public policies for school health that provide resources.
To foster supportive environments that are the result of assessment and improvement of the physical
and psychosocial environment of the school.
To encourage community action that supports the process of health promotion and the linkages
between the school and other relevant institutions.
To promote personal skills development (through both curriculum and the teaching and learning
process) that emphasizes specific health-related behaviour, as well as the skills need to sport health
throughout life.
To reorient health services.
> provide enhanced access to services within the school as well as referral to the external health
system;
> identify and implement specific health interventions that are best carried out through the school;
> integrate curative and preventive interventions.
TEACHERS TRAINING
Training for school personnel is an important aspect of school health promotion programmes. Studies show
that training teachers in the use of a health education curriculum improves their implementation of it (1). 1
Teacher training also builds tlie commitment, understanding, skills, and attitudes that enable teachers to use
curricula effectively and confidently. A complete training programme should have the following five broad
goals:
•
•
•
•
•
for teachers to have an appropriate understanding of the human organism and causes of disease and
injury;
for them to develop positive altitudes towards and commitment to a comprehensive approach to school
health;
to increase their understanding of the principles of behavioural change that are effective in health
education;
to improve their teaching skills in areas such as class discussion, role playing cooperative group
activities, small-group discussion, community-involvement activities, family-communication activities,
games, and simulations;
to prepare teachers to deal with sensitive issues and refer students with additional needs.
I (+0
66
Implementation issues
Training for teachers, supervisors, and school administrators can be offered for curriculuni development,
the provision of school services, and improvement of the school environment, as well as in specific content
areas.
Successful teacher training:
•
•
•
•
•
•
•
•
•
•
•
addresses issues of concern identified by teachers;
is conducted as close as possible to teachers’ work plances;
covers theory and demonstration, includes practice teaching offers feedback on performance, and
emphasizes peer-coaching skills;
has the support of both teachers and the school administration;
enables participants to feel a sense of ownership of the programme;
uses adult-learning theory;
is conducted over an extended period of time;
provides opportunities for reflection and feedback;
involves a conscious commitment by participants;
builds specific skills;
works with groups rather than with individuals.
Strategies
The Expert Committee noted that accepted recommendations for teacher training include the following:
teacher training should be reviewed and upgraded at pre-service, in-service, and continuing-education
levels;
teacher-training programmes should ensure that student teachers receive field experience;
routine workshops seminars, and short courses should be carefully designed and implemented;
health teachers and staff as well as non-teaching school personnel should be trained;
mechanisms for continuing education and supportive supervision to maintain and enhance the quality
of teaching should be developed (2).
REFERENCE:
1.
2.
Ross JG & Nelson G. The role of teacher training and other factors in fidelity and proficiency.
Presented a the 63rd annual Convention, American School Health Association, 19 October 1989,
Chicago, IL.
Health education strategies in South-East Asia. Report of an Intercountry Consultation on Health
Education Strategies in South-East Asia in the context of Health for All by the Year 2000 and with
special reference to the prevention and control of AIDS. New Delhi, 10-15 December 1990. New
Delhi, World Health Organization Regional Office for South-East Asia, 1991.
61
RECOMMENDED OUTLINE OF CURRICULUM ON HEALTH FOR PRIMARY AND
SECONDARY SCHOOLS - FIRST STANDARD TO TENTH STANDARD.
Goal and Objectives
GOALS
To enhance the promote health knowledge and health practices of school going children in every
possible manner to enable to adopt measures to achieve positives health and remain healthy and to develop
in them a self reliance and social responsibility and better quality of life not only as children, but also as
adults and parents of tomorrow.
OBJECTIVES
To create health consciousness and make them understand that health is most precious possession
and resources to realize the genetic potentialities of every child.
2. To make them realize, that he, his parents family and community are primarily responsible for his
and community health.
3. To help him to acquire healthy habits, healthy behaviours and healthy life style as he grows learns,
and develop through out school going years.
4. To inculcate a sound scientific through as to root causes of diseases and disability in man and
rational of prevention of diseases and prevention of promotion if health.
5. To make him realize the unnecessary burden of health care expenditure resulting from negligence
and not preventing preventable illness and disability.
6. To make him realize his and community responsibility towards the community and need for
tearful, and wholehearted cooperation and achieve participation in creating and maintaining health
infrastructure in any human settlement.
1.
TOPIC AND AREAS OF STUDY INCLUDED IN THE SYLLABUS
Human Biology, Anatomy, Physiology, Growth and Development, Heridity and Genetics.
Human Sociology and Psychology, Individual, Family and Community, socialization,
Interdependence; Friends; Peer groups; Social behaviour; Psychological factors; and Mental
Health.
3. Human Nutrition and Health.
4. Human environment, Physical-Environment, Biological environment and social environment.
Role of the individual and community in creating and maintaining health environment.
5. Concept of health. Root causes of illhealth and promotion of health.
6. Concept of diseases, communicable and non-communicable diseases and their control - role of
individual and the local community in control and prevention of diseases.
7. Responsibility for health of the individual and the community and family. Community
organizations local self govenunent. State and Central Governments. Village and ward Health
Committees.
8. Accidents - home accidents, road accidents - Calamities - First Aid.
9. Common illnesses among infants - children - Adolescents and adults - Home Remedies, proper
use of common drugs.
10. Reproductive and Child Health and adolescent health.
11. Demography and Population.
12. Health Care System - Health care infrastructure - School Health Service.
13. National Health Programmes.
14. Health and Medical Care Institutions.
15. Voluntary Sector for Health Promotion and protection of community Health.
16. Role of the individual and community in creating and maintaining health facilities and health
behaviour of people, in the local area.
1.
2.
i4<a.
68
STANDARD-I
1. Knowing the external parts of the human body and their functions. Writing their names and functions.
Knowing the role of parents in growth and development - writing the Names of parents - Family Tree
- peer groups and their functions.
3. Making a list of Teachers and their role in learning and better Health.
4. Making a list of friends and need for interaction with friends and peer groups for better health.
5. Making a list of food articles used at home.
6. Classification of foods - Body building, energy yielding and protective foods.
2.
ACTIVITIES:
1.
2.
3.
4.
5.
6.
7.
Teachers weekly observation and Record.
Drawing the external parts of the body and labeling them.
Health appraisal by Doctor. Eveiy Child should be examined by the doctors only.
Maintain Health Records.
Question and Answer session at least one per month.
Group discussion at least two per year.
Role play or drama one per year.
STANDARD-H
1.
2.
3.
4.
5.
6.
7.
8.
9.
Method of caring for the external parts of the body - Washing - Bathing - Wearing footwear - Change
of Clothing - Use of cleaning agents - Local and Home made materials.
Knowing the internal systems and their functions of the body - Skeleton system - Circulatoiy Respiratory & Excretory systems.
Human being as a social animal - need for family - parents - friends for healthy growth and
development.
Quantity of food required for different age, sex and occupational groups.
Healthy and Protective foods. Hand pounded rice - Germinating Grams - Leafy vegetables - cooking
of food to preserve nutrients and safety - Use of left-overs - food poisoning.
Physical Environment of Man: Water - Sources - Pollution-diseases transmitted - Purification of
Water - Domestic purification - There is no need for bottled mineral water except during tours and
excurtion.
Biological Environment of man: Rodents - Dogs - Cattle, Housefly and Mosquitoes.
External Parasites of man: Louse - Scabies - Mode of Spread and Prevention and personal Hygiene.
Good & Bad Health habits & Health behaviours - Avoidance of Alcohol - Smoking - Chewing
tobacco.
ACTIVITIES:
1. Writing the Skeleton of Human body and Labeling.
2. Drawing the Circulatoiy and Respiratory systems and Labeling.
3. Teachers Weekly examination for cleanliness, early symptoms of illness.
4. Daily play and Exercise.
5. Health Appraisal by Health Assistant.
6. Parents report on Health habits and Healthy eating habits.
8. Question and Answer session at least one per month.
9. Group discussion at least two per year.
10. Role play or drama one per year.
STANDARD - DI
1. Knowing the digestive and Nervous systems of the body and their functions.
2. Social system and Social life in villages - Wards - Towns and Cities.
3. Quality of food - Balanced diet - uses of Milk, Vegetables - Eggs - Meat.
4. Solid and Liquid waste produced by human activities at home - Disposal from houses - Soak pit Compost - Garbage disposal.
1^3
69
5.
6.
7.
Housefly - Breeding places - Life history - Diseases spread - control.
Meaning of Health and Diseases.
Factors that determine Health.
ACTIVITIES:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Excursion to show the physical environment - Demonstration of Housefly breading places.
Weekly Teachers observation and Record.
Parents Report.
Health Appraisal by Health Assistant and identification of departure from normal growth and
development of habits.
Cleaning the Class Room.
Daily Exercises.
Question and Answer session at least one per month.
Group discussion at least two per year.
Role play or drama one per year.
STANDARD - IV
1.
2.
3.
4.
5.
6.
7.
8.
Knowing the various digestive glands and their functions.
Socialization - Love - Affection - Hatred, Jealousy.
Malnutrition - Grades - Deficiency - Vitamin A and Vitamin C and ways to prevent by using fruits
and vegetables - Vitamin A Supplement.
Mosquitoes - Breeding Places - Life History - Diseases spread and control.
Physical Environment around the school and houses - Drains - Ponds - Water collections and their
effect on health.
Common communicable diseases in the locality - Method of Spread and prevention.
Accidents - Home - Traffic.
Primary Treatment for common cold - Fever - Respiratory Tract infections - Diarrhea.
ACTIVITIES:
1.
2.
3.
4.
5.
6.
7.
8.
Excursion to show drains - Ponds - Mosquitoes breeding places.
Demonstration of Housefly and Mosquitoes and their eggs and Larvae.
Teachers observation weekly and scrutiny of parents report.
Health appraisal by Health Assistants.
Physical Exercise.
Question and Answer session at least one per month.
Group discussion at least two per year.
Role play or drama one per year.
STANDARD - V
Coordination between various systems in the body - Functioning of the body as a whole - Refractive
Errors - Hearing defects Hormones and their functions.
2. Growth and Development - Physical growth of infants - Toddlers - Adolescent Spurt. Developmental Mile-Stones.
3. Friends - Relatives - Interaction with them - Behaviours - Society norms - Adjustability - Tolerance
- Avoidance of Stress.
4. Healthy eating and Learning habits - Cultivation of good habits and avoidance of bad habits.
5. Use of Vegetables and other nutritive foods. - Avoidance of Chocolates - Other tasty bites which are
injurious to health.
6. Domestic Animals - Pet and Street Dogs - Diseases spread by dog bite.
7. Common cold - Fever - Cough - Diarrhea - their management at home.
8. Avoidance of Unnecessary medication. And use of simple bed rest - Aspirin or paracetamol - oral
Rehydration for diarrhea.
1.
70
9. Routine Immunization Schedule for children.
10. Sanitary disposal of Human excreta - Toilets al home - Suitable in villages - Towns - Cities.
ACTIVITIES:
1.
2.
3.
4.
5.
6.
?
Excursion to show the open air defecation - Soil Pollution - How the fecal matter enters the food
chain.
Writing the Health Needs of the Human being.
Teachers observation weekly.
Health Appraisal by Doctors.
Review of the Health Record by Health Assistant - Report to the Doctor - Doctors Advise and follow
up.
Question and Answer session at least one per month.
Group discussion at least two per year.
8. Role play or drama one per year.
STANDARD - VI
1. Knowing the Human Reproductive system and function.
2. Primary and Secondary Sexual characters and Health Problems of Adolescent.
3. Social behaviour - Social Values - Role of Individuals in creating and Maintaing community health.
4. Group living - Group Activities - Play - Aggressiveness - Isolation and with drawing behaviour Courage and boldness. Mental health.
5. Malnutrition - Grades - Iron and Iodine deficiencies - Root causes.
6. Community water supply - Deep wells shallow wells - Ponds and tanks as sources water.
7. Common Non communicable diseases - Diabetes - Hypertension - Cancers - HIV/AIDS.
8. Healthful house minimum requirement for health of a family - Danger of cattle Shed with in the
dwelling house.
9. Growth of population and population explosion - Need for limitation of population growth small
family norm.
10. Health care System in the village - Primary Health Centre - Sub-Centres and their functions.
11. Ignorance - Superstitions - Rituals - Poojas - Need to know the effects of these on health and the
scientific view of the causation of disease .
ACTIVITIES:
1.
2.
3.
4.
5.
6.
7.
8.
Visit to primary Health centre or subcentre and learning the uses of doctors and Health assistants in
maintaining health.
Measurement of Height and Weight of Friends - Keeping their own Health Records.
Arranging group discussion and seminars on environment - Food - Water.
Teachers observations.
Health Appraisal by Health Assistant.
Question and Answer session at least one per month.
Group discussion at least two per year.
Role play or drama one per year.
STANDARD - VH
1. Endocrine glands and their functions.
2. Heredity - Genetics and Genetic disorders.
3. Occupation and Health - Factory - Small Work shops - Hotels - Abuse of child labour.
4. Habits dangerous to Health - Alcoholism - Smoking - Use of Drugs - Chewing Tobacco - Their
impact on Health - Social problems.
5. Mental Health Problems - Recognition and counseling - Parents interaction.
6. Air and Noice pollution - Impact on Health.
71
Cardiovascular diseases - Role of Diet - Exercises. - Smoking and stress.
Reproductive and Child Health - Age at Marriage - Age at Pregnancy - Child Birth - Safe Delivery Low Birth Weight babies - Antenatal and Natal Care - Food and Health Care of Mother during
pregnancy and lactation.
9. School Environment - Need for Toilets - Separate for boys and Girls - Drinking Water - Sufficient
Play Ground.
10. Role of the panchayet - In maintaing Healthy Environment in and around the Villages - Slums Towns.
7.
8.
ACTIVITIES:
1. Taking part in Health Examination of Lower grade students - Measurement of Height and Weight Taking Pulse Rate - Eye Sight Examination.
2. Taking part in Health Teaching of Lower Classes - Pupil to Pupil Teaching.
3. Arranging debates on population - HIV/ADIS - Social Behaviour - Moral Restraints - Superstitions Wrong and dangerous beliefs - Scientific Temper.
4. Health Appraisal by doctors.
5. Review of follow-up measures by health assistance.
6. Parents report on Social Habits and Health Habits and counseling if required.
7. Question and Answer session at least one per month.
8. Group discussion at least two per year.
9. Role play or drama one per year.
STANDARD - VIII
1. S.T.D. HIV/AIDS - Mode of spread and prevention - Moral restraint.
2. Family - Family Norms - Family Controls - Sexual mis behaviour - Crimes - delinquency.
3. Responsible parenthood - Sex education Family Size - Spacing of children.
4. Food Adultration and Food Preservation.
5. Sanitation of Public Places - Temples - Bus & Railway Stations - Jatras - Shandys - Play grounds
and schools.
6. Measurement of diseases in the community - Prevalence Survey.
7. Mortality and morbidity rates.
8. Secondary and Tertiary Healthcare.
9. Health Needs of Infants - Toddlers - Handicapped - Sick - Old People.
ACTIVITIES:
Taking part in teaching Health to lower class children.
Helping in conducting school health services by health assistant.
Measurement of pulse and blood pressure.
Practice of First Aid Activities.
Conducting debates, seminars group discussion on health and social issues.
Question and Answer session at least one per month.
6.
7. Group discussion at least two per year.
8. Role play or drama one per year.
1.
2.
3.
4.
5.
STANDARD - IX
1. Health Assessment of the Individual.
2. Health Need Assessment of the Community.
3. Important National Health Programmes - Role of the People in implementing them.
4. Village Health - Ward Health Communities.
14 6
72
5. Training of Dais on Safe delivery.
6. Anganawadi Kendars — Their function and management.
7 Family planning - Family Welfare - Family Planning Methods.
8. Role of Men and Women in Family limitation.
ACTIVITIES:
1. Visit to Anganawadi Kendars and Knowing the fiinctions.
2. Visit to Health Centre and Subcentre and Knowing the facilities for safe delivery.
3. Help in Health Teaching.
»-•
4.
“
Participating School Health debate, Seminars and group discussion.
5. Health Appraisal by Health Assistant.
6.
Question and Answer session at least one per month.
7. Group discussion at least two per year.
8. Role play or drama one per year.
STANDARD-X
1.
Voluntary Health Organization - Principles of Voluntary Health work - Social Services - Need for
Voluntary Organization for Health Care.
2. Private - Public Health Care Services.
3. Minimum Health Care Facilities in villages - Tows - Diagnostic facilities.
4. Peoples participation in organizing and managing health care services like Immunization - Antenatal
care - Health Awareness campaign.
5. Identification and Management of Pulmonary Tuberculosis - Leprosy - Malaria - Diabetes Hypertension - At home following the doctors consultation.
6. Poverty - Employment - Education and their relationship to health.
7. Equity and Empowerment of Weakers sections of people for better health of the community.
8. Right to health - Constitutional Provision and States Responsibility.
ACTIVITIES:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Conducting W.H.O. Day on 7th April.
Helping School to conduct seminars, symposia on health.
Helping Teachers and Health Assistant to conduct Teachers observation and Health Assessments
Giving Health Talks to Children and Public People.
Health Appraisal by Doctors.
Review of His/her Health Through School years - Report by Health Assistant.
Question and Answer session at least one per month
~
' at least two per year.
Group
discussion
Role play or drama one per year.
144
Il'3
3J
DOES KARNATAKAJSTA
BED
• r
RE MEDICAL COL
" 'I
ES?
[/Av/c^ and concerns requiring an urgent 'public initiative' to counter the gross
conimercialisation and devaluation of medical educationhy the Government of
A •
Karnataka]
by
The Socie
■ I
Community Health Cell,
for Community Health Awareness, Research and Action,
‘Srinivasa Nilaya’Jakkasandra I51 Main,
1st Block, Koramangala,
Bangalore - 560 034
553 15 18 & 552 53 72
Phone:(0
il: sochara-fS’vsnLco.
Fax: (080) 552 53 72
5 I
m2
u
•f
i
I
e.
We tcel that we should all suggest that the State Government review this
populist decision’ by involving all these expert and professional bodies who
would help to ensure that the policy on medical college expansion be determined
by wholistic planning considerations like health manpower needs, quality’
standards and norms rather than leave it to considerations of populist
politics or market driven compulsions. The Savadatti Report should be
reviewed once again by a small expert group. Perhaps the Rajiv Gandhi
University of Health Sciences-Karnataka could be requested to set up such a
'think tank'.
f.
Your involvement to put public and professional pressure on the State
Government is urgently requested. As citizens and concerned persons and
professionals, we owe it to the people and to the goal for Health for All.
g-
We enclose a short report which has been evolved from a summary of our
Society’s recent research projects and reports submitted by us to the Independent
Commission on Health in India; and to the recently constituted Sub-Committee
on Medical Education of the Parliamentary Standing Committee on Human
Resource Development. We have tried to address some of the key issues about
Medical Education in Karnataka.
These are however -relevant to other
professional institutions as well. Dental, Nursing, Pharmacy - the trends are
similar in these groups - perhaps even worse.
d)
We invite you to join us in a campaign to ensure that the over medicalisation and
commercialisation of Health Care and health human power development in
Karnataka does not become ‘a vested interest in the abundance of ill health’.
We remain in solidarity.
Yours sincerely,
for SOCIETY FOR COMMUNITY HEALTH AWARENESS,
RESEARCH AND ACTION
Thelma Narayan
V. Benjamin
C.M. Francis
Ravi Narayan
r
■r
3
h
The Society for Community Health Awareness, Research and Action (SOCHARA)
is a multidisciplinary professional think-tank that among other issues in Health care
has been seriously researching the issue of Medical Education in the country and
looking at alternative policies and options for Health human power development.
Community Health Cell is the functional unit of the Society. In the 1990s, the Society
has:
1. Undertaken an All India Survey of Strategies for Community Orientation and
Social Relevance in medical colleges. It identified 30 colleges with some
innovative experiments, documented these and then focussed on 6 pacesetter
colleges to arrive at strategies for action andfactors that promote and or obstruct
curriculum innovation (three publications from this study are now available).
2. Undertaken a detailed review of Medical Education in India for the Independent
Commission on Health in India looking at issues such as : situation analysis,
regional distribution, commercialization, norms, qualitative decline in standards,
admission requiremens, curriculum development, cost /financing, corruption, PG
courses, continuing education and so on. The report also reviewed all the
innovative experiments in Medical Education and expert comittee
recommendations. It identified 6 issues for further dialogue and evolved a 12
point programme for improving the quality of Medical Education in the country
and countering the unhealthy commercialization and decline in standards and
quality.
This formed a chapter on Perspectives in Medical, Nursing and Para Medical
Training and Education in The Report of the Independent Commission on Health
in India submitted to the Prime Minister recently.
3. Participated in some workshops of the newly established Rajiv Gandhi University
of Health Scienc es in the State in restructuring the curriculum.
4. Facilitated a continuing dialogue with a host of medical colleges in the country
and in neighbouring countries of Nepal and Bangladesh on evolving mechanisms
to operationalise strategiesfor change.
i
5. Submitted a memorandum to the Sub-Committee on Medical Education of the
Parliamentary Standing Committee on Human Resource Development,
Parliament House Annexe, New Delhi - 100 001 (on 14th November, 1998).
The summary offacts and notes are extracts from these publications. Copies of the
publication are available on request from the Society.
■■
ISO
4r
,
■/
CONTENTS
I
Pages
Particulars
SI.No.
A.
Growth of Medical Education in India
6
B.
Regional Distribution
6
C.
Commercialization : Beyond Privatization
7
D.
Supreme Court Judgement and Thereafter
9
E.
Implications of Government’s Recent Decision
10
F.
Issues Raised in Recent Debate in Media
12
G.
Some Additional Trends of Relevance to Medical
13
j
Education Expansion
I,
H.
Wrong Type of Doctors
13
Braindrain - External and Internal
15
Corruption in Medical Education
15
The Medicine - Industrial Complex
16
Teaching Faculty Vacancies
17
Quality Control
17
The Way Ahead - Some Suggestion for Action
17
APPENDICES
1.
Notification of Medical Council of India & Medical
20
Education in India, 1995
2.
Proceedings of Government of Karnataka - Intake of I
21
MBBS and I BDS for Medical Colleges in Karnataka 1996-
97
3.
Relevant Extract from letter of Secretary, Medical Council
23
of India
4.
I
Extracts from the Expert Committee Report to consider
24
intake of existing professional colleges and need to start
new professional colleges in the state
5.
A Submission
Education
to
The
on Medical
Sub-Committee
46
of the Parliamentary Standing Committee on
Human Resource Development at Bangalore, on 14th
F
November 1998
6.
Newspaper Reports on New Medical Colleges
X’-’
F
151
V-
51
■■
5
i
State of Medical Education in Karnataka
Facts, Figures and Notes of Concern
A. Growth of Medical Education in India
1. Medical Education in India has shown remarkable growth in numbers since
independence (1947-93).
From 22 medical colleges in 1947 with an
admission of 1983 we have increased to 145 medical colleges with an
---- admission of 16,200 students in 1993. A 600% expansion in colleges and
800% expansion in admissions (see Appendix A). The estimate of The
Medical Council of India in 1996 was 162 medical colleges!
2.
The world has a little over 1400 medical schools - so presently India has 10%
of the world’s medical schools (the data on admissions is not known).
Karnataka has 13% of the medical colleges in India and presently 1.3% of the
colleges in the world. With the recent decision it could potentially have
nearly 23% of the colleges in India.
3.
The increase was gradual till 1975 with a predominant increase in
‘government run and sponsored medical education’ during the earlier phase.
Following the Srivastava Report 1975, (3) there was a plateau till 1985 and
then another phase of expansion till the Presidential Ordinance of 1993 - a
phase which was characterised as the ‘commercialisation and private sector’
phase of medical college expansion.
4.
Significantly, three states contributed most to this privatization and
commercialisation of medical education - namely Maharashtra, Karnataka
and Tamil Nadu, opening 18, 8 and 5 colleges respectively since the 1980s all the new colleges being in the private sector.
B. Regional Distribution
I
5. The Mudaliar Committee of 1969 (3) recommended the norm of one college
with 100 seats per 50 lakh (5 million) population. A review of the present
regional distributions of colleges taken against the 1991 census (see Appendix
B) show some important trends:
1
a) Karnataka, Maharashtra and Tamil Nadu show a number far beyond their
' entitlement and requirement against this norm :
State / Population
Karnataka 45 million
Maharashtra & Goa 80.1
million_______________
Tamilnadu & Pondicherry
56.7 million
yI
^1
'
Entitlement
Entitlement 9
Actual
Actual 19
Excess
Excess 10
Entitlement 16
Actual 30
Excess 14
Entitlement 11
Actual 15
Excess 4
LIBk.Ri
4 NO
INFORMATION1
CENTRE
) ~
pH- IOO
11C51 p°>
6
iI
b) Karnataka and Maharashtra, the ‘commercial medical education belt’ in India
also have the largest admission ratios thereby proving the economy of scale
theory - more admissions, more income and more profits! (2)
c) It is important to note that the Srivastava report (1974), had recommended a
series of steps for qualitative improvement in medical education rather than
further quantitative expansion (3). The special study group set up by the
Indian Council of Social Science Research and Indian Council for Medical
Research (Health for AH : An alternative Strategy, 1981) consisting of
internationally renowned National Experts had also categorically stated as
early as 1980 that:
i)
There should be no ne^v medical college and no increase in the intake
of existing medical colleges11
ii)
There is no need at all to set up ne\v and additional institutions to train
additional doctors through short term courses31
d)
The Bajaj Report which later became the National Education Policy for
Health Sciences has also recommended primarily qualitative changes in
standards and no further quantitative expansion. (4)
e)
A report of the Medical Council of India in 1996 (5) has noted that “..... it is
evident that there is no shortage of doctors in the country and there is really
no need for starting more medical colleges for production of more doctors,
except perhaps in certain States which do not have any medical college as
yet With the amendment of the I.M.C Act, 1956, in 1993, (under the
provisions of which no medical college can be established, no neiv
postgraduate course can be started or increase of scats in medical colleges
allowed, without the prior permission of the Central Governnient), it is
hoped that the much needed breaks for the mushroom-growth of medical
colleges in the country, will be applied11.
>
11
I
C. Commercialization - Beyond Privatization
6.
In terms of ownership and governance there has been a gradual increase in the
number of medical colleges run by the Private Sector (Trusts or Societies)
from less than 5% at Independence to 30% in 1993-94.
7.
In Karnataka, the percentage in the late 1970s was 33% private (2 out of 6)
and by 1993, it was 78.9% (15 out of 19).
8.
All serious, quality oriented policy makers and professional associations are
concerned about the ‘commercialised’, ‘unhealthy trends’ that this private
sector take over of medical education represents, namely :
i
I
a) All the new private medical colleges belong to the ‘capitation’ fee
charging variety of medical colleges with capitation fees rising from 5
lakhs in the 1980s to 35 lakhs in the 1990s.
i
1S3
I
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... —--
7
11
b) All were initiated by trusts and societies with either caste or communal
affiliations or by individuals and groups representing specific sectoral
lobbies in agriculture and other areas (sugar barons in Maharashtra, and
other pressure groups in Karnataka and Andhra Pradesh), with little or no
involvement in higher education and health care.
c) In the 1993-94 Ministry of Health and Family Welfare (Government of
India) Annual Report, 26 colleges out of 146 were unrecognised by The
Medical Council for shortfall in standards (but recognised by state
government and local universities!). All belong to this -group of
commercial capitation fee colleges.
d) In Karnataka, the power of the commercial medical education lobby has
been significant. Some of the policy decisions they had been able to
facilitate at state or university level have been
I
i
1
•
In the beginning, fixing of the level of capitation fees rather than
banning or opposing it, even after banning was on the political election
manifestos of all the recent governments (this also meant a permissible
fees that had been regularised and not surprisingly, exceeded by
irregular and unofficial means);
•
contracting out public sector government hospitals to private sector
colleges for use of clinical facilities at a fee per bed which was most
often not collected; since these medical colleges did not have the
necessary clinical facilities to begin with;
•
permission to allow government college professors to go on deputation
to private medical colleges for varying periods of time with lien on
their jobs, thereby losing the services of experienced teachers in a
situation where there were not enough teachers.
e) The NRI Quota - the Non-resident Indian quota allowed by the
government permitted NRIs to be charged 1,00,000 USS for a seat in a
private college. A few years ago at the instance of a Union Health
Minister and to counter growing opposition to the ‘commercial medical
education lobby'* an NRI quota has been suggested even in government
colleges with the proposal that the money so collected would be used to
upgrade the technological facilities in the government teaching hospitals!
f) There is reason to believe, from an informal survey of examiners, that the
‘commercial factor’ has also begun to affect examination systems with
payment for ‘ensuring success’ being required at different levels - within
the department, or within the institution and/or at the examiner level.
While this has been a feature reported sometimes even in government
institutions, this is more in the ‘commercial
colleges’ where the
availability of resources is greater among the students. Also with the focus
on quantity rather than quality there is an increasing phenomena of
substandard teaching producing substandard students who are unable
to pass exams in the normal way and have to ’purchase’ a pass.
Alternatively with the availability of monetory resources among these
8
154
v'
I
capitation fee paying students, examiners and institutions are also
indulging more in unethical market-economy processes.
This commercialization is contributing to a fall in qualitative standards by
allowing money, power and political influences to affect results.
D. Supreme Court Judgment and Thereafter
9. To place the above trends in context, it is important to take note of the
Supreme Court Judgement in a special writ petition from Andhra Pradesh on
Capitation Fees, which recorded that Capitation fees as it is practiced today
Violates the right to education under the Constitution....
is wholly arbitrary^; is unconstitutional according to
Article 14 — equality before law;... is evil unreasonable,
unfair and unfit... and enables the rich to take
admissions whereas the poor have to withdraw due to
financial inability... and therefore is not permissible in
any form....r
10. The Supreme Court judgment effectively put a legal brake on this unhealthy
trend. State governmentals and state politicians had to come to terms with it
and so after much dialogue and lobbying a differential fees scale has now been
introduced allowing private ex-capitation fee colleges to charge substantially
higher fees for ‘paying students’, with government quota introduced into all
the private colleges as well with some exceptions.
In a Government Order dated 21-11-96, the Government of Karnataka has
now fixed the intake of all colleges and fixed numbers in four quotas - free
(merit seats); Karnataka (payment), Non-Karnataka (payment); and
NRI/others (See Appendix)
There is need to review this whole recently evolved fees system. Apart
from it being inequitous and very much supporting the market economy
in medical education, there is reason to believe that once again it is also
being circumvented by unofficial means.
I
11. The Medical Council of India was also directed by the Supreme Court
judgment of 9-8-1996 to evolve a fee structure keeping in mind the student
community management and also the location of the colleges. The Executive
Committee of MCI gave its recommendations to the Central Government in
September 1996.
While appearing to rationalise the fees issue this
recommendation (see Appendix) has further strengthened the market economy
by justifying differential fee structure from 15,000 for free merit seats (for 18
months) to 1.5 lakhs per course for 18 months and $75000 for NRI and foreign
students. The ethics, legality and ‘commercialisation’ trend generated by
this recommendation is still to be reviewed and there is need for a urgent
professional / public dialogue on it
1
9
15^
u
12. The recent controversy about the ‘illegal’ expansion of seats in some
government and private medical colleges in the state in the 1990s through the
permission of the state government against the norms of recognition by the
Medical Council of India are well known including the judgement of the
Supreme Court, declaring it illegal. This has vindicated the increasing
concerns about the nexus between commercial lobby and professional political
leadership but has also put a legal impediment to this state sponsored
illegality.
13. In the light of the above trends in the market economy driven medical
education in Karnataka there is need for an urgent study on the potential nexus
between the commercial lobbies and the medical education policy makers and
leadership at state / central levels to understand the active and continuation of
the trend. In the light of this, the recent announcement of a list of 20 medical
colleges being given essentiality certificate by the Government of Karnataka
is a matter of serious concern.
E. Implications of Governments Recent Decision
14. In the previous sections, we have utlined the situation, the trends in the
development of Medical education, the concerns regarding the growth of
‘capitation fees’ and commercial medical education culture and the dangers
of the ‘market economy’ related transformation of medical education
planning in the state. It is obvious that thedecision to give ‘essentiality’
certificates to 20 more colleges initiatives will worsen these trends.
However, even if the ‘market economy’ factors were to be regulated or
controlled there are other implications that have just not been given adequate
consideration by the State authorities.
15. Teaching Faculty - from where?
The Medical Council of India recommendations on teaching faculty for a 100
seat medical college requires a minimum of 100 faculty of varying grades Professors/Associate/Assistant Professors, Lecturers/Demonstraters, etc. 20
new colleges means 2000 new faculty. Where are these large numbers of
adequately trained faculty going to come from? especially when recent
medical council surveys themselves record. shortage of faculty all over the
country! Such a massive expansion will only lead to recruitment of
inadequately qualified staff; movement of qualified staff from existing
institutions to the new ones often due to the lure of enhanced salaries;
irregularities such as the appointment of part-time staff or the same staff
appointment being shown in two different institutions. All these are already
taking place and are no longer in the realm of hypothesis!
'I
I
10
156
u
16. Teaching Hospital Beds - where is this available?
The Medical Council of India recommendation of teaching hospital beds per
student is 7 and hence a 100 seat medical college requires 700 hospital beds
for recognition purposes . For 20 neiv medical colleges, we need 14,000
hospital heels. Where is this resource available in the state? It is important
to emphasise that these guidelines are ‘minimum’ with the proviso that
anything less would severely jeopardise the quality of medical education since
adequate teaching hospital beds’ are an important pre-requisite to bed side
clinical teaching, which in the training of doctors is absolutely crucial. Any
alternative arrangements like showing other government hospitals, private
hospitals, district and taluka level hospitals to add up adequate numbers
without upgrading facilities and services in these hospitals and making them
suitable for medical education’ will be a disservice not only to the medical
students who will become ‘guinea pigs’ subjected to substandard medical
education but also to the state resulting in the production of sub-standard
doctors.
17. Ethos of Higher Education
Medical Education is a serious professional challenge and trusts, organisations
and institutions that are given the essentiality certificate must be (i) those that are
capable of understnading the professional complexities of medical education
including the essentiality of maintaining quality and standards (ii) have some
previous experience of running higher educational initiatives (iii) have the
resources and experience in health care — not just financial but in terms of human
expertise (iv) have credibility in operationalising social ventures in the public
interest and so on. Do the 20 organisations in the recently announced list of
potential medical colleges meet these requirements? What were the criteria on
which the state government gave the essentiality certificate? The professionals
and general public have a right to know and the state government should be
invited to be more transparent and evidence based in its planning.
18.
J
I-
Complexity of Recognition and Affiliation
The recent announcement by the State government and its reporting in the media
has confused the complexity of recognition and affiliation of Medical Education.
Since the Presidential Ordinance of 1993 and the recently updated Medical
Council of India Act, the National standardisation and recognition and
monitoring of Medical Education has become the responsibility of the Medical
Council of India. When the state gives an essentiality certificate, it only
authorises an institution / association or trust to apply for permission to MCI. An
essentiality certificate cannot a guarantee MCI recognition. However, some of
the organisations in the recently announced list of 20 have already announced
recruitment of staff (see Appendix) which is rather unusual!
The MCI requires proof of adequate resources including land, access to hospital
beds and other facilities. The MCI inspects the institution before giving the
green signal. All this taken times and any rush, over confidence, shown by
organisations contemplating such a venture can only be based on inadequate
understanding of the complexities of the process.
11
u
Incidentally, only 5 out of the 20 applicant managements
hospital.
have a teaching
F. Issues raised in Recent Debate in Media
19.
Since the state government announcement there has been a spate of letters to
the editors of newspaper and frequent pronouncements by various policy
makers especially the Minister of Higher Education of the State that has
further confused the issues.
Some of these -need clarifications (see
Appendix)
20. MCI has a dominant role in the functioning of medical colleges and the
state government is unhappy with in (refer appendix) The Hindu, 29-11-98 Government seeks more powers on medical admissions.
The State Government has to realise that it is precisely because of the
‘irresponsibility’ that previous governments of Karnataka and Maharashtra
have shown in the past vis-a-vis promotion and collusion with capitation fee
medical colleges and with standards in general, that the Presidential
Ordinance and the MCI Act of 92-93 was brought in. The Training of
Doctors were seen as too important to be left completely to these forms of
state sponsored changes in framework and standards.
21. (lAs per the MCI rules, the intake of under-graduate medical course could
not be more than 150”.
The state government must note that the guidelines on Medical Education
standards for colleges, teaching faculty are based on colleges with low seats.
Medical Educationists all over the world have come to realise that 50-100
seats in the maximum number to be handled by a college if complex quality
/ requirements teaching standards have to be maintained. Keeping in mind
the Indian situation, there has been some relaxation to 150. However, mass
production of doctors is not called for. The previous state governments have
already shown their irresponsibility in increasing the intake of students for
above this limit in a number of colleges in the state with no increase in
teaching faculty or faculties. That the Supreme Court had to intervene to
regulate this state sponsored illegality and degradation of medical education
in the state is a matter of great concern. It is high time that policy makers
stopped making a mockery of the production of doctors as if they were a
‘commodity’ whose production can be enhanced or reduced according to
market demand.
Another important MCI Guidelines is the enhanced use of small group
learning methods. Clinics are supposed to be organised in small group not
more than 10 students per teacher. Group discussions are encouraged with
not more than 20 students in a group. A 100-150 seat medical college means
simultaneously 10-15 clinical units to be involved in teaching or 5-8
simultaneous group discussion. This itself is quite a load. Mega educational
effort 150 to 300 make small group work near impossible.
I £2
12
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u
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22.
■
“One medical college for every district”
The government has recently justified part of the applications given
essentiality certificate on the basis of ‘districts where medical college are
being established for the first time’ - these being Raichur, Bidar, Bangalore
Rural, Hassan and Bagalkot.
While ‘one medial college per district’ may sound a good decentralised
proposition especially if the medical college and its teaching hospital was
closely involved as an apex referral hospital for other secondary and primary
health care centres in the district, this is not a practical proposition in the
existing skewed and disparate situation of medical college distribution in the
state.
Already, Bangalore has 5, Mysore-2 and Bijapur-2 each.
Bangalore in the list.
5 more from
Unless seats are reduced in these colleges further and transferred to new
medical colleges in new districts - the college per district lobby will only be a
convenient and populist proposition to increase the number of colleges / seats
irrationally.
23. There are many more issues of relevance some highlighted in the letters of
concern appearing already in the media. These three issues were given as
examples to show that the State Government seems to have gone ahead with
the matter without ’ any evidence based planning, rational norms of
doctor/population ratio, medical college/population ratio, state needs or
regional disparities. This is a very sad reflection of the non-serious and adhoc
nature of state planning in spite of the presence of a multidisciplinary state
planning board and a capital city which is considered the Science capital of the
country!!
1
G. Some Additional Trends and the Relevance of Medical Education Expansion
in the State in that Context
24. To understand the context and appropriateness of Medical Education
expansion in the state or country four other well established trends need to be
understood as well. There are :
a) the continuation of the production of the wrong type of Doctor for India
and the State;
b) the problem of Brain drain and student wastage;
c) corruption in Medical Education; and
d) market economy and medical education.
25. Wrong type of Doctor
a) It is now well documented that majority of the doctors who graduate from
the existing 145 medical poleges In India are not motivated to primary
health care, public health or rural service and opt for urban clinical
practice and / or furthur specialisation.
13
u
The Srivastava Report surveying the Indian scene in
1974 had identified the problem as <(stranglehold of
the inherited system of medical ' education, the
exclusive orientation toyvards the teaching hospital
(urban), the irrelevance of the training to the health
needs of the community, the increasing trend toyvards
specialisation and acquisition of post graduate
degrees, the lack of incentives and adequate
recognition for yvork within rural communities and
the attraction of the export market for medical
manpoyver”.
b) The WHO South East Asia report in 1988 reviewing the medical schools
of this region including those in India noted :
((Medical schools in the Region yvere, for the most
part, originally modelled on European-American
institutions. They have functioned within a clinical,
scientific and administrative system which retains
much of its colonial inappropriateness, and aspire to
'international9 (Le., often irrelevant) standards of
excellence. Medical students are Hable to be selected,
formally and informally, for upper middle-class career
aspirations, and then trained in high-technology
curative biomedicine. They look fonvard to working
alone or yvith other physicians, in an urban setting,
yvith predominantly middle class patients. The science
and values to yvhich they are exposed emphasize the
old biology, and it is this, together yvith the credo of
their profession, yvhich shapes their behaviour”.
c) A decade later the situation has not charged drastically. While the recently
established Rajiv Gandhi University of Health Sciences is trying to
restructure curriculum and improve quality, the recent move by the State
government may fuel counter productive trends which will worsen the
situation drastically.
d) The doctor population estimates used by planners are further skewed by
this ‘irrelevant doctor’ factor. So we have an increasing number of wrong
type of doctor concentrating in the urban situation and a continued
shortage in rural area. Not surprising the Bajaj Report of 1994 has noted
"The state of Maharashtra yvhich accounts for almost one fifth of the
total national outturn of doctors annually, has about one fourth of the
sanctioned pasts of doctors at rural PHCs lying vacant as of 1st January
of the current year”.
g •
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rso
14
H
26.
‘Braindrain’ - Internal and External
Estimates of ‘Brain drain’ both external (from India to the developed world)
and internal (from the public sector to the profit oriented private urban sector)
is variable but on the whole have been showing an increasing trend.
In 1986-87, it is estimated that 5304 doctors representing 30% of the
annual output migrated from India. The trend today is similar or slightly
increased.
Studies are beginning to show that the tax-payer supported governmental
medical education sector benefits the private sector in the country and the
health service sector of the established market economies of the western
world, more than the health services of the government and this is
probably even more significant in Karnataka and Maharashtra.( )
There is therefore neither a shortage in the country nor any evidence that
increase in numbers either in public or private sector will improve the health
care in the underserved regions of the state or country.
Any expansion can therefore only be justified as a response to ‘market
economy forces’ not state priorities or peoples health needs.
27.
Corruption in Medical Education
Corruption and graft have become the bane of public and private life in India
and Medical Education is no exception particularly in Karnataka State. Apart
from the commercialisation problem engineered by the ‘capitation fee’
concept which has now been temporarily regulated by the Supreme Court
Judgment and the MCI Recommendations other forms of corrupt practices are
becoming quite common.
Influence of money power and power politics in the selection of medical
college admission and postgraduate seats have been rife (recently
regulated by centralisation of admission tests and allotments! for
undergraduates only)
Influence of money power and politics at examinations at various levels;
From anecdotal and often experiential evidence and media reports.
It is however surprising how reports and studies undertaken by
professional researchers and numerous internal and external reviews, fail
to highlight or even mention this fall in ethical standards in medical
colleges. One wonders whether the ‘conspiracy of silence’ has a
professional / class bias as well;
Increasing concern that other practices are becoming fairly common;
Extraneous influences in promotions and transfers- of medical college
teachers in government colleges;
1
15
ICl
H
Ok.
.
Growth of private practice values in patient care in government and
private teaching hospitals. —- -
There is growing evidence that the situation in 'Karnataka in this area is
probably among the worst in the country and at least one contributory
factor would have been the growth of the ‘capitation fees related
commercial medical college culture’.
28. The Medicine — industrial complex
Commercialization of Medicine is rampant in India with the country in
recent years becoming the ‘Mecca’ for the medical-industrial complexes of
the world especially since the new economic policy has ushered in the
triple force of Liberalisation, privatization and Globalisation. Many
important trends in the state are symbolic of this new development and the
inroads that these market forces are make into existing medical education
infrastructure is a cause for concern.
a) Private Practice
While MCI and state / central government and most professional
bodies have endorsed in the past the need for teachers of medical
colleges to be full-time non-practicing, this situation is changing
rapidly with clandestine or officially sanctioned private practice,
becoming common place.
Under pressure of the Medical profession, who are getting more and
more involved with lucrative and competitive practice, more colleges
are beginning to reconsider this rule and allow various forms of
practice, to the detriment of the medical educator’s primary
commitment. The ‘teachers status’ is now becoming a status symbol to
help the competition in private practice rather than as a vocation of
commitment. This trend is very significant in Karnataka and will be
further accentuated by the state Governments "promotion of
‘commercialised medical education’.
NRI Phenomena
b) The recent phenomena of NRIs from the ‘US’ promoting High
technology Diagnostic Centres in the country is reflective of the MNCs
in the ‘west’ opening new market avenues for high tech gadgets whose
sale in the ‘west’ has shown a slump in recent years. Thus while the
NRI process in Health care is often portrayed in the media and policy
formulations as an ‘altrustic process’ in reality it is also a ‘market
economy process’ and is strengthening the commercialisation trend.
There is urgent need to dialogue with NRI groups to share these
concerns and ensure that NRI support the social/societal
needs/priorities as well.
—I
.3
I
16
H
9.
Adi
Chunchanagiri
Institute of Medical
Sciences, Bellur
'
Dr.
10.
Ambedkar
Medical
College,
Bangalore.
11.
J.S.S.
Medical
College, mysore
12.
Kempegowda Institute
of Medical Sciences,
Bangalore___________
13.
M.R. Medical College,
Gulbarga
14.
B.L.D.E.A.
Medical
College, Bijapur_____
15.
Siddartha
Medical
College, Tumkur
*
TOTAL.
100
50
20
15
15
120
60
24
18
18
100
50
20
15
15
120
60
24
18
18
100
50
20
15
15
150
75
30
22
23
130
65
26
19
20
1750
1075
270
200
205
* Nos. in paranthesis excluded
Sd/-
22-11-96
N.O. Palekar
Under-Secretary to Government
Health and Family Welfare Department
(69
J
Appendix - 3
Relevant Extract from letter of Secretary, MCI.
To: All the members of the Council.
No. MCI-34(41)/96-Med./18457/Medical Council of India.
1
Subject : Evolution of the structure for unaided professional institutions in light of
Supreme Court’s Judgment delivered on 9-8-1996.
“..The Executive Committee noted that the Constitutional Bench of the Hon’ble Supreme
Court of India_in W.P. No. 317/93 dated 9-8-1996 has stated that the Central Govt, and the
authorities concerned shall be free to fix fee structure in such an appropriate manner as they
think just and equitable to all concerned. Further they have stated that this would be done
keeping in mind the student community, management and also the location of the colleges”
The Executive Committee decided to classify the medical institutions under the following
heads
a)
b)
c)
Institutions with their own hospital
Institutions utilising the facilities of Govt, as well as their own hospital
Institutions utilising the facilities completely as provided by Govt, hospitals.
Taking into consideration tire above classification, the following fee structure is
recommended:
1.
Rs. 1.5 lakhs per Prof. Course (18 months)
institutions/medical colleges belonging to category (a).
per
student
for
medical
2.
Rs. 1.3 lakhs per Prof. Course (18 months)
institutions/medical colleges belonging to category (b).
per
student
for
medical
3.
Rs. 1.1 lakhs per Prof. Course (18 months)
institutions/medical colleges belonging to category (c).
per
student
for
medical
4.
Rs. 15,000/- for each Prof. Course per student for free seats belonging to medical
institutions/medical colleges falling under the categories (a) (b) and (c).
ri
5. $75,000/- to be charged from NRI/foreign students for the complete MBBS course.
However, the institutions which are running post-graduate courses and admitting more than
50% of the students at their own discretion in clinical specialities and Pathology, 25%
relaxation in the fees stated above will be given.
For the following non-clinical courses the institutions will charge no fee - Anatomy,
Physiology, Biochemistry, Microbiology, Forensic Medicine, P.S.M. & Pharmacology.
The Executive Committee also recommends that the Govt. Colleges be allowed to admit upto
a maximum of 15% of the total seats by NRI/foreign students. The committee was of the firm
opinion that the funds collected by these admissions should be utilized for the development of
the particular institutions”.
Since the Hon’ble Supreme Court directed the authorities concerned to submit its
recommendations within 3 months relating to fee structure, the decision of the Executive
Committee quoted above was communicated to the Central Govt, vide Council letter dated
18-9-1998 as directed by the President”
SdA
Mr. M. Sachdeva,
Secretary.
■
■
•
|
a®
■
w■ •
j.
L
Appendix - 4
BMMWggfWW^^^SjW
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2,4
foreword
The Government appointed Ibis committee to go into the entire issue of
professional education in the state Keeping in; view the
requirement .1 the state
man
power
aiso the fact that' students from outside
Karnataka come to the state'for education and some of the students of
Kantaf^ka after the compleiion-ofieducation.ntay go out of Karnataka and
report on policy decisions for Ute next ten years. The whole canvas ol
professional education includes Medical, Engineering, Dental, Pharmacy,
Ayurveda, Homeopathy, Nursing and other Paramedical courses, the last one
being a cluster of number of subjects.
The committee tried to obtain the man power requirement for the
state/country from possible sources. It happens that some systematic data
are availabie for engineering and some data are availabie for medical and
inadequate data exist for Dental, Pharmacy and Nursing and absolutely no
dependable data exist for paramedical courses. The job of this committee
became more compiicated since the norms that were suggested by various
committees (Nations! & Internationa!) were more in the nature of ach.evab.e
recommendations rather than scientificaHy evolved requirements. There is no
data system avai.abie except for Engineering to know the employment
profiles of professionals. A .arge number of these professionals am-either
self employ ed or emptoyed in private establishments wherein .t is not feasible
to know the remuneration package. Hence the committee had to rely on
geneS indications as to what the peopie in the field say or what seme
graduates say. Another ve^ important factor taken into consideration is the
quality of the professional education which is
badly hurt becau
unplanned-and’rapid expansion..
With this background the committee has endeavored for the last seven
months to arrive'at the recommendations which are.in the best jnjeres
establishing quality institutions. The reason for this emphasis
^
q
that Institutions without quality are ruining the quality mstmmo^
’
17ft
35
I
^nirnittee appreciates that the Government thought it fit to appoint a committee
and to have a serious.look.at the situation.. The committee while appreciatin.
opportunity given to its members to examine the status of professional
education, it hopes that the government would take serious note of th,
recommendations made in the report...
The committee wishes to place on record the assistance it has-jeceived from
.nany-sources. It is a pleasure to thank Prof. D.M.Nanjundappa, Chairman.
Planning Board and Prof. Ashokclmndra, Director, Institute of Applied Mar
power research, New-Delhi for discussion on man power &
planning,
h-.
r
The committee
appreciates
perspective
ph .p AAi-hi T
the support
of the
member secretary
Dr.C.R
Thirumaiachar, Director of Medical Education and his team ■ particularly Mr.
A.M.Vishwanath, Professor of Statistics, Bangalore Medical-college and Mr. H
ShivaKumaraswamy for putting in efforts beyond the call of duty to see that
the J committee
departments
had
adequate
of Government
editorial
and
secretarial
particularly Health,
Planning
support.
and
. Th(
Education
through their Secretaries and Directors have rendered usefuliassistance.
The committee wishes to appreciate Mr. R.Shankara, and.Mrt L.Shama Sender
of Karnataka Govt. Computer center for their quality design and nice printing o
the report
:T'v
- I
I
The chairman appreciates the active support of all the members.
I
(Prof. M.I.SAVADATTI)
Bangalore /j?
Chairman
September 24,..1997
:
EXPERT COMMiTTEE
.# I 1
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PART I
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174
■■
REPORT OF THE EXPERT COMMITTEE TO CONSIDER
INTAKE OF EXISTING MEDICAL COLLEGES AND THE NEED TO START
NEW MEDICAL COLLEGES IN THE STATE.
The Cabinet sub-committee constituted to look into the question
of granting permission for starting new medical, dental, engineering,
ayurvedic, homeopathic and unani colleges and determine the intake not
only of existing institutions but also of new institutions, set up an expert
committee headed by Professor M.I.Savadatti, former Vice Chancellor
and member UGC, comprising experts from different related disciplines
in
Government Order no.
no.
HFW350MSF96,
dated:7.10.96
with
the
following terms of reference.
"The Expert Committee should go into all the factors determining
the need for medical, paramedical and engineering manpower in
different systems of medicine and engineering in the State for the next
ten years,
keeping in view the fact that many of the students who are
trained in the existing institutions do not
stay in Karnataka but go
elsewhere.”
The Committee was requested to give its findings within a period
of two months. A list of members of the committee is given below:
l S'
I
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w
w
1. Prof.M.I.Savadatti
Retd. Vice Chancellor.
Chairman
2. Dr.S.Kantha
Vice Chancellor
Rajiv Gandhi University of
Health Sciences
Member
3. Dr.C.M. Gurumurthy
Retd. Special officer,
Health University
Member
r-""
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4. Shri.R.N. Shastri
Secretary-ll, Health and
Family Welfare Department.
Member
5. Director,
Manpower and Employment
Division, Planning Dept.
Member
6 Dr.Renuka Viswanathan
Secretary to Government,
Planning Department
Member
7 Dr. N.R. Shetty
Vice Chancellor,
Bangalore University
Member
8 . Dr.Rame Gowda
Former Vice Chancellor,
Karnataka University
Member
9 .Prof.M.H.Dhananjaya
Director, J.T.E.
Mysore.
Member
10. Dr Chennabasappa
Retd.Prof, of surgery
Member
11. Dr.Thirumalacliar C. R.
Director. Medical
Education
Member Secretary
Expert Committee deliberations:
The Expert Committee met on 7.11.96 and decided to get
first hand information about professional colleges, how they are
run.
their
requirements,
needs,
problems
and
possible
expansion. It was decided to visit three medical Colleges: the
■
y'.
Bangalore Medical College (government), J.N.Medical Collage,
Belgaum(private),
and
the
Adhichunchanagiri
Institute
of
Medical Sciences, Bellur (private/rural).ln the second meeting
held on 20.11.96,the committee reviewed data on the number of
H
II
I
17 G
graduates passing out from different medical colleges in the
State upto 1995. Manpower and Employment Division, Planning
Department was requested to help the committee in working out
the
demand and
account
the
supply of medical
government
graduates
private
sector,
taking
into
and
self
sector
employed professionals. In the 3rd meeting heldon 10.12.96 the
methodology, of perspective planning for various sectors with
particular reference to the need for medical graduates was
discussed at length and it was agreed that Planning Department
should forecast the requirements of doctors taking into accout
the estimated needs of the State and the estimated number of
students seeking medical education from outside the State and
outside the country. It was also agreed that the report of the
Planning Department
should clearly state the
methodology
adopted, the assumptions made and the limitation involved
taking into account similar studies made at the National level. In
the
4th
meeting
held
on
10.1.97
the
report
of
Planning
Department was discussed and it was decided that reports
submitted by similar committees be studied. At the 5th sitting oT
28.1.1997,the
recommendations
of
various
reports
were
discussed and it was decided that a draft report be prepared
based on all the above discussions. The Committee decided to
take up the assessment of medical and engineering manpower
for the next 10 years on top priority and go into the question of
the
manpower
requirements
of
other
professional
and
paramedical personnel paramedical personnel in the second
phase.
*
3o
Present Status:
The Expert Committee reviewed the present status of
medical education in the State in terms of the number of
institutions and their intake and the out turn of medical students.
Karnataka had only two medical colleges in 1956 with an intake of
200 At present there are 19 medical colleges in the state. Of these
19, two colleges K.M.C., Manipal and K.M.C., Mangalore have
become part of MAKE and only 63 seats are available for the state
quota. With the remaining seats being filled on all india basis with
their own entrance examination.
Similarly
College,
on
Bangalore
also
admits
the
St.John’s
basis
Medical
of its
own
examination on an All India basis. Therefore in effect the intake for
the state is for 16 Colleges plus 63 seats from MAHE. Details of
total intake and outurn in these institutions are as below:
Expected Outturn
Intake
Year
Total
N K
Total
NK
KAR
1992- 93
2755
402
1418
1993- 94
1994- 95
1995- 96
1996- 97
3076
2960
1820
2025
730
2049
694 2382’
1952
2159
801
1946
2158
790
1402
1541
587 ____________
KAR
1667
382
1511
441
1511
435
2948
1079
323
2128
arrived at by
In this table total intake for the state is
in MAKE (except 63 seats given to state by
excluding admission
MAKE and in St. John's,. Bangalore)
Many of the Colleges have postgraduate programmes and
have superspecialisation and Phd. Programmes. These
some
colleges attract students from other states and countries and
have been by and large providing training as per the norms of the
Medical
Council of India . Except for four Government Medical
I
tig
SI
Colleges,
they
are
self-financing.
The
demand
medical
for
education is high as available seats are filled soon leaving
thousands of qualified aspirants disappointed. In the last five
years no new medical colleges has been started in the State under
the assumption that the number of colleges is Optimum, desprte
increasing demand for admission to medical Colleges.
Many
private managements have applied to universities and the state
government for permission to start new medical colleges. There
are instances of applicants and managements moving the H.gh
Court for directions to process such applications.
There have
been many court cases because of the huge deman
education.
Methodological options:
The expert committee did a quick review of a recent study
made
by
the
planning
department
of
the
requirements
manpower in medical, denta! paramedical and pharmacy co.Ieges
in the state. The study had assessed the requirement for the Sth
plan period on the basis of the end users method. The study was
however confined to the period 1992-97, while the cabinet sub
committee wanted an assessment of the next 10 years i.e. 1997-
2007.
i
To assess the requirement of medical manpower, the Expert
■2
Committee had to adopt a methodology that would result in a
reasonably reliable estimation of public and private sector doctors
needed over the period 1997-98 to 2006-07.
I
Broadly
1
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•
the
Expert
Committee
had
the
following
methodological options available.
I
t•
a I
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I^-St
32.
1.
Methodology based on the incidence of morbidity.
According to this methodology, demand for doctors can be
estimated on the basis of morbidity patterns, duration of
sickness by disease etc.
2. Another approach considered was the end users approach
with estimates of demands for doctors in
i terms of different
components public sector, private sector and selfemployment requirements.
t
J
3. The third methodology that was considered was the
normative approach based on the doctor population ratio
under which demand for medical doctors is estimated on
the basis of the desirable population to be covered per
doctor.
The major constraint in selection of methodology was the
time factor of two months given for completion of the report.
Approaches 1 and 2 require detailed sample surveys based on
schedules and can be completed only over at least 6 months.
Hence the committee opted for the normative approach of the
doctor population ratio hoping to base its findings on any ratio
accepted
by
level
National
committees,
policy
makers
of
International agencies and also make comparisons with the ratios
prevailing in other countries.
Report of the Planning Department:
The Expert
Committee requested the planning department
to prepare the prespective oi nedical doctors for Karnataka for a
to 2006-07). It was also suggested
period of ten years (1997-98
that in the demand projections factors such as migration, drop
outs
and
replacement requirements
consideration.
*
..
*
The
Committee
also
should
be
taken
into
suggested
that
while
assessing the requirement of medical doctors, the intake level
prescribed by the Medical Council of India for 1996 -97 was to be
adopted and the exercise
restricted to only Karnataka students.
Jj
..M'-
I: K.
fc-l
33
The Director of Medical Education was. requested to provide data
on the intake and out run of medical students (excluding non
Karnataka students) from 1992-93 and the 1996-97 intake level
based on MCI standards.
As regards the desirable doctor
population ratio to be adopted, the Expert Committee requested
the Director of Medical Education to
provide Nationsl Health
Policy norms if available.
■
The Planning Department prepared a paper on the health
man-power
prespective
for
medical
doctors
(Allopathic)
for
Karnataka for the period 1997-98 to 2006-07, utlilising data already
available in the department and data furnished by the Director of
Medical Education on the intake and out turn of medical students
since 1992-93.
For the desirable doctor population ratio the ratio
as recommended by the various committees was adopted to get a
feel for the situation. The expert committee on health man-power
popularly known as the Bajaj Committee which is the most recent
expert committee on health at the National level 1987 also
recommends 1:3000 as the ratio. No report goes into detail about
•the determination of a ratio.
Universally
accepted
The Bajaj report says, "there is no
method
of
assessing
the
future
requirements of health professionals and para-professionals. The
techniques of health manpower forecasting are yet at the stage of
infancy. Nonetheless, three methods are available for estimating
the projections viz., (1) the normative approach which is the most
common method for projecting requirements of doctors and
nurses based on norms(2) the medical user approach which takes
into consideration the willingness and capacity of people to pay
for medical services.
price and would
of the family,
expenditure on
Demand in economic sense is realted to
generally be limited by the financial resources
There is relationship between family income and
health services.
13)
On the basis of the household
■Hr•
data on common expenditure, the perspective planning division of
the planning commission has worked out the income elasticity of
household expenditure on medical services to be 2.3. This means
that if per capita income goes up by 1 percent, households are
inclined to increase their expenditure on health services by 2.3
percent.
(3) Finally the third viz., the Component or pragmatic
approach for projecting the demand for health professionals
i
requires a clear outline of the development of integrated and
comprehensive medical health services in the country over a
period of 15 to 20 years”.
The Bhore committee of 1946 or the Health Survey and
*
Development Committee with Sir Joseph Bhose as Chairman, had
recommended 1: 3000 as the norm of doctors to population. While
making
this
suggestion
he
mentioned,
“the
possibility
of
achieving the target one doctor for 1000 population seems to be
very remote”. Adopting this norm and projecting population up to
2006-07 using demographic projections made by the
Expert
Committee on Demographic Projections headed by the Registrar
General of Census operations based on the 1991 Census, the
following inferences were arrived at.
1. The total number of doctors (active stock) in Karnataka
is estimated at 23727 for 1997-98 which gives a doctor population
i
ratio of 1:2110. This is slightly better than all India ratio of 1:2460
for 1990
2. The cumulative stock of doctors for the period ending
2006-07 estimated at 33393 which gives a doctor population ratio
of 1:1682.
I
3. Demand projections show that for 1997-98 the number of
as per the ratio of
doctors required
1:3000
is 16687 and for
2006-07 shall be 18727.
4. A comparison of supply and demand projections shows
that there would be a cumulative surplus of 7040 doctors during
1997-98 and a cumulative surplus of 14666 doctors by 2006-07.
5. The total supply of doctors of the year period (1997-98
I
and 2006-07) is estimated at 10740 and the total demand for
doctors during the period is 2040 leaving a surplus of 8700
doctors.
Doctor-population ratio: how effective is the norm:
There
are
different
views
expressed
on
the
doctors-
population ratio as a norm to estimate the requirement of doctors.
Several organisations such as the World Bank and the Planning
commission at the national level have extensively relied on the
doctor-population ratio in their publications as macroindicator of
health services and as an instrument for estimation of the demand
projections of doctors.
The World Development Report 1993- investing in Health, makes a
reference to the minimum requirement of number of doctors
required per thousand population (refer page 139 of report) it is
mentioned in the report that “Public health and minimum esential
t
clinical interventions require about 0.1 physicians per thousand
population. There is no optimal level of Physicians per capita.”in
the same report an International comparision has been made for
countries with different levels of economic development and
respective ratio per physician. A selected list of countries is given
in the following table.
isg
2^
Il
i
I
350
100
180
330
340
610
400
2480
1350
1550
1640
3530
2560
6330
31050
12450
14210
18520
22240
25110
4010
Low income economies
1. Tanzania_______
_____2. Nepal__________
____ 3. India___________
!
4. Nigeria_________
5. Egypt
~~
r
6. Ghana_________
Middle income economies
____ 7. Uzbekistan_______
8. Kirgystan________
9, Georgia__________
Upper middle Income
10. South Africa______
11. Korea
_________
High Income:____________
12. Spain
__________
13. Singapore________
14. Italy________
15. USA
__________
16. Sweden: _________
World
6760
24880
17700
2460
4240
1320
22970
2060
280
280
170
640
1750
1370
420
280
820
210
420
370
3980
Source World Development report 1993. Investing in Health,
World Development Indicators, Basic Indicators (page
238 and 239) and health and nutrition (pages 292 and
293)
i
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The above inter-country comparison shows the disparities
in health service as reflected in the indicator of population
covered per doctor.
The ranges in doctor-population ratio for
each income group are as below:-
‘ Population covered per physician;'(1990 )
Highest
Lowest
Low Income countries
72990’
1450
Lower middle income countries
17650
250
Upper middle income countries
5150
210
High income countries
820
210
India falls within the group of low income countries its
doctor population ratio is the best within the group after Nicargua.
The Indian ratio is equivalent to the average ratio of lower middle
income countries.
The Shore committee norm of 1:3000 population was
adopted during the first and second five year plan periods.
For
the third plan, the guiding factor was the report of the Health
Survey and Planning Committee popularly known as the Mudaliar
Committee 1961.
i
This Committee recommended a target of one
doctor for every 3000/3500 population at the end of the Fourth
Plan. A component approach to estimate the demand for doctors
was adopted for the fourth and fifth plan periods. The Medical
and Health Care Policy for the fifth plan has observed that "in
regard to minimum public health facilities, generalised norms
r
such
as
improvement in
doctor population ratio and
bed
population ratio or per capita expenditure on health are not
adequate”
(refer report of the Working
Group on Medical
38
.jgsrr
’
b
• '
I
Manpower,
Employment
and
Manpower
Commission, GOI, September 1973 p.3).
Division,
Planning
The National Health
Policy - 1983 Government of India has not set any targets for the
country in terms of doctor-population ratio.
■
Although several organisations both at international and
national levels and several expert committees have relied on
i
j
I
doctor population ratio both as a health services indicator and as
a norm to estimate the requirement of medical personnel, there
are views which are against using it as a norm to estimate the
requirement of medical personnel.
One criticism is that the doctor-population ratio is a gross
figure of medically qualified persons which includes a large
number of doctors who are engaged in administration, teaching,
family planning
I
services.
etc.,
and are
not providing
direct medical
The doctor population norm does . not take into
consideration the distribution pattern of doctors According to an
IAMR study (IAMR Report on 2/1966 page 20) only 33 per cent of
doctors serve 80 percent of the country's population which lives
in rural India.
This shows that all doctors do not cater to the
needs of equal segments of population.
Further the number of
doctors registered at the Karnataka medical council over the year
were:
Year
■
Number registered
(January to December)
till 1985
25571
1985
1020
1986
1028
1987
1206
198
1262
1989
1516
1990
1527
1991
1785
1992
2110
1993
2528
1994
2439
1995
2596
1996
2727
The mean number of doctors registered during the last 5 years
works out to 2478 of which if emigration, non Karnataka and mortality is
taken into consideration (36%) roughly 1586 doctors stay in Karnataka in
a year.
Although the doctor-population ratio is a useful tool in the
estimation of the requirement of doctors, this ratio by itself is not
exhaustive and there are other factors which influence the demand for
doctors.
4(9
I
.ik •
. *
Other Factors which influence demand for doctors-
-i
Demand for medical care and for medical manpower is the net
result of a number of factors such as demographic changes, social
economic and technological factors. Important among these factors are
population and its age and sex composition and economic
growth
growth which affects per capita income and standard of living including
demand for medical services. According to the Bajaj Committee there is
a
relationship
between
family
income
and
expenditure
on
health
services. On the basis of household data on consumer expenditure the
Perspective Planning Division of the Planning commission has worked
out the income elasticity of household expenditure on medical services
to be 2.3 which means that if per capita income goes up by 1 percent
household expenditure on health services goes up by 2.3 percent
shows
that
as
proportionate
personal
income
goes
up
there
is
more
This
than
increase in demand for health ser/icas- w/iictr crsat'es'
additional demand for medical personnel.
The Expert Committee felt that factors other than demographic
changes which influence demand for medical doctors have
to be
considered taking into account location development, nearness to
similar facilities and possibilities of contribution to education health
care and economic and social development of region. These factors
I
can
be measured on the basis of data derived from a detailed survey
I
covering users, medical personnel and applicants to medical colleges
F
i
but at least 6 months would be necessary for conducting the survey and
analysing results.
Given that the committee is expected to furnish its
recommendations within two months, such as detailed study would not
be possible.
i
1
■4
I
also of concern to the exper.
additional
factors
were
The following
committee:the impact of establishing a medical college on
of thePhealth care delivery system in surrounding
i)
improvement
areas.
ii)
to the socio
the contribution of medical college
including .
economic and cultural development of an area
catering
and
indirect development sectors
like
transport.
medical college for jobs and
the
facilities
offered
by
a
iii)
for medical personnel
innovative training programmes
and others.
the medical college as an
iv)
development imbalances.
v)
instrument for correcting
the attraction of quality medical college for stude^
fro“d leading to the export of educabon and the
students..
help these colleges give to our local studen
vi)
sEEiSsgig
medical education and willing and capa
the costs.
vii)
Viii
-a of a new medical college not becoming
the importance
a burden on the
C.: State exchequer.
the responsibility of the Medical
Council of India for
the maintenance of quality.
Feasibility and desirabjlllYl
desirability tor a new medicai college has to be deed
The
0,0 account location, the development of the region, the
f s miiar facitities and the possibie contribution of the coiie, .
Lth care and economic and socia. deve,oPment of the
region.
I-aS
42.
Feasibility may be based on the possibility of building and
taining a quality institution in a desirable location and the strength of
SUaSnagement that proposes to set it up. The management should have
b Aground and experience, adequate financial strength and a time
bound programme for implementation of the project.
The yardstick
?
should be whether the project is achievable in a given time.
These
general guidelines have to be applied to individual cases after assessing
03ch case on merit.
With the short time at its disposal, the committee would not be
able to quantify the above factors and test its assumptions on empirical
data.
Nevertheless, if a decision to open fresh colleges is taken the
following
principles
may
be
adopted
to
determine
location
and
desirability.
r E C O M
i
1.
MEDAT10NS
From 1946 to 1987 in various expert committee reports the
doctor population ratio of 1:3000 is stated as a target/norm.
has been prepared or suggested by the Govt, of India.
No target
Therefore, it is
not possible to draw any firm conclusions on what should be the target
for the next decade for the State.
Further to quantify unemployment
amongst doctors is not feasible, because - a) the employment exchange
registration is not reliable as many doctors do not register and many
doctors do not find job placement through employment exchange: and
b) self employment opportunities available for doctors are difficult to
asses.
2.
In view of these if a decision to open new colleges is taken it
should be necessary
to have a cell or a committee at State level that
the number of doctors, their profiles in
would obtain data on
employment & such other related economic indicators (essentially
i
Ho
information system for medical practitioners) on a continuing basis so
•4
that the exercise would provide inputs for future decisions that may
modify the policy in the best interest of health care and economy in the
State.
3.
In view of what has been said earlier and in view of the
uncertainty of data available for employment status, it is difficult to
recommend precise intake for the State.
However, taking into account
the demand and other factors mentioned earlier, it appears reasonable
to keep the admission level for the State as 3000 (excluding MAKE &
St.John's) this would give a doctor: population ratio of 1:1528 by 2006.
4.
It is evident from the report of the committee that visited the
medical colleges, that establishment of medical colleges has helped in
improving the economy and health care of the area.
This strengthens
the case for fresh medical colleges in areas where there are no medical
colleges at present. Therefore it is desirable not to have a fresh college
in Bangalore city and not to encourage new medical colleges in areas
already having medical colleges.
5. While giving recommendations for feasibility for additional
intake or a fresh college, Government should rigidly adhere to MCI
norms.
Rl
z
44
i
J L;-'
EXISTING MEDICAL COLLEGES IN THE STATE
-
-aS’
excluding Mahe & St. Johns Medical College
7
Intake
1S9G -97
1
■
BANGALORE
Bangalore Medical College
L
245
Kempegowda Inst, of Medical Science
120
120
,2
—.
3
Ambedkar Medical College
120
120
4
MSB Medical College
150
150
•
5
BELLARY
Govt. Medical College
100
140
6
BELGAUM
JN Medical College
200
195
7
BIJAPUR
Al Ameen Medical College
100
130
BLDEA Medical College
150
180
8
9
DAVANGERE JJM Medical College
245
328
5,
10.
HUBLI
Karnataka Medical College
50
147
1 i
11.
GULBARGA
MR Medical College,
100
185
12.
KOLAR
Devarak Urs Medical College
150
150
13
MYSORE
Mysore Medical College
100
205
JSS Medical College,
100
200
14.
-
■
■
;
n
J
I
I
1507
J
■
•
1995-96 •
■
I 15.
BELLUR
AIMA.
100
195
16
TUMKUR
Siddartha Medical College
130
195
17
MAKE (Mangalore) seats given to state quota
63
63
2128
2948
TOTAL
Appendix - 5
A Submission to
the sub Committee on Medical Education
OF THE
Parliamentary Stand.ng Commjttee on
Human Resource Development
Bangalore
On 14th November 1998
By
n>e Society f„ Co„mu„ily H„l,h Awareness, Researeh and Ae.lon
367, SnnivasaN,lays’ Jaklas.ndra l-'M.ln
’
1 Block, Koramangala,
Bangalore - 560 034
Phone : (080) 553 15 18 & 552 53 72
ax_ (080) 55 333 58 (mark Attn : CHC)
Email; sgchara@blr.vsnl.net.in
iqs
46
I
Introduction
he Society for Community Health Awareness, Research and Action is a
mu .disciplinary resource centre consisting of professionals interested in makina
ea h care services, medical and health personnel education, and health research
activities m the country
more responsive to the needs of all our people, especially the poor and
marginalised;
more relevant to rural, urban poor and tribal communities; and
more sensitive to disadvantaged groups.
♦ Many members of our CSociety have worked in
medical colleges and teaching
institution in various senior capacities.
♦ Among our many activities has been a
longstanding and continued interest in the
Reorientation of Medical Education
towards greater Social Relevance and
Community Orientation.
In this connection, we have undertaken the following in recent years:
♦
i)
A detailed study of Recommendation on U
Medical Education from the Bhore
Committee (1946) upto the MCI Curriculu
.Jm Recommendations (1997).
ii)
A study of Social Relevance ;and' Community
~
Orientation in Medical
Education in the country.
We studied initiatives of around 25
-----------> medical
colleges.
iii) A study of feedback on the curriculum from 1
young doctors (medical
graduates) who have had work experience in peripheral health
i care
institutions in the early 1990s.
iv) A study of innovative Community Health
Training Experiments in the
country.
v)
A policy study on “Perspectives in JMedical
' C. Education” for inclusion in the
Report of the Independent Commission
—on Health in India — recently
submitted to the Prime Minister.
vi) A.contmuing dialogue with a host of medical colleges in the country and in
eighbouring countnes
countries of Nepal and Bangladesh on evolving mechanisms to
neighbouring
operationalise strategies of change.
Based on these studies and reviews we make a submission to the Sub-Committee’on
Medical Education (Parliamentary Standing Committee on Human Resource
Development).
A. CONCERNS
The following disturbing trends and developments in Medical Education in India
are a cause for grave concern.
1. Commercialisation of Medical Education
Growih of Capitation fee’ colleges in Maharashtra, Karnataka and Tamil
Nadu.
Mushrooming of institutions based on caste and communal affiliations
often sponsored by trusts and lobby groups with little previous credibility
or commitment to higher education.
Commercial growth of high technology secondary and tertiary medical
care at the cost of primary health care.
Increasing involvement of full time medical college teachers in private
practice.
*
Increasing problem of ‘money power’ land
_._1 political interference in
selections, examinations, appointments and transfers
--------- j even in government
health services and medical colleges.
2. Overall Fall in Standards of Medical Colleges
*
Inability of increasing number of medical colleges in the country to
maintain even the minimum requirements for undergraduate and
postgraduate medical education as laid down by Medical Council of India
especially with regard to:
Teaching staff
Hospital beds
Pedagogical norms.
Growing dissonance between present selection procedures of medical
students and the type of doctors the countiy needs.
3. The Increasing Erosion of Norms of Medical Ethics
*
Increase in medical mal-practice and negligence.
Growth in doctor-drug producer axis.
Growth in powerful medical industrial complexes.
Inadequate response of the medical profession to the societal needs.
Inadequate Social and Community Orientation
4. -Inadequate social and community reorientation of Medical Education of all
faculties inspite of MCI guidelines, expert committee recommendations and
innovative experimentation by pace-setting medical colleges in the country.
48
AGENDA FOR ACTION
In the report to the Independent Commission on Health in India, which submitted its
report to the Prime Minister in May 1998 (recently forwarded by us with some
modifications to the sub-committee on Medical Education), we suggest the foliowins
agenda for action, reform and governmental initiative:
1. Control of Commercialization Education in Medicine
a)
Setting up Health Human power Development Commission consisting of
representation of all the professional councils such as MCI, DCI, NCI, etc.,
professional resource groups and knowledgeable other persons, to plan
Health Human power Development including undergraduate and postgraduate
medical education on need based and evidence based planning.
b)
Review of Financing of Medical Education under both government and
private ownership to identify the problems, options and prospects and
approaches that are rational, legal and do not allow merit and social justice to
be compromised. This should include a review of the concept of Capitation
Fee colleges, ‘self financing’ colleges, free and paying seats, NRI and
management quotas and the recently recommended differential fee structure
for various categories by MCI, so that the options are decided by people’s
needs and not market forces.
2. Quality Control and Improvement of Standards
*
Ensuring that all the existing medical colleges have adequate infrastructure,
teaching faculty, clinical facilities and pedagogical standards and banning
quantitative expansion of medical education.
Strengthening of MCI and Directorates of Medical Education at State level, to
ensure quality control and monitoring of standards.
*
Evolving mechanisms to include wider societal representation in decision
making to ensure greater social relevance.
3. Introduction of short courses in Medical Colleges to improve ethical
standards and broaden the horizons.
Ethical standards
* Medical Ethics (Recently introduced by Rajiv Gandhi University of Health
Sciences - Ordinance 1998)
Rational Drug Use and Essential Drugs concept.
Broaden horizons
Introduce Mental Health Care; Integration of Medical Systems; Management;
and Gender sensitivity in Medicine/Health
nc
43
4.
Continued Reorientation of Medical Education to enhance Social Relevance
and Community Orientation
Universal acceptance and promotion of recent MCI 1997, Regulation on
Graduate Medical Education especially institutional goals; skill development,
Oinen^t'on’new internship guidelines, (which have substantial changes since
the 1982 guidelines).
Proper faculty selection and reorientation
objectives of medical education, of ail faculty.
*
towards
social/community
Proxision for creative autonomy for a few selected pace setter colleges to
expenment with Alternative Track Medical Education - geared more
specifically towards Primary Health Care / Family Medicine / General Practice
(cf. kakkar Report to MCI, 1995),
We request the Chairman and Members of the Sub-Committee
on Medical Education
to consider these recommendations and include them in their report for necessary
actions We would be happy to provide further information, data and resource
materials on these and other concerns.
Thank you.
Dr. Ravi Narayan
6^--^
Dr. C.M. Francis
3.hr I.
Dr. Thelma Narayan .
On behalf of
Society for Community Health Awareness, Research and Action,
Bangalore.
Dated : 14th November, 1998
SD
u
< '
approves over 20
By S.Rajendran
While the applications of some of the influential
BANGALORE, Sept. 3. applicants such as the Dayanandasagar group
The State Government, after a gap of about of educational institutions (which had moved
10 years, has granted approval for the setting up the court and obtained a directive), the iWJ
of over 20 medical colleges in the belief that the . Institutions and the Sringeri Math have been
Union Government would give its final sanction kept on hold, those of some little known educa
to at least seven medical colleges, thus ensuring tional institutions have been approved.
that there is at least one medical college in each
The Minister of State for Medical Education.
district.
Dr. M.Shankarnaik. told The Hindu here today
Under the rules of the Medical Council of In that he would not like to go into the details of
dia. amended in 1992, the State governments how approval was granted since the Cabinet
have been deprived of the powers to give out- had. at a recent meeting, authorised the Chief
• right permission for the establishment of med Minister to take a final decision on the matter “I
ical colleges. The States, based on the stand by the Chief Minister's decision since it is
applications received and the necessity for new in the interest of the State. The State Govern
colleges, may issue an "essentiality certificate”. ment is confident of securing the final approval
Thereafter, the applicants have to approach the for at least seven medical colleges and this
Medical Council of India, which gives a recom should suffice for the present.” he said.
mendation to the Union Government. The Gov
The districts where medical colleges are pro
ernment decides whether to accept the posed to be established for the first time are Rairecommendation or not.
chur, Bidar, Bangalore Rural. Hassan and
The Chief Minister. Mr. J.H.Patel, now on a Bagalkot. Bangalore City, which already has five
fortnight- long official trip to Europe, reportedly medical colleges including the St. John's Medical
accorded permission to the Medical Education College (a minority institution and consequently
Ministry to issue essentiality certificates to 20 of out of the purview of the State Government),
the 60 applicants, according to official sources. will have three more medical colleges. While the
to the respective managements and the non
Karnataka quota, nearly 500 additional scats
will be available for the local candidates. The
intake of the medical colleges will thus Increase
to around 2.500 from 1.900.
Most of the applicants for medical colleges
have claimed that they arc ready with the in
frastructure, including a building and hospital.
As per information available with the GowmIn the view of Dr. Shankarnaik. the objective ment. at least six of the applicants are willing to
of giving approval for starting new colleges is to face an inspection by the MCI. The Slate Govern
neutralise the sudden drop in the intake of med ment itself will have to get into top gear to pre
ical colleges following the Medical Council of pare the Bowring Hospital for the MCI team’s
India deciding to go by the rule book and the visit.
Union Government strictly folloiving the recom
The Savadatti Committee, which went into
mendations of the MCI irrespective of the over
the need for new medical and engineering col
riding powers vested in it. The four Government
leges two years ago. had recommended that
medical colleges in the State have been worst hit
there was a need for at least 3.000 MBBS seats
with their intake reduced from 1.585 to 790.
in the State. The Government thereafter consti
The intake of private colleges has come down. A
tuted a Cabinet sub-committee under the chair
few years ago. the intake of Davangere college
manship of the Minister for Law. Mr.
was reduced to 150 from 345. The J.S.S. College
M.C.Nanaiah. to study the matter and scrutinise
at Mysore is perhaps the only college the intake the applications. In 1990-91. late Veerendra Pa
of which has been enhanced.
til put a halt to new medical colleges and said
The State Government is hopeful that the MCI they would not be allowed for five years. Succes
would approve an intake of at least 700 seats in sive Governments have conformed to the policy
the new colleges. Even if 30 per cent of these go • in the last eight years.
State Government will open another college in
the premises of the Bowring and kidy Curzon
Hospital, the Indian Air force, which runs a
major hospital for the personnel of the 1AE and
their kith and kin. has also received the essen
tiality certificate. The third college proposed to
. be established in Bangalore will be managed by
members of the Adi Jambhava community.
na
£/
c.' CJ^
‘ - Ic
1/
Newspaper Reports on new Medical Colleges
dH- 2^_6/^T
s
I
03
Opening of new medical
colleges: To what end?
J
c
a
Sir, This has reference to
A
Karnataka’s Minister of State MCI. Thousands of medical B
for Medical Education M Shan graduates are without proper fr
kar Naik about the Govern Job and the Government has no ir
plans to employ them. The posi
ment’s proposal to start six
tion of Government medical col Y.
more medical colleges in the leges are still worse.
n<
State (DH, June 19). The Govrc
There is a need to collect
erament will definitely have an
ultimate say in the governance exact figures from all the col
and policy making. But in the leges, analyse them realistically ti
changing trends of our democ- and arrive at an information di
racy, where in the governments base. This should be followed by ir
and ministers keep changing in a debate. Such formed opinions v;
months or years, floating half- only shall be the guiding prin tl
baked policies for their con ciples, for such policy making tl
venience may have long term and not the desire of those in
power
who
feel
no
harm also.
tf.
accountability for the future of
M
The ministers will not be in the State.
cc
power to share the good and
The Issues in question are: it
bad results of their actions. The
Has the Government worked ai
governments cannot tailormake such policies to suit their out the future needs of medical
doctors? Can’t the present medi
convenience and tenure.
cal colleges be improved Instead
Karnataka has 17 medical col of starting newer ones? How
leges in Bangalore, Belgaum, can the Government take up
Bellary, Bijapur, Gulbarga, such issues for short-term h
Davangere,
Hubll,
Kolar, gains? Is the Government
si
Manlpal, Mangalore and My bypassing the MCI leaving the
ai
sore.t Twelve medical
cofleges
I
x _
-------- — Institutions and graduates high ft
are p--*
?,
c
ru
y by and for
ye^
y
the Medical Council of??
India
DR
H
R
VIVEKANANDA
(MCI) for reasons like inad
Medical Superintendent P
equate staff and poor facilities
Karnataka Institute of P
Nearly 80 per cent courses of
Medical Health t
fered are not recognised by the
dharwad £
It has become necessary for the
people themselves to find out the
quality of milk being supplied to
them.
t
some
enthusiastic
entreprenuers come forward to
manufacture lactometers to exam
ine the density of milk supplied to
them? Thia will go a long way in
assisting the public to check the
quality of milk.
1
S S UNDARA '
Bangalore
R9
5A.
ivia.Ke it need-based
I.
decision on Thursday to for-
Medical Education, Mr Shankar Naik, had hinted £Sy Jat
SeEesei^epnn Was thinkmg of sancti°™g six new medical
nnn f
^^Presented and newly-carved out districts
’•?ef°re recommending the need for 20 new medical
.
°,e3’14 15 not clear whether the State Cabinet had ascerWhlT* the Pro^SSIonaI requirement in the existing colleges
X » ~
cann0^overlook
or X oo°o“?LX7“"a'
"d
1»Sed “ ““
1S1°n °n 016 matter and recommend the same to the
Union Government for approval. Thus, the MCI needs to plav
it has°tnSlb eJ°Ie “ 0115 regard- Before according approval
■ ? 2 make 3 c®3118110 assessment of the potential for
infrastructural facilities, quality of equipment, condition of
aboratories and the teaching staff in the new institutions in
offirig so that they fulfill the statutory norms prescribed
nf dnrlh
31633 m 4116 S4a4e continue to face a dearth
, d ct 3 ,ln g°verrunent hospitals because of the doctors'
reluctance to serve in these areas. To that extent, the prolifer
ation of medical coUeges and increase in medical manpower
will continue to be a paradox. Most modern-day doctors
chlnPpref UC^ntJ,° g° t0 rUral areas' 71148 attdude should
“™swem s“a
teXXX
I
‘More medical colleges needed’
Express News Service
If violation of rules is brought‘ °ns which had applied for medto our notice, we will write to' leal colleges had infrastruct- |
Gulbarga, Sept 12: Medical
• the MCI to derecognise the col ure as per the MCI nonns.
Education Minister Shankar lege,” he said.
Nayak said it was for the MCI
Nayak has said that Karnataka
Nayak justified the issuance
needs more medical colleges as of essential certificates by the to ascertain such factors. He
said the government had rece
thousands of students from the
State Government for starting ived about 60 applications for
State are deprived of medical
20 medical colleges. He said alt starting medical colleges and’ 1
education.
hough the State Government after thorough screening, the
Speaking to reporters, the had recommended the starting State
had
minister said only 1,900 stude of colleges, the decision rested
-- —J recommended only
20 applications.
nts from Karnataka could now
with the Medical Council of In
He pointed out that although
get admission to medical colle dia CMCI). He hoped that the
ges while the Savadatti Comm MCI may approve about half a the Andhra Pradesh Governm
ent had recommended opening |
ittee had observed that 3,000
dozen medical colleges.
of 17 medical colleges the MCI !
students could afford it. Based
He denied that the State Gov
on the Savadatti Committee re ernment had arbitrary and in approved only two.
The minister said most of
commendations, the State Gov discriminately issued essent
ernment felt the need for reco ial certificates to proposed the applicants would use gove
mmending more medical colle medical colleges although he rnment hospitals for teaching
facilities.
ges, Nayak said.
agreed that caste and commun
He said the government had
He said the government ity factors of the promoters of
would not allow any medical the institutions were conside no objection for allowing priv
ate medical colleges to use gov
college to admit students in ex red in some cases.
ernment hospitals as it could I
cess of the prescribed quota.
Asked whether the instituti- charge clinical fee.
|
Soo
S3
!
-........................................... ;------------------------------- ..■■■.
■•.■;»»
■■■•
................................................................... ........................
'W
’",
->-r:;
■
Slate imames usi vi
new medical colleges
DH News Service
BANGALORE, Sept 3
The Government has finalised the
list of 20 new medical colleges to
be set up and sent the list to Medi
cal Council of India for its appro
val Chief Minister J H Patel is
learnt to have cleared the new col
leges before leaving on his foreign
tour last week.
Two colleges to be opened by the
Government and one by The
Malnad College of Medical Science
and Research Education Trust of
Shimoga headed by Mr Patel him
self also figures in the list.
The cabinet sub-committee rec
ommendations came before the
Cabinet meeting on Friday. How
ever, the Cabinet is learnt to have
authorised the chief minister to
take the appropriate decision.
The other educational institu
tions whose proposals have been
cleared, are: Nitte Educational
Trust, Mangalore; • Siddaganga
Educational Trust, Tumkur;
Kaginele
ivixuioocunouicuuua
Mahasamsthaana ,
Kanaka Gurupeetha Educational
Institution,
Chikmagalur;
Jagadguru
Murugarajendra
Vidyapeetha, Chitradurga; Islamic
Academy of Education, Manga
lore; Dharmasthala Educational
Trust, Dharwad; Father Muller’s
Institute of Education and Re
search Institute, Mangalore; H D
Deve Gowda Medical College (Adi
Chunchanagiri Educational Trust,
Belur); KVG Medical College,
Sullia; Karnataka Adi Jambava
Social and Educational Trust,
Nelamangala;
Shantivardhaka
Education Society, Bhalki; Khaja
Hajarat Bandenawaz Education
Society,
Gulbarga;
Basavalingamma
Sanganatha
Subedar Trust, Raichur; Govern
ment Medical College, Bowring
Hospital,
Bangalore; Armed
Forces
' Medical
Institute,
Bangalore; Vijayanagar Education
Trust, Bangalore Rural District;
Navodaya Education - Trust,
Raichur; Sanchara Charitable
Trust, KGF; and Basaveswara
Vidyavardhaka
Sangha,
Bagalkote.
i
* ‘
■
|
MCI unlikely to grant new colleges for State
dian Express that a surprise in Health Department will in
spection of the existing 17 med turn refer the applications to
Bangalore, Sept 4: The Medi ical colleges in Karnataka the Medical Council. If the app
cal Council of India (MCI) is would lead to many of them be lications are in order, the Cou
unlikely to grant any new med ing disqualified. Most of them ncil will send teams to the new
ical college to Karnataka.
lack in clinical facilities and colleges for inspection and la
Indications to this effect teaching staff. “No new medi- ter take a decision based on
were available from the MCI cal college can manage the req their opinion”.
headquarters in Delhi on Fri uired teaching staff overnight.
The State Government is bel
day. The stand follows the Kar They invariably woo teachers ieved to have cleared the appli
nataka Government’s reported from existing medical colleges cations of the following colle
decision to give ‘essentiality’ causing deficiency there,” the ges, and decided to recommend
certificates to 20 new colleges. officials said.
them to the Centre. .
These include - two to be set
MCI president Ketan Desai
The Malnad College of Mediup by the Government, one speaking from Gandhinagar in. cal Science and Research Edu
named after former Prime Min Gujrat said: “The State Govern cation Trust at Shimoga hea
ister H D Deve Gowda and one ment can only give ‘desirabil- ded by J H Patel: Nitte Educati
headed by Chief Minister J H ity’ certificate, and recomm- onal Trust, Mangalore; SiddagPatel.
end the applications to the Uni- anga
Educational
Trust,
The MCI officials told The In- on Health Ministry. The Tumkur; Kaginele MahasamstExpress News Service
mma Sanganatha Subedar!
Trust, Raichur; Government!
. Medical College, Bowring Hos-|
pital,-Bangalore; Armed Force t
Medical Institute, Bangalore;!
Vijayanagar Education Trust, j
Bangalore rural district; Navo- j
daya Education Trust, Raic-i
hur; Sanchara Charitable I
Trust, KGF and Basaveshwara •
Vidyavardhaka Sangha, Bagal-»
kot.
!
Meanwhile,
Bangalore-1
based Rajiv Gandhi University [
of Health Sciences has already i
cleared the applications of Kur- [
unji Venkatramana Gowda [
Medical College, Sullia and i
Yenepoya Medical College, i
Mangalore.
i
3.01
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.
£....
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■■ ?
•
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■
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hana Kanaka Gurupeetha Edu
cational Institution, Chikmaglur, Jagadguru Murugharajendra Vidyapeetha, Chitradurga;
Islamic Academy of Educa
tion, Mangalore; Dharmasthala Educational Trust, Dharwad; Father Muller's Institute
of Education and Research Ins
titute, Mangalore; H D Deve
Gowda Medical College (Adichunchanagiri
Educational
Trust, Bellur); KVG Medical
College, Sullia; Karnataka Adi
Jambhava Social and Educati
onal Trust, Nelamangala; Shanthivardhaka Educational Society, Bhalki; Khaja Hajarat
Dandenawaz Education Society, Gulbarga; Basavalinga-
Minister wants MCI’s wings clipper
Express News Service
Gulbarga, Sept 13: Medical
Education Minister Shankar
Nayak has made a strong plea
for clipping the wings of the
Medical Council of India (MCI)
and restoring the power of san
ctioning medical colleges to
State and Central Governme
nts.
Inaugurating the XII Karnat
aka State Obstetics and Gynae
cological Societies Conference
organised jointly by the M R
Medical College and Gulbarga
Obstretrics and Gynaecologi-
cal Society, Nayak criticised proper to accept whatever MCI
the MCI for its “dictatorial” does and says?” He urged the
and “authoritarian” behavi- Central
Government
to
our in sanctioning new medi—withdraw these powers from
cal colleges, a power vested in the MCI.
it by the Supreme Court.
Shankar Nayak. who has tak
“MCI should only be a reco en an active role in issuing ess
mmendatory body and should ential certificates for 20 medi
not be given powers to overr cal colleges, said he hoped the
ide the decisions of Governme MCI would clear at least half a
nts.”
dozen.
Nayak said the Supreme
There was a shortage of doct
Court had vested the powers ors particularly lady doctors
with the MCI but went on with , in rural Government hos
a volley of rhetorical questi pitals. Despite facilities, doct
ons: “To whom is the MCI acc ors are unwilling to work in
ountable? Is it a dictator? Is it rural areas.
“.Doctors want to make fast
money. However, they should
realise their social responsibil
ity.
“Doctors should develop the
tendency to serve the poor and
the needy to make their profes
sion meaningful,” Nayak said.
Without adequate health
care facilities in rural areas, it
would not be possible to achi
eve the goal of “health for all
by the year 2000. ”•
Director of Medical Educat
ion Shivaratna Savadi inaugur
ated the scientific session.
Gulbarga University Vice
Chancellor M^^Iuniyamma,
who released the souvenir,
urged the medical community
to organise camps in rural
areas to bring about awaren
ess on health and hygiene, par
ticularly among women.
Hyderabad Karnataka Educ
ation Society president Dasavarj Bhimalli presided over the
function.
The three-day conference
was attended by about 500 dele
gates coming from across the
length and breadth of Karnat
aka as well as neighbouring
states.
So a
G5
4
H
H
j “tea TOite/ace on nodfor new colleges
Express News Service
adequate financial
—
would be given permission.*
Bangalore, Oct 7: In a compl
The State Cabinet had, last
ete turn around from its earl month, given essentiality certi
ier stand, the Medical Council ficates to 21 medical colleges
' of India, (MCI), has said it and had forwarded the propos
would accord permission to al to the MCI. Dr Desai had,
new colleges only if they met however, reacted by saying
the regulations stipulated by that the MCI would not permit
them.
any new colleges from coming
When asked about the ratioTalking to media persons on up in the State.
nale behind granting any new
Wednesday, MCI president Dr
Justifying the present stand,
Ketan Desai said those institu Dr Desai said if these instituti
tions which owned 25 acres of
ons followed the legalities,
land, a 300-bedded hospital and there was no way he could
1
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.! <P
|
S5SL-S
Politicians control professional colleges
B21B2iE
has its members in one medi-;.
I
Bangalore, Oct 7; At least 45 Cal ar!^ thre^en8ineer
ing colhi
professional colleges in Karnat Zdi ™e.^Aat?t.leJaSLOne'
‘ in Shimoga. In th^ same
aka are run with active involv medical, two dental and three
district, fonner Chief Minister
ement of politicians.
engineering colleges.
S Bangarappa’s son, Kumar
; Of the 20 applications recen
That’s not all. Bhanumathi
tly floated by the Government, Tambidurai, wife of Union Bangarappa, looks after Shara8 have politicians including Law Minister M Thambidurai vathi Dental College.
In Hassar. Mal/ad College of
Chief Minister J H Patel on the is one of the three trustees of
Engineering
is headed by senimanagement.
the Bangalore College of Engin
Karnataka has 17 medical eering and, Technology at Mal- or Congress member Hamahally Ramaswamy. Hassan1 .^y
<’ol leges, 40 dental colleges and ur in Kolar district. An And ___
00 engineering colleges. Of th- hra Pradesh politician too has soon get a medical college
i <‘se, only four medical colleges, set up an engineering college named after H D Deve Gowda.
In Bangalore, fonner Minis
| one dental college an no engin- in Bangalore. Evidently Karn
, < ering college are run by the ataka has some special attrac ter for Information C M Ibra
him of the Janata Dal adminis
: Oovernment.
tion to those who run educat ters KhwaJa Khuthubuddln
: A rough estimate shows that ion as business.
Bakthiar Kaki College of Engi
i he Congress party has tacit
Patel heads the proposed
control over three medical, Malnad College of Medical Sci neering while Adult Education
seven dental and 14 engineer- ence and Research Education Minister R Krishnappa is with
Revanasiddeshwara Institute
■
I?
' !
os
to take a decision on the issue.
Commenting on the recent
statements of Medical Educat
ion Minister Dr M Shankar
Naik against the powers of the
their
MCI, Dr Desai said the body
they
was constituted by an Act of
Parliament.
“
If
the
Minister
h^ X Dmhlpmt \ ?1S'^ tl’°SC CoUe8es which ofTer
has
any problems,
takeTun
wiTihhe pshould
h d m°re Salaries- This situatlor>
take it up with the Centre.
There is no need to issue such
statements. The Supreme said.
Court verdict has also upheld
the powers of the MCI”, he
T
to open new colleges, either
J a
comparison between Karnat
aka and Gujarat, he said while
Gujarat had j ust two dental col
leges, Karnataka had the distinction of having 40 dental col
leges.
Dr Desai said opening new
colleges would not solve the
problems if quality teachers
were not produced. He urged
academicians to Indulge in Int
rospection to improve the qua
lity of medical education.
£0lle®e?Engineering, Bapuji
ry Rural Engineering r«-ii
CoUege Dental College
~
other Collat Bellary last year.
eges at Davanagere.
of Technology. One of the old
Former Sericulture Minister
Shanti Vardhaka Education
engineering colleges in the and Congress member G Para
City, named after Dayananda meshwar is looking after Sidda- Society at Bhalki in Bidar. dist
Sagar is being run by former rtha Institute of Technology in rict involves fonner Transport
Minister and Congress MLC
Premachan' Tumkur. His brother looks Bheemanna Khandre on its
after Siddartha Medical Coll
Two Ministers have got two ege there. Last year, former management.
A trust headed by Mysore’s
medical colleges cleared for Congress MLA Shafi Ahmed’s
former mayor Vasu runs
Raichur district. Textiles Mini*
HMS education trust started
ster M S Patil and the other Rel an engineering college in Vidya Vikas Institute of Engin
igious Endowments Minister Tumkur. In all, Tumkur City eering and Technology, Mys
Muniyappa Muddappa. Intere has three engineering colleges. ore. Former JD MLA P M Chikkaboraiah started the Vidyavastingly, some political groups
Congress-turned-Dal -tume- rdhaka College of Engineering
in Raichur have opposed med d-Congress
leader R L Jalappa at Gokulam in Mysore.
ical colleges with the involve heads the Devaraj Urs Medical
__ .
« -------------- ■ Why are politicians, inclument of Ministers. They want rrt11
College in Kolar. Davanagere’s ding uneducated ones, profoa Government college.
Congress MP Shamanur ShivaFormer Union Minister and shankarappa is also a ‘leading undly interested in educat
senior Congress member M educationist’ running Bapuji ion? Read all about it tomor
row.
—u
Govt, seeks more powers
on medical admissions
------------- i -^l /"/ sBy Our Special Correspondent
The Minister said the applications for 20 new '
Tk
z.
BAxNGALORE. Nov. 28. medical colleges, which were cleared by the
I he State Government, unhappy with what it State Government a few months ago, were pend
cails the dominant role played by the Medical ing with the Centre. It was for the MCI to send
Council of India in the functioning of medical an inspection team and the Centre to act on the
coHeges . has urged the Union Health-Minister. MCI recommendations. The applicant-manage
Mr. Dalit Ezhimalai. to vest powers with the ments would have three years to meet the condi
State Government in the management of private tions laid down by the MCI though the MCI
and Government-run medical colleges.
generally gave its assent only to the colleges
Barring the issue of Essentiality Certificate to which had an attached teaching hospital. Of the
managements seeking to set up medical colleg- 20 applicants, five had attached hospitals The
/ St?te
under the amended State Government is an applicant and has
MCI Act. have been deprived of any control----- sought to establish a medical college at the
admissions. The Union
Bowring Hospital here.
has -------also urgedllJUlcua
for increashas been vested with adequate powers to over- • The" Government
— *-.22
.
rule the MCI recommendations and has the final !n8 ‘h^kc in the Bellary. Hubli and Mysore medical
colleges.
For the
the Hubli
Hubli college,
coilege. itit has
say with regard to professional colleges.*
colleges.
. C0,,e
Ses- Bor
has sought
sought
The Minister for Medical Education Dr M
ilS <,8‘.,inst 50 now and for the MysoreC
Shankar Naik. told presspersons here today that nPH? u?/01 egcs. lo° agninst 1()() now As
he had met the Union Health Minister reccntiv P >thC MC
thc ,ntakc for thc undcrgradand requested that the Centre be more assertive ?-n £°ursc/MBB5>) could not be more than
and not be carried away by the recommcnda- r 11 T 1US’ lhc lntJ,kc °f thc Bangalore Medical
tlons of thc MCI. which at times. In the ?lew of
|u8C ?VnS rcduced froni 245 t0 150 seat5the State Government, were questionable. The , 4 1 Government was yet to decide on thc rclatter had assured that he would call a meeting introduction of outpatient charges inTts hosph
Collecting
outpatient
charges would cn
ensure
of State Health Ministers to discuss thc issue If tals.
k*’* \y
MU‘’ullK uul
Pi|Ucni cnarges
need be. thc Centre would amend thc MCI Art lhat thc PaUcnLs concerned preserved their
patient
card.
It
would
help
in
lh=
l^,Uon
thc Union Minister had said.
u
! “
Dr. Shankar Naik said thc States should at Of the case-sheet of thc patient concerned.
Most of thc Government teaching hospitals,
least have powers to increase thc admission in
r Jai , sufTercd
poor upkeep and shortage
take Into thc undergraduate and postgraduate
courses in medical colleges and the Union Gov of drinking water. Thc sinking of five borcwclls
ernment and thc MCI could have powers to ap in each hospital had put an end to thc water
prove new medical colleges. With the orders of shortage. The Government had ordered that
the High Courts and thc Supreme Court the contractors be involved in the upkeep of the in
State Governments were now virtually deprived stitutions and this was found to pay better diviclass- four vi
employees
of any power.
.dends. The recruitment
-----------of------UpU}
On the status of the Government medical col ed ‘for
h°S?itaJS haS been susPend'
leges in the State, he said the four medical col wn.dd
C J
‘l6 present employees
leges and their attached hospitals had been The Gowrnmen^hn^'k'^d ®uPerjlnnuatlongiven Rs. five crorf,<? pnrh
u u
1
Government had issued directions to all
used for upgrading the facilities includingequi[> in^thp3^t0
mepdicines to the inpatients
had been revised for the first time in 30 years.
<T7
Comments on the Savadatti Report
NEW MEDICAL COLLEGES
* Dr. C.M. Francis
1. Essentiality Certificate
It is the State Government which should look into the need for new medical
colleges or increase in the number of admissions.
The Medical Council of India / Universities are concerned with the maintenance
of standards :
Buildings
Equipment
Faculty
Number of admissions
Conduct of examinations.
Even when standards are not kept, there is a hue and cry and political and other
pressures are brought on MCI and University and recognition got somehow or
other.
Criteria for issuing 'essentiality certificate' should include
•
Is it essential to have more medical colleges in the state to meet the requirements
for medical graduates in the state?
doctor: population ratio
medical college : population ratio
capacity of people to pay
practitioners of other systems of medicine meeting the needs of people.
•
Organizations who understand the ethos of higher education and ethics.
•
Organizations which can and will maintain standards / quality.
•
Experience in conducting institutions of higher education and performance
Have the resources
Human
Financial
Buildings
Equipment
Land
Hospital beds.
d
Opening of new imedical colleges : will it affect the standards of existing
colleges, by drawing off staff from them?
Each medical college will require 100-200 qualified teachers.
2. Is there a need for more medical colleges / increase in admissions?
The stock of doctors qualified in Modem Medicine (Allopathy) in 1997-98 is
23,729. According to Savadatti Report, this works to a doctor : population ratio of
1:2110. With the presently approved intake of students, in 2006-7, the cumulative
total will be 33,393. (With a better appreciation of the attrition rate it will be more
than 39,000). Assuming the total given by the Savadatti report, the doctor :
population ratio will be 1:1682. The desirable ratio is 1:3000. The report puts the
cumulative surplus of doctors at 7040 in 1997-98 and 14,666 doctors in 2006-7.
What are the criteria for fixing the number of seats?
•
•
Needs of the state / country
Demand for MBBS seats.
P31. Intake vs. outturn
Why give ’expected outturn’? The actual intake and outturn could have been
obtained from the Universities.
The expected outturn is estimated at less by about 30% than the intake for 4 years
and 36% for the year 1996-97. This is not acceptable. For Karnataka students, the
intake and outpu: and therefore the deficit has been calculated as follows:
Year
1992- 93
1993- 94
1994- 95
1995- 96
1996- 97
Intake
2025
2382
2159
2158
1541
Outturn
1418
1667
1511
1511
1079
Deficit
607
715
648
647
562
Very few students drop out completely. Students fail but generally continue and
graduate. The attrition due to leaving medical education, migration or death or
other reasons may be kept at about 5-7%.
Commercialisation of Medical Education; Ethics
Examination : Examiners Corruption; Malpractices
2
Ac 6
^9
(1
There is no equity. The rich get in on payment. When they 'purchase admission',
many of them 'purchase class / pass'. There is corruption; values are lost and this
will be reflected in the practice of medicine.
Politicians and Medical Education
Politicians belonging various parties are involved in the control of medical colleges
(existing and proposed).
Advantages in opening new medical colleges.
Most of the advantages is due to opening of hospitals.
If existing government / private / voluntary hospitals are used for teaching, they will
be no increase in the number of hospitals. Among the new medical colleges
recommended, one is governmental, to be attached to Bowring Hospital, Bangalore :
No advantage;
One is to be attached to Command Hospital, Bangalore : No advantage;
Most of the others will be using existing Government / Private Hospitals : no
advantage.
RECOMMENDATION
The committee had suggested that there should be constituted a cell or committee
which can obtain relevant data, which are not available. Yet, they have suddenly
come out with an adhoc figure of 3000 admissions, without giving any reason,
presumably to maintain the large number of admissions which were being made
illegally.
3
60
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NOTE OF niSSEMT BY DR.RENUKA VISttA^THAN, SECRETARY,
PLANNIbX?, INSTITUTIONAL FIL’ANCE, STATISTICS AND SCIENCE
AMD TECHNOLOGY (McMS-.'R, EXPERT COMMITTEE TO LOOK INTO
THE RECUIREMerFS OF NE;V ?^EDICAL/DE>JTAL/ENGir^ERING
COLLEGES IN THE STATE)
I, .Or•Renuka Vishwanathan> Member of the above Export Coj^ittee offer ay note of dissent on the Second recommendations
of the Expert Committee’s report to be submitted to the Cabinet
sub-cominittee .
Th^ third item of th'? recommendation states that wtqklng
in to account demand and other factors mentioned earlier
(in take) it appears reasonable to keep the admission level
for the Stat? as 3000 (excluding ^ahe & St.John’s Medical
College ) e
The above recommendation Is not bas~d on any rationale or
reasoning. The detailed analysis made by the Planning
Department on certain para-meters giv'.n in t he report came
to the conclusion that t?;ere would be an excess of graduate
doctors by the end of 2006—07 and that there would be no
Justification for increasing the number of seats* It was
also recognised by the committee during detailed discussions
that certain issues relating to employment potential for
medical graduates including that of setting up practice on
their own could be ascertained if mor© tlmo was available
by a regular survey of graduates through using schedules*
Since, the to Cabinet sub-committee wanted a report within
three months, there is no tile for a surbey and no reliable
data to take a precise view of the employment potentio&al
of medical graduates.
In vi'iw of thocbove^ there is no rationale for determining
the number of additional s;cats at 3000 as done intho draft
report♦
y*
-x-
6/
A
None
Tn view of tb.c uncei* tai nd. tv a:f tlio data available for
the c::ip 1 Gyme n u o ta tus aixl the degre e of unomployrnent
amongst doctors, it is difficult to precisely quantif3r
the optimal intake of medical colleges in the S ta te
At the same
time,
the recommendations to keep the
admission level at 3^00 (exc lading MAllE & St.John’s
Medical Colleges) is not based on any rational reasoning.~
As per the available
the S ta te .
data,
there are 23,7^.7 doctors in
If the intake is pegged at 2 62 5 (total) and
2128 (exc lading i’-IAIlE a St.John’s) over a period of 10
ye ar s 10,7^0 Karnataka doctors will be available,,
intake is permitted
to be raised
If the
to 3495 to tai, (3000
excluding MAHi. d St.John’s) the output of doctors will
.
X
be 13059.
Based on
the growth of population and
requirement for
other factors,
the corresponding period woul leave a
considrable surplus of 87OO doctors,
This is also
co nfitmed by Planning Department figures,
the intake ;
the
Even . keeping
at 262$ (total) and 212 8 excluding MAllE
a nd St. John 1 s 9 at-:e3ad of 2CO6-2OC7 , doc tor s: population
ratio would come to 1:1-682, which is' more
than,
2
1
2 :
adequate 0
Hence, there is no justification for
increasing the intake of 1996-97 or restoring the
intake of 1995-96 or sanctioning of new colleges
for the present.
However, the situation may be
reviewed after 5 years.
6V-'\..,'-UvvvV\LwV I
!•
( Dr.C.R. Thirumalachar),
Member-Secretary, Expert Commi
ttee & Director of Medical
Education, Bangalore,
(
AS A P P /\ )
Member, Expert-Committee.
aio
63
I
: R-iMAjJKS OK.
(road
to
:
tbo niombers present) on the le t ters rece ived .
Dr . Ro ii uk a Vi sh i/a na th a n ,
Pro f. ha nna ba sap pa a nd
Dr.Thircsnalachar mention tha t there iszno rationale
for suggesting the intake at 3000
The rationale
for indicating the intake at 3^00 is basedpn the
following observations:
1)
There is no 5 tandard norm based on sc ien ti f ic
considerations available for determining the
requirement of doctors;
2) Tne desirable norm for doc tor: population was
suggested because 1:1000 was considered
• unachievable (Bhore);
3)
At 3000 intake for the year 2006 the estina^ted
ratio is about 1:1500, which is still higher
than 1:1000 and also that in other countries
of the world including Egypt, Korea, European
. co untries;
A scope
to review the intake' is provided when
•• i
reliable data are available or obtained as
r-
suggested in recommendations.
M ■\
(prof.m.i.savadatti).
Chairman, Expert Committee,
Bangalore^
Encl: Copies of
cletters received.
Ah
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xr
GOV ERNMENT OF KARNATAKA
TASK FORCE ON HEALTH AND FAMILY WELFARE
INDIAN SYSTEMS OF MEDICINE AND HOMOEOPATHY
By
Dr. Jayaprakash Narayan,
Member
Task Force on Health and Family Welfare
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AYURVEDA
Ayurveda, the oldest system of medicine in the world, traces its roots to the vedic period in
ancient India. The Vedas contain practical and scientific information on various subjects
beneficial to humanity like health, philosophy, engineering, astrology etc.
Ayurveda is a holistic healing science that comprises of two words, Ayu and Veda. Ayu
means life and veda means knowledge or science. So the literal meaning of the word
Ayurveda is the science of life. Ayurveda is a science dealing not only with treatment of
diseases but is a complete way of life.
Ayurveda aims at making a happy, healthy and peaceful society. The two most important
aims of Ayurveda are:
■ To maintain health in the healthy people
■ To cure the diseases of the sick people.
Doctrines of Ayurveda:
Ayurveda is based on certain fundamental doctrines known as the Darshanas which
encompass all sciences — physical, chemical, biological and spiritual. Ayurveda, born out of
intuition and revelation, developed in due course into eight well defined specialized
branches as indicated below and two major schools, the School of Physicians (Atreya
sampradaya) and the School of Surgeons (Dhanvantri Sampradaya).
The specialties comprise the following:
1. Internal medicine (Kayachikitsd)
2. Paediatrics {balachikitsa/kaumarabrityd)
3. Psychological medicine (grahachikitsa)
4. Otorhinolaryngology and ophthalmology {urd^angachikitsa/shalakya - tantra)
5. Surgery (both general and special) (shalyatantra)
6. Toxicology (damshtrachikitsa/agadatantra).
7. Geriatrics (jarachikitsa/rasayanatantra)
8. Science of eugenics and aphrodisiacs (yrishyachikitsa/vajikarana-tantra).
The basic theories of Ayurveda arise from the concepts of Panchamahabhutas / five
primary elements and Tridosha, the three primary life forces or humors which embrace the
process of creation and evolution of the universe and all laws of life therein. According to
Ayurveda the human body and all matter in the universe are composed of
Panchamahabhutas. So far as the function of the body is concerned this system considers
the body, mind and soul as complementary to one another.
513
Diagnosis and Treatment:
Before starting the treatment the physician examines the patient as a whole and takes a
careful note of his internal physiological characteristics and mental disposition. He also
studies such other factors as the affected bodily tissues and humors (dushya and doshd)\ the
individual bodily state (deshd) and the site in which the disease is located; the strength,
resistance and vitality of the patient and the severity of disease in terms of vitiated humors
and bodily tissues (bald)\ the time or season of onset of disease or the gravity of the clinical
condition (kala); the strength of digestion and metabolism (anald)\ individual constitution
(prakriti^ the age of the patient as well as the relation of age with the principal vitiated
humour (vaya); psychic power (satva)} the habits of the patient in relation to the vitiated
humour (sathmya)} and dietary habits (ahara).
The classics of Ayurveda prescribed two types of examinations - examination of the patient
(rogi pariksha) and examination of the disease (roga pariksha).
Treatment of disease consists in avoiding the causative factors, in advising medicines,
suitable diet, activity and regimen that will restore the balanced state of the body, or in
surgical procedures. It requires the combined effort of the physician, nurse, patient and
medicine. The treatment of disease can be mainly classified as shamana I palliative therapy
and shodana detoxifying therapy.
Shamana Therapy:
Elimination of vitiated doshas or humors. The process by which the vitiated dosha subsides
or returns to normal without creating imbalance or other doshas is known as shamana. The
administration of carminatives (pachana), digestive (deepand), the creation of hunger
(kshudha) or thirst (trishno). exercise (yyayama), the sun’s rays (atapa) and exposure to sun
(jnarutha), etc., come under shamana therapy.
Shodhana Therapy:
Emesis (yamana), purgation (yirechana), enemas (basti), and blood-letting (rakta
mokshana) and nasya - snuffing are classified under the shodhana type of treatment. They
are also called panchakarma treatment. Ceremonial washing of the patient (snehana) and
diaphoresis (swedana) are two important techniques of treatment in the above categories.
Surgical Treatment:
Ayurvedic classics also advocate surgical treatment for those diseases that are not curable
by medical treatment or in cases where surgical treatment may provide immediate relief.
Details of preoperative, operative and postoperative methods are also discussed in the
Ayurvedic classics.
- 2 IM-
Diet:
Ayurveda lays great emphasis on regulation of diet and other regimens as part of the
treatment (pathya-apathyd).
Prevention:
The preventive aspects include personal hygiene, rejuvenation, virilification and Yoga.
(a) Personal hygiene includes daily routine, seasonal regimen and good behaviours.
(b) Rejuvenation called Rasayana, includes use of special drugs to improve longevity,
delay aging, impart immunity, mental faculties and add vitality and luster to the
body.
(c) Virlification called Vajikarana - includes aphrodisiacs and fertility improving
agents.
(d) Yoga and Meditation.
Drug Sources:
The practitioners of Ayurveda normally prepare the medicines needed for their patients in
their own clinics. For simple decoctions, powders etc., the physician often advises patients
to prepare them in their own homes from locally available herbal resources. However, in
urban area the practitioners give prescriptions to the patient for dispensing by chemists.
They also prescribe patent drugs. The large-scale production of Ayurvedic drugs is now
undertaken by modem technology. These include patent and proprietary drugs and classical
preparations. There are as many as 250 pharmacies that produce these drugs in Karnataka.
Pharmacopoeia:
Ayurvedic scholars have compiled all the available information about the drugs and their
therapeutic uses. There are some 70 such books containing about 8000 recipes. Ayurvedic
medicines are prepared in the form of distillates {arka\ fermented preparations (asava and
arista), linctus (avalehd), incinerated matter, minerals, shells etc., (bhasmd). powder
(churnd). ghee (ghritd), tablets, pills (yati gutika), decoction (bvathd). and so on.
Patient-physician relationship:
The ayurvedic practitioners are closely related to the society in which they live and practise,
and their advice as elders in the village is much sought after in village activities, whether
cultural, social, economic or political. They are accorded great respect by the villagers; the
village physician is not merely regarded as a physician but considered as a friend,
philosopher and guide by the community. Even today in rural areas these physicians remain
the first contact of the villagers in times of illness and difficulties.
For the promotion, prolongation and maintenance of positive health and prevention of
disease, Ayurveda prescribes the observation of certain principles: daily routine
(dinacharya), nightly routine (ratricharyd), seasonal routine (ritucharya) and ethical routine
(sadvratdy and also emphasizes that one must follow a regulated diet (ahara), sleep (nidrd)
and regulated gratification of sex (brahmacharyd). Thus Ayurveda is not merely medical
science but is in fact a way of life.
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UNANI
Unani Tibb or Greeco-Arab medicine may be traced to that system of Greek medicine that
was developed during the Arab civilization. The Moslems still call it Unani medicine out of
adherence to its true historical derivation, whereas European historians would call it Arab
medicine. It is now practiced in India as Unani System of Medicine.
Basic concepts of health and disease:
The basic framework consists of the four-humor theory of Hippocrates, which presupposes
the presence in the body of four humours: blood, phlegm, yellow bile, and black bile.
The body is regarded as comprising the following:
1) Arkan (Elements) comprising the different states of matter and materials entering into
and forming a part of everything in the universe.
2) Mizaj - the bodily temperament.
3) Akhlat — the structural components.
4) A "da - the fully developed and mature organs.
5) Ruh - the vital force or life-force.
6) Quwa - the bodily power
7)
“the corporeal functions.
It will be seen that these seven working principles are comprehensive in that the arkan
include the elementary constituents of the body; the mizaj. the physicochemical aspects of
the body; the akhlat, the bodily humors; a "da, the anatomy of the body; ruh, the life-force or
vital force; quwa', energy; and af’al the physiology of the body including the biochemical
process.
Temperament (mizaj') occupies a very important place in Unani Tibb and forms the basis of
pathology, diagnosis and treatment. The temperament of the person to be treated is
expressed by the Galenic concept of its being sanguine, phlegmatic, choleric or melancholic,
according to the respective preponderance of the humors. In other words the temperament of
the individual is equal to the uniqueness of the individual or, in modern terminology, the
psycho-neuro-endocrinal system with its orientation tempered differently in each individual.
Any change in the temperament brings about a change in the person’s state of health. Thus
disease is an expression of the imbalance of the humors or the disturbance to their harmony
and of the failure of one or more parts of the body to eliminate pathogenic waste.
The humors are assigned temperaments, i.e., blood is hot and moist, phlegm is cold and
moist, yellow bile is hot and dry, and black bile is cold and dry (in their physical
temperaments).
Drugs are also assigned temperaments and there are degrees of these temperaments. The
temperament of a given drug is assessed by its action on the temperament of the body itself.
Thus a drug said to be hot means that, when it enters the body and interacts with the vital
faculties it produces a temperament that is hot. Hence drugs are principally used to correct
the abnormal pathological temperament of the body itself or of any particular system or
organ.
Concept of Preventive Medicine and Self-care:
The basic philosophy of Unani is that the body, composed of matter and spirit, is taken as a
whole because harmonious life is possible only when there is a proper balance between the
bodily (Physical) and spiritual functions. Unani Tibb seeks the restoration of the body as a
whole to its original state.
A power of self-preservation or adjustment, which strives to restore any disturbance within
the limits, prescribed by the constitution or state of the individual has been formulated. This
corresponds to the defence mechanism that is called into action in case of injury to the body,
the aim of the physician being to help and develop its action. By the use of Unani medicines
not only is the system enabled to overcome the present disturbance through its intrinsic
power, but it emerges after recovery with a greater power of resistance to future
disturbances. Only in case of immediate and imminent danger to life is it considered
necessary to resort to drastic methods of treatment.
In time of epidemics, every precaution in maintaining a balance in diet and general health
habits is recommended. Unani practitioners recommend inoculation and immunization
against diseases. In the classical literature of Tibb, there are certain prescriptions and
prophylactic measures along with general preventive measure against the spread of
infectious and contagious diseases.
The healer - patient relationship:
The Unani practitioner holds a respectable place in society, particularly in rural
communities. In urban areas, hakims (unani doctors) are often consulted for treatment of
diseases and in matters relating to the protection of health. The hakims adhere to the
traditional moral and social values while treating their patients. This ensures an excellent
healer-patient relationship that can be favourably compared to the old-style relationship
between general practitioner and patient.
Diagnosis, Treatment and Management of Disease:
Diagnosis is carried out in the following manner:
(1)
Body heat is measured by pulse, palpation and thermometer.
(2)
Urine gives many indications of disorders in kidney and liver and in the organs of
digestion, and plays an important part in the Unani system.
(3)
Examination of stools helps in the diagnosis of certain diseases. (Laboratory
examinations of urine and stools are made).
(4)
Observation, palpation and percussion are used to diagnose diseases of internal
organs. Every disease is fully described in Unani literature with its symptoms, points
of differential diagnosis, and all its complications. A detailed examination of a
patient entails studying the person as a whole. The tongue gives an indication of the
condition of the blood and functions of the digestion. The eyes, lips, teeth, throat and
tonsils have all indicative signs together with other physical conditions and
secretions. Sleep, fear or grief, anger or happiness also provide indicative signs.
The prescriptions are begun with the legend Howash Shafi (God is the Healer), generally in
the Persian language. The prescriptions contain detailed instructions about the dosage and
the preparations of medicine. The medicine is prescribed initially for three days, the
treatment being continued or changed according to the response of the patient. A strict diet
is also prescribed.
General features of the pharmacopoeia:
The pharmacopoeia consists of an extremely rich armamentarium of natural drugs, mainly
herbal but also including animal, mineral and marine drugs. The drugs can be used singly or
as polypharmaceuticals, in the form of decoctions, infusions, tablets, powders, confections,
syrups and aquas.
It is true that the Unani pharmacopoeia is lacking in detailed experimental, physicochemical
and biomathematical data, but it is nearly always safe. One keynote of Unani medicine is
that the drug should not serve as a quick curative and in the end generate serious side-effects
such as those sometimes observed with synthetic drugs. Another aspect of its approach is
that the physical faculties (temperament) should be allowed to function according to their
own nature and at their own speed under the operation of the natural laws, and that their
functioning should be given help in every possible way.
NATUROPATHY
Nature cure is the system of man building in harmony with the constructive principles in the
nature (Akasha, Vayu, Agni, Ap and Prithvi) on the physical, mental and moral planes of
being - Dr. Henry Lindlhar.
The roots of nature and its manifestation are identified from the Sankhya Philosophy. Man
leamt the use of nature's principles in curing diseases from the animals. The different
drugless treatment methods like fasting therapy, hydrotherapy, sun and chromo therapy,
food therapy, etc are also called as "Naturopathy".
Basic Principles of Naturopathy:-
1.
2.
3.
4.
5.
Body is made up of five great elements (Pancha Maha Bhutas - Akasha, Vayu, Agni,
Ap & Prithvi)
Roga-Adwaitha\ Chikitsadwaitha ie., unity of disease and unity of treatment.
Foreign Matter is the root cause for all diseases (Foreign Matter means unutilised/
unwanted / uneliminated matter occupying the body) - Foreign matter theory.
Healing power is within the body itself. If scope is given (by fasting, rest, change of
food etc.,) body eliminates foreign matter and cures itself-theory of vital economy.
Whenever body is exposed to an exciting factor (cold, heat, stress, stimulants etc.,)
acute disease results.
I.
Akasha Bhuta Chikitsa - Fasting Therapy:
Patients are subjected to different types of fasting like-water fast, juice fast, fruit fast
etc., from one day to few days. The saturation level of foreign matter (excess of fat
and metabolic end products) is brought down to physiological level through
elimination. Factors like rest, enema, mud packs, water drinking etc., assist during
fasting, starting, continuation and breaking of fast is carried according to need of the
patient by juices, fruits, raw salads and cooked diet respectively.
II.
Agni or Taijasa Bhuta Chikitsa> Helio and Chormotherapy:Different methods of using sunlight in treatment is called Helio therapy.
The cells of the body absorb and vibrate their selected colours from the sunlight. The
disturbed balance in colours leading to stepping up or lowering frequencies leads to
diseases. The supply of required colours by coloured rays, colour charged water,
colour charged foods and coloured vegetables and fruits balance the colours and cures
the diseases.
III. Ap Bhuta Chikitsa - Hydro Therapy:All the activities of the body like assimilation and elimination are going on in water
media. Water is used in therapy in 12 different temperatures. Cold water is a tonic
agent and produces good action and reaction. Warm water is sedative and hot water is
exciting in nature. Hence water is used in the form of drinking, irrigation (cleaning
and culturing the passages) compress and packs (chest pack, abdomen pack, joint
pack, full wet sheet pack etc.,), fomentation and vapour baths etc..
IV.
Prithvi Bhuta Chikitsa
a) Mud Therapy:
Mud is used in the form of mudpacks, local and general applications to the body.
Mud absorbs excess of heat and draws more blood into its place of application.
Mud is a strong healing agent.
b) Diet Therapy:
Food remedies are used in the form of eliminative, soothing and constructive
diets. Sathvic diets are given more importance. Raw juices and diets used in
treatments are the healing panacea of naturopathy.
Complementary drugless therapies of naturopathy
a) Yogic Therapy:
The disturbance in psycho-somatic balance by Viksepas (inborn or acquired factors),
Kleshas (disturbed tonic rhythms) leads to disease. Improper circulation of blood and
lymph and disturbance in the action and reaction of neuro-muscular glandular activities
also leads to diseases. Hence, yogic management of disease is to bring good elimination,
circulation and psycho-physical balance. Panchakosha diseases are (annamaya kosha,
pranamaya kosha, manomaya kasha, vignanamaya kasha and anandamaya kasha)
treated with astanga yoga (Yama, Niyama. Asana. Pranayama. Prathyahara. Dharana.
Dhyana and Samadhi) to cure diseases and to maintain health.
b) Massage Therapy:
Different types of manipulations like stroking, percussions, pressure movements,
frictions and vibrations are used to activate blood circulation and elimination from the
body using lubricating oils and powders. Osteopathy and Chiropractics are the
developed therapies of massage therapy.
c) Magneto Therapy:
Imbalanced electro-magnetic potentiality in the body leads to diseases. Proper supply of
magnetic power by using high power and low power magnets, magnetised water etc.,
vitalise the cells and their activity.
d) Acupressure and Acupuncture:
All the internal organs are connected with channels of energy called meridians. They
emerge out in the skin in certain points. The blockages of energies in these channels are
cleared by applying pressure (Acupressure), heat treatment (Moxibustion) or by pricking
pins (Acupuncture).
Nature Cure is a way of living. There is no place for addiction, stimulant foods or
irregular way of living. People have to be educated about proper usage of five great
elements. (Swastha Swavalambana-Heaith Self Sufficiency of Mahatma Gandhiji).
Naturopathic practitioners often use all normal diagnostic techniques including blood
and urine tests, palpation, X-rays, observation and so on. Naturopaths prepare carefiil
case histories, paying particular attention to eating and living habits, environment and so
on. It is usually during this case note-taking procedure that a clear course of
recommended future action for the patient begins to emerge.
After the root causes of disease have been established the patient receives immediate
treatment. As it continues the practitioner will offer suggestions on how, through
personal hygiene, the patient could alter his way of life, his diet and perhaps even more
important, his attitudes in order to improve his health significantly and to stay healthier
generally. The element of preventive medicine is ever present in the Naturopath's
approach to his patient. Strict naturopathic diets disallow all processed and refined
foodstuffs, including all kinds of white flour, white rice and white sugar. Also taboo in
an ideal world are rich and concentrated foods, butter, cream, eggs, fatty cheese and
animal fats. Dietary reform is the keynote.
Mahatma Gandhi was, of course a firm believer in nature cure and felt strongly that
disease came from ignoring the laws of nature. He was convinced that a timely return to
those laws could ensure the restoration of health. He also claimed "nature cure treatment
brings us nearer to God".
SIDDHA
The Siddha System of Medicine owes its origins to the Dravidian culture that is of the
prevedic period and is one of the oldest systems of medicine practised in South India and
particularly in Tamilnadu. This system was propagated by the Moola Siddhars right from
Agasthiar which dates back to thousands of years. This system of medicine has been
recorded in palm leaves, the periods of which is not known. Many of the palm leaves
literature have been transcribed and printed into Tamil and other languages and sufficient
number of books are now available.
The word “SIDDHA” comes from the word SIDDHI which means an object to be attained
or perfection or heavenly bliss. The Siddhars have written not only on medicine, but also
stressed the importance of the elixir of Life. A close reading of the literature would reveal a
marvelous advancement in chemistry which can be demonstrated by transforming one
element into another. It is therefore evident that the Siddhars had attained perfection not
only spiritually but also materially.
There is not much difference between Ayurveda and Siddha system of medicine. There are
similarities in some approaches like doshas, herbomineral preparations, etc. Siddha
literature stresses the importance of the binding of the cells in the human body for the sake
of longevity and to attain this end they have pointed out certain preparations like the binding
of mercury, mercuric sulphide, chloride of mercury, calomel, etc. If the volatile substances
are fixed such fixed substances according to Siddhars would bind the cells. Salvation
(Mukti) can be attained only after Kayasiddhi (fight against ageing) through fixation of the
human body.
The Siddha System of medicine was practised throughout Tamilnadu, Karnataka,
Andhrapradesh and Kerala by certain hereditary physicians who are called “Vaidyas”. They
had their own Gurus who imparted their knowledge in theory and practice to their disciples
through the Gurukula system of training. The students firmly believe that their Guru was
embodiment of God and later in turn treated the students as their own children. As a result
each student has close contact with the Guru and the knowledge he perceived. The literature
relating to it was called ‘Siddhantam’. They believed that human body is not mere matter
only, but is the temple of God.
The Siddha physicians consider their patients as a combination of mind and body and try to
treat them together (psychosomatic approach).
In Karnataka it appears that there are about 2500 Siddha practitioners practicing in various
parts of the state with hereditary experience and most of them have been registered under
Ayurveda - as there is no separate register maintained for Siddha Practitioners. There are a
couple of institutionally qualified doctors of Siddha system registered in the Karnataka
Ayurveda and Unani practitioners Board.
There are 10 beds reserved for Siddha system of medicine at the Government Ayurveda
Hospital attached to the Government Ayurvedic Medical College, but for many years
Siddha System doctor has not been appointed.
HOMOEOPATHY
Homoeopathy is a medical discipline whose primary emphasis is on therapeutics. It is a lowcost system employing non-toxic drugs exclusively. It can be used to treat both acute and
chronic diseases, but its greatest contribution lies in its successful treatment of chronic
illnesses that have become difficult to manage by orthodox methods.
Homoeopathy takes a holistic approach towards the sick individual and treats his
disturbances on the physical, emotional, and mental levels. Its aim is to bring back the lost
equilibrium of the sick individual on all three levels by stimulating and strengthening his
defence mechanism.
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What are the basic homeopathic assumptions?
Hahnemann presented his system as a complete scientific method of healing based on
demonstrable laws and principles. The basic homoeopathic laws are:
The Law of Similars
1.
The Law of Direction of Cure
2.
The Law of Single Remedy
3.
The Law of Minimum Dose
4.
The Law of Similars:
The assumptions that led Hahnemann to formulate this law were:
(1)
Every symptom complex or syndrome is not the disease per se, but the reaction of the
defence mechanism mobilized by the body in order to counteract a morbific
influence, be it a specific stress such as bacteria or viruses, or a non-specific stress
such as climatic changes, environmental pollution, mental and emotional
disturbances, etc.
(2)
Symptoms are the best possible reaction of the organism under stress and are the
means through which the organism tries to regain its lost balance, its homoeostasis.
(3)
In order to help the organism re-establish order, the physician should assist and
strengthen these reactions rather than suppress them.
The Law of Direction of Cure:
It was Constantine Herring, a disciple of Hahnemann, who formulated into a law what
Hahnemann and his students had earlier observed to take place in a homoeopathic cure.
What they actually observed was that the restoration of internal order and consequent return
to health of the sick individual follow a predictable pattern. In the progressive movement
towards cure it is noted that the principal symptomatology moves from the more vital to the
least vital functional centres within the organism, in other words, from the vital organs to
the skin and in the larger context of the whole individual, from the mental to the emotional
to the physical centres. In the healing process we may also note the brief reappearance of
old symptoms as the remnants of previously suppressed disease complexes make their way
to the periphery, to be cleared out by the homeopathically strengthened defence mechanism.
As in all holistic and natural systems of healing, the process of cure may involve a slight
initial aggravation of symptoms as the patient becomes more capable of producing a strong
symptom complex. This permits the defence mechanism effectively to combat the noxious
factors that produced the diseased state originally. In a successful homoeopathic treatment
the initial eliminative phase with mildly enhanced symptoms is rapidly followed by the
amelioration of all symptoms and a return to health. Cure is considered complete when there
is a full restoration of vital functioning and expression, free from limitations of freedom in
the mental, emotional or physical spheres.
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The Law of Single Remedy:
It must have been already understood that the physician who wants to effect a real cure in
his patient must find the one and only remedy that has produced in its proving the greatest
similitude to the symptom complex existing in the patient. Any other remedy will have no
real curative effect as it will not bear the necessary sensitivity towards the peculiar and
individualized response of the defence mechanism of the patient and hence will not resonate
with his disorder.
The Law of Minimum Dose:
Once the physician has found the indicated remedy it is as if he has found the allergen to
which an allergic patient is most sensitive. It is therefore understandable why in
homoeopathy the physician has to prescribe a very minute dose in order not to bring about
an enormous aggravation of the patient’s symptomatology. Giving such a patient a dosage
of 1 or 2 mg of the raw substance of the indicated remedy could be a dangerously excessive
dose. Hence microdosages of frequently imperceptible amounts of material substance are
used in homoeopathy.
Once the initial microdose has acted, it will bring about a curative response through a
sequence of predictable internal events, as the strengthened defence mechanism re
establishes order. In this the remedy acts as a triggering and catalytic agent and need not be
repeated too frequently. Therefore the pharmaceutical cost of homoeopathic treatment will
be minimal.
The initial aggravation of the patient’s symptoms followed by a full amelioration, together
with the observation of the Law of Cure (such as, for example, the alleviation of a chronic
bronchial asthma after a homoeopathic dosage and the subsequent appearance of a skin
eruption) is a confirmation that a lasting restoration of health, i.e. a cure, has taken place.
Individualisation:
In addition to its different laws, homoeopathy approaches the problem of illness in another
unique way: Individualisation. In homoeopathy every case is treated as peculiar individual.
Although the disease for which different patients are consulting the physician may be the
same, the indicated homoeopathic remedy may be different for each one. A highly refined
individualising process is used. The physician uses the homoeopathic interview to solicit
from the patient the unique way in which this patient reacts to his illness. The physician has
to consider the whole range of mental, emotional, and physical pathology in order to
understand the peculiar ways in which the patient’s defence mechanism is reacting. In doing
so, he seeks the most suitable remedy to further stimulate these reactions. In this approach
he will be particularly cautious not to suppress one or two troublesome symptoms to the
detriment of the whole organism.
In homoeopathy the physician’s interest is not only the alleviation of the patient’s present
symptoms but also his long-term well-being. Therefore in the interview the physician has to
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probe deeply into the most subtle and unique response of the patient’s defence mechanism
to varying stresses. The physician needs to spend considerable time with each patient in
order to have a really thorough understanding of the totality of the patient’s disequilibrium
at all levels of both subtle and gross symptomatology.
Homoeopathy in chronic diseases:
Homoeopathy is effective in the treatment of chronic diseases also, especially before tissue
changes have taken place. Homoeopathy has been of value in reversing diseases such as
diabetes, arthritis, bronchial asthma, epilepsy, skin eruptions, allergic conditions, mental or
emotional disorders, especially if applied at the onset of the disease. The long-term benefit
of homoeopathy to the patient is that it not only alleviates the presenting symptoms but it re
establishes internal order at the deepest levels and thereby provides a lasting cure.
YOGA
Yoga is a traditional science which helps us to co-ordinate body and mind more effectively. It
enables a person to maintain tranquility of mind and greater calmness in the conscious state is
perhaps the easiest and the safe method to promote mental health. It can also be used as a
preventive and curative technique for the management of various psychic and psychosomatic
disorders. Although Yoga had been described in the Book of wisdom - the Veda about 4000 years
ago, it was presented by Pathanjali in an abridged form about 2500 years ago. Since then a large
number of commentaries and books have been written to explain more clearly how one can promote
mental health through the different practices of Yoga.
What is Yoga?
1. Yoga is the total integration of personality .
2. “ Samatvam Yogamuchyate” - Maharshi Vyasa. i.e., Balanced way of life is called Yoga.
3. “Yogah chitta vritti Nirodhah” - Maharshi Patanajali i.e., Yoga is the inhabition of Mental
modifications. Chitta= Intellect + mind + Ego + Indriyas + Tanmatras.
The integration of personality is disturbed by VIKSEPAS (Inborn or Acquired tendencies - Disease,
Idleness, Doubt, Charmlessness, Carelessness, Worldliness, Illusion, Lack of Concentration and
Unpleasantness) and KLESHAS (Disturbed tonic rhythm - Ignorance, False Ego, Attachment,
Aversion, Self projection)
Klesha tendencies give rise to a particular stage called instincts or emotions. The clash between
emotions leads to conflict. Conflicts lead to troubles (Diseases).
Yoga teaches us to resolve the conflicts by reasoning, rationalising viveka and tackle the mind and
its states.
Maharshi Patanjali enumerates 8 steps of yoga called Astanga yoga. They are
Yama (self restraint)
1)
Niyama
(Individual discipline)
2)
3) Asana (Posture)
4) Pranayama (Rhythmic control of breathing)
5) Prathyahara (Withdrawal of senses from their respective outside objects)
6)
7)
8)
Dharana (Concentration)
Dhyana (Meditation)
Samadhi (Super consciousness state)
1)
a)
b)
Yama:
Ahimsa (Love to entire creation)
Satya (external and internal truthfulness)
Astheya (Non-possessiveness beyond requirement)
Bramha charya (Control of temptations of lust through words and deeds)
Aparigraha (giving up of hoarding of materials of enjoyment).
c)
d)
e)
2)
a)
b)
c)
d)
e)
Niyamas:
Shoucha (internal purity),
Santosha (Contentment)
Tapa (Doing sincere efforts to reach the aim of life)
Swadhyaya- (Study of spiritual books and satsanga)
Iswara Pranidhana (Complete surrender to God in words, thought and deeds.)
3) Asanas:- Asana means a posture or a stable position of the body . All the Asanas are named
after living and non-living creations. In the name of animals ( Bhujangasana, Shalabasana,
Makarasana, Mayurasana, Simhasana etc., ) Few are named in natural objects ( Parvathasana,
Vrikshasana, etc., ); some are in the name of saints (Matsendrasana, Vasistasana, Marichasana,
Viswamithrasana etc., ) some follow postural patterns ( Vakrasana, Trikonasana, Chakrasana ,
Shirshasana etc.) Some are named after Gods (Natarajasana, Hanumanasana, Veera-bhadrasana
etc.,)
Asanas are grouped into three types.
a)
Meditative- Sukhasana, Swasthikasana, Padmasana and Siddasana. These Asanas keep
the spine erect and prevent compression on adbomen.
b)
Cultural- Sarvangasana, Matsyasana, Bhujangasana, Shalabasana, Halasana,
Dhanurasana, Paschimothanasana, Chakrasana, Shirshasana, etc., Asanas maintain gravity- Anti
gravity in the body. The circulation to abdomen enhances due to pressure changes. Some asanas
work on endocrinal glands {Sarvangasana, Ardha- Matsendrasana, Mayurasana, Shirshasana
etc.,). Asanas increased the forbearence in muscles, joints. They prevent psycho-physiological
conflicts if they are practiced in static method.
c)
Relaxing Asanas:- They are Shavasana and Makarasana. They release stress and strain
if practiced properly.
4) Pranayamas:A pause produced either in the deep inhalation or exhalations called pranayama. The aim is to
control the mind. “The breathing activity is directly proportional to the mental activity”. To
decrease the tension of mind and body, deep conscious exhalation (Rechaka) is helpful.
Maharshi Patanjali explained as “Dharasachha Manasa Yogyatham” i.e., Pranayama increases the
concentration of mind. The conscious inhalation is called puraka. Retention of breath inside or
outside the lungs is kumbhaka and Conscious exhalation is rechaka.
Prathyahara:- The different methods of withdrawal of senses from their respective outside
5
objects are grouped in this category.
6,7 & 8) Dharana, Dhyana and Samadhi are the internal in relation to the preceding ones (Thrayai
Mantharangam Poorvebhyah)
Shatkriyas:- Shat kriyas are the cleansing processes of yoga. They clean the body, mind and adjust
it to seasonal changes. They are 1)
Neti- Washing Nasal passages with saline and thread
2)
Dhouti- Method of cleaning the food pipe and stomach with water ( Kunjala), Rubber
tube Danda Dhouti) & Cloth ( Vastra dhouti).
3)
Basti- cleaning the large intestine by passing the warm water.
4)
Nauli - Separating the abdominal recti muscles into Left (yama) Right (Dakshina) and
Central {Madhyama Nauli) and clock wise and anticlock wise rotation.(Nauli-chalana)
5)
Kapala Bhati- Expulsion of breath and inhalation by using abdominal muscles.
6)
Trataka- One pointed gazing in different methods.
Integrated Yoga:Among all the methods so far described, the sage Pathanjali's methods of integrated yoga are the
most important. These are 1) Yama or improvement in our social behaviour 2) Niyama or
improvement in our personal behaviour 3) Physical postures 4) Breath-holding practices
5) Restraining the sense organs 6) Contemplation 7) Meditation and 8) Attainment of
superconsciousness.
1) It has been stated that improvement in social behaviour can be achieved by the following five
noble practices: a) non-violence, both physical and psychological b) truthfulness c) non-stealing d)
self restraint in every sphere of life and e) non-hoarding.
2) Similarly, our personal behaviour can be improved by : a) maintaining purity of body and mind
b) developing a habit of contentment c) practising austerity in every sphere of life d) intensive study
of relevant literature and e) daily practice of dedication to God. These are the basic requirements for
attaining success in our daily practice of yoga.
3) Physical postures
A large number of yoga postures have been described by various authors. They are mainly meant to
improve the bodily health, especially the functions of the various organs such as heart, lungs, liver
and other organs of the gastrointestinal tract, kidneys, endocrine system, etc.,
4) Breathing exercises:
This is an important part of yogic exercise in which one inhales fresh air to the maximum capacity
through one nostril, holds it for a while, and exhales it through the other nostril, practicing deep
expiration.
After the behavioural practices and physical exercises one should continue to practise step by step
what maybe called the four mental exercises.
5) Control of sense organs: In this procedure we have to restrain the activities of all the sense
organs which are the main gate-keepers of our body and mind. This can be achieved by minimizing
the chances of having the sense organs stimulated by various external objects, and then by leading
as simple a life as possible. It is really hard to restrain the mind, but by constant practice with a
definite goal one can restrain the sense organs and thereby the mind to a considerable extent.
6) Concentration of mind: In this process one gradually learns how to concentrate on any object
by avoiding all distractions. This practice of concentration on an object of one’s choice will greatly
help to calm any mental excitement and at the same time will induce tranquility and serenity in the
mind. In order to succeed we must have tremendous perseverance and willpower.
Prevention of psycho-somatic disorders:
Regular practice of the integrated type of yoga cannot only prevent the development of various
psycho-somatic disorders but also improve a person’s resistance and ability to endure stressful
situations more effectively. Regular practice of yogic postures leads to psychological improvement
in the intelligence and memory quotient and a decrease in the pulse rate, blood pressure, respiration
and body weight. The bio-chemical examination of the blood has shown decrease in blood sugar
and serum cholesteral, and a rise in the serum protein level. A significant improvement in the
functioning of the endocrine glands has also been found, as evidence by the increased hormonal
level of thyroid, adrenal medulla, adrenal cortex and gonads.
Yoga for treatment of stress disorders:
The integrated type of yoga has been used for the treatment of different stress disorders such as
hypertension, anxiety neurosis, mucous colitis, bronchial asthma, diabetes mellitus, thyrotoxicosis,
migraine and rheumatic disorders, with gratifying results.
Promotion of mental health:
In addition to the integrated practice of yoga, there are many other methods of yoga that can be used
for the promotion of mental health. Among them, the practice of Kundalini yoga is the most
important one.
Yoga as rehabilitative measure:-
There are a number of yogic measures that can be used for the rehabilitation of persons exposed to
stress and strain in life. These include praying through devotional songs daily for 30 minutes or so
(bhakti yoga), undertaking missionary service to the poor, sick or deprived people (karma yoga)
and educating people through philosophical lectures (jnana yoga). By following one or more of
these measures, all those who are passing though intense mental stress and strain can rehabilitate
themselves well enough to lead normal lives and render efficient service to people.
Thus, yoga is a truly a very important preventive, curative, promotive and rehabilitative measure for
maintaining sound mental health.
-3^8
LIFE STYLE FOR HEALTHY LIVING
A person wishing to be healthy throughout his or her life has to be healthy every day. Health
depends on how one spends each day. Controlled and guided activities of body and mind are
essential for maintaining sound health. If one adheres to the rules of healthy living, the dosha-bio
energies will remain balanced and one will maintain optimum health and well-being, and have long,
healthy life. The ideal way in which a healthy person with a well balanced constitution or samaprakruti should spend his day is described as healthy life style.
Time to wake up:
A healthy person should rise early in the morning i.e. 4 ghatika or 96 minutes before sunrise. At this
time the mind is fresh and the surroundings are calm and quiet. Hence one can concentrate on
meditation, prayers or studies. Immediately after getting up one should pray God for acquiring
mental strength. This period is called “Brahma muhurta” because this is the best time for
meditation. Children, pregnant ladies and aged persons require more sleep. The aged should lie
down in bed even if their natural sleep is over, as they require physical rest.
Morning Ablutions:
Bladder and bowels should be emptied regularly after waking up in the morning as the autonomic
reflexes are naturally active at this time. This gives a sense of relief and makes one feel more
energetic. Regular bowel habits help one to prevent borborygmy, distension and heaviness in the
stomach. One should never suppress the natural urge to pass urine or stools as it can lead to
many diseases.
Personal Hygiene:
Face and eyes should be washed by medicated cold water, warm decoction or medicated milk
prepared by soaking or boiling the bark of the banyan, ashwattha (peepal), or udumbara (country
fig) tree, lodhra (Lodhtree) and amalaka (goose berry) in water or milk. Persons with thin, delicate,
red and warm skin should use medicated cold water or cold milk. Persons with dry, rough skin
should use warm medicated milk. Persons with oily or oedematous face should use warm decoction
of herbs in water.
Washing the face with herbal decoction helps to get rid of pimples and skin diseases of the face. It
prevents any bleeding tendency of facial skin and gives lustre to the face.
One should wash hands whenever one touches another person, after cleaning the discharges from
the eyes or nose, after touching trimmed hair or nails, before and after taking meals, after waking up
from sleep, before worshipping God and after returning home.
Oral Health:
Animals never clean their teeth. Probably man in ancient times also never cleaned his teeth as his
food contained a lot of hard and rough substances that had a natural cleansing action on teeth. With
civilisation, man started using more and more cooked food and hence the need to chew food grew
less and less. As a result the third molars have become a vestigeal structure in most persons. The
cooked food sticking to the dental crevice serves as a good medium for bacterial growth. Therefore
it is essential to clean and brush the teeth in the morning after getting up and after lunch and dinner
or after eating anything for that matter.
-asq
A soft brush can be made by biting and chewing the tips of fresh stems of arka (madar), nyagrodha
(banyan), khadira (catechu), karanja (Indian beech), arjuna or nimba (neem). Mastication of stems
acts as a good exercise for the teeth and gums. It also causes attrition of biting surfaces that get
leveled out.
Nimba (neem) stems should be preferred to others amongst bitter ones. Similarly khadira (catechu)
leads other astringent stems, karanja (Indian beech) the pungent ones and yestimadhu (glycerrhiza)
the sweet ones.
One should use a thin plate of gold, silver or copper for cleansing the tongue. One may alternatively
use a leaf or a thin wooden plate. The tongue cleaner should be soft and smooth, with rounded
edges. Its length should be 10 fingers.
Cleansing the tongue helps to get rid of waste products and bad odour of the mouth, improves taste
sensation and exerts a tonic effect on the tongue. Cleaning the tongue considerably reduces
bacterial flora in the mouth.
Morning Drink:
It is suggested that one should drink water in the morning on empty stomach (300 - 500 ml), which
is kept overnight preferably in a copper vessel. Drinking water on empty stomach helps in
detoxification and in people with malabsorption, constipation, piles, abdominal disorders and
abdominal distention and hyperacidity.
Developing Positive Mind:
Every society and every religion considers a few objects or events as auspicious and others as
inauspicious. Curd, ghee, durva (grass) used in worship, mustard, bibva (bael) fruit, and gorochana
are considered auspicious. Similarly looking at priests, cows, sacred fire, gold, ghee, sun, water and
the King at the time of meals is auspicious.
The auspiciousness or inauspiciousness depends on the way one is used to looking at a particular
object or event and the thoughts associated with them, e.g., when one sees a sacred fire, one
immediately thinks of religious people, good events and God. On the other hand when one sees a
burning pyre on the cremation ground, one’s mind is filled with sorrow and grief. Hence sacred fire
and the pyre are considered as auspicious and inauspicious respectively.
Looking at a Mirror:
One should look at self in a mirror as it gives an idea about one’s appearance, state of health,
happiness and cleanliness.
Care of the special Senses:
Eye Care:
The eye is the most important sense organ in the body. Eyes link man with the entire universe
including stars situated miles apart. They are exposed directly to environmental factors such as
wind, dust, and frequent temperature changes. During the wakeful state the eyes are at constant
work supplying important sensory information. Therefore it is important to take utmost care to
maintain this sense organ of vision in the best state of health.
Perception of light is the function of eyes and hence it is important to maintain the clarity and
transparency of the eyes. The mucoid conjunctival secretions tend to collect daily in small quantities
in the eye. Therefore it is important to use an eye ointment that has both a soothing as well as
cleansing action. Souveera ointment - i.e. surma - prepared from natural antimony compound is
used daily in the morning and evening. Surma is applied by a thin metal applicator made of copper,
iron, silver or gold with a smooth and bulbous end. The applicator should be thin and ten fingers in
length. The soothing ointment is applied thrice a day. It is important to maintain the surma or any
ointment as well as the applicator sterile.
Advantages of daily application of souveeranjana ointment are:-
1)
2)
3)
4)
5)
Cooling effect on the eyes.
Removal of dirt and relief from irritation, burning and pain.
Clear vision and lustrous eyes.
Resistance to the heat of the sun and wind.
Protection against common eye diseases.
Skin Care:
Oil massage, kneading the body with hands and then a bath helps to main the skin healthy. 2 drops
of anutaila (medicated oil) in each nostril daily prevents wrinkling of facial skin and premature
graying of hair.
Ear Care:
Regular instillation of oil drops in the ear is necessary to maintain good hearing, which prevents
deafness and tinnitus. The kind of oil drops instilled depends upon the constitution of the person.
Generally sesame oil can be used. Drops of sesame til oil put in the ear daily as well as massage of
the head with oil is good for eyes.
Nasal Care:
Nose is termed as “Gateway of head”. Nose is the sense organ of smell and is exposed to the
external environment and is in contact with air which continuously exerts its drying effect on it. It is
therefore important to keep the nose healthy and prevent it from drying by regular administration of
nasal medicines.
Instillation of medicines in to the nose is called ‘Nasya\ Medicated oil drops are advised. The
advantages of Nasya are, it helps to keep the nose, eyes and ears clean and healthy, exerts
soothening effect, strengthens the joints of head and neck and prevents stiffness of neck. It prevents
premature greying and baldness. It also prevents cervical spondylitis, facial palsy, nasal allergy and
headache.
Mouth Gargling:
It is important to gargle the mouth after meals, eating any food and after brushing the teeth. One
should use cold or hot water, cold milk or sesame oil for gargling.
Gandusha and Kavala:
Gandusha and kavala are both variants of gargling. In gandusha, one takes such a large quantity of
a fluid into mouth that one is unable to move it inside the mouth. In Kavala one holds and moves
A? I
the semisolid or pasty solution in the mouth. It exerts a soothing and cleansing action in the mouth
and prevents caries and oral diseases.
Body Massage: (Abhyanga)
Application of oil and massage is to be practiced every day. Fatty substances like oil, ghee or
animal fat can be used for massage. However sesame oil being easily available and cheap is
advocated for daily regular body massage.
Advantages: Skin becomes soft, strong and its complexion improves. Relieves exhaustion, has
tonic effect on all the tissues and the body as a whole and promotes longevity. It induces sound
sleep, improves vision, prevents premature greying and falling of hair, prevents arthritis, delays
ageing process and promotes longevity. Massage is very good in elderly people as it helps to
prevent geriatric problems.
Physical Exercise (Vyayama):
Exercise or Vyayama can be defined as a systemic physical activity aimed at increasing strength and
stability. Regular exercise keeps the body fit and strong and depletes the extra fat. Ayurveda
advocates how much exercise one should do in different age groups and when.
Ethical Life style:
An excellent character and good behaviour themselves act as the best mental and social tonic. All
the benefits of rejuvenation and repair can be derived without taking any medicine. A person who
wishes to undertake this rasayana should speak the truth, be free from anger, abstain from alcohol
and observe celibacy, trust no one without verification, avoid over-strain, always remain calm and
composed, speak good about others, be advocated to penance and hold chants, maintain cleanliness,
understand and appreciate others view points. Enjoy helping others, be diligent in spiritual
endeavours, take delight in revering God, priests, teachers, seminars and elders, be compassionate,
moderate and observe non-violence, be regular in sleep and work, take milk and ghee regularly, be
conversant with the sciences of medicine and dosage, be devoid of egoism, possess a good moral
character, be attached to person who believes in religion and have self-control . Hence moral health
i$ equally important. Charaka says “Diseases do not befall a man in whom thought, words and deed
are happily blended, the mind is controlled, the understanding is clear and who is possessed of
knowledge, austerity and absorption in yoga”
Seasonal life style:
Just as diurnal and nocturnal schedules of activities are essential for physical fitness and mental
alertness, Ayurveda has advocated seasonal regimen that helps to keep us healthy in various
seasons. The whole year has been divided into six seasons of 2 months each.
The environmental factors in various seasons result in the accumulation and increase of certain
toxins in the body. The appropriate diet and the seasonal regime counteract the effects of seasons on
man to a great extent.
Transitional period of between two seasons
The last week of the out going and the first week of the incoming season is called the junction of or
the transitional period between the two seasons. During this period the seasonal regimen of the
previous season should be gradually omitted and the regimen of the forthcoming season gradually
introduced.
-2M
I
If one follows the daily and seasonal life style changes intelligently and religiously he / she will
surely enjoy a long, healthy, happy and useful life full of vitality.
I
PANCHA KARMA
This five-fold purification therapy is a special form of treatment in Ayurveda.These procedures
eliminate the basic doshas (bio-energies) from the system i,e., cleanses the whole system, makes the
body fit to accept and for genuine absorption. The five procedures are
1.
Vamana - Administration of Emetics
2.
Virechana -Administration of Purgatives
3.
Nasya Karma - Installation of nasal drops
4.
Nirooha Basti - Medicated decoction enema
5.
Anuvasana Basti -Medicated oil enema.
Acharya Susruta who is the father of surgery includes Rakta Mokshana (Venesection /blood letting)
as one of the five fold therapies.
The entire group of eliminative procedures is based upon promoting the body’s natural methods of
eliminating unwanted substances.
Objectives ofPancha Karma:-
1.
2.
3.
To maintain health
For Treating diseasses
As a preparation for Rasayana (Rejuvenation) and Vajikarana (virilification) therapy.
Rejuvenation Therapy:
Old age commences at 60, according to Charaka. However, Sushrutha says that symptoms of
degeneration set in after the age of 40. The destruction of tissues exceeds their production. Tissues
become feeble, sense organs begin slackening, eyesight and hearing are weakened, intellect is
feeble, hands and feet are lax and efficiency gradually falls.
Ayurveda has studied old age in minute detail and has advocated various ways, means and devices
to maintain the tissues in optimum condition. Moreover Ayurveda advocates the use of rasayana
therapy right from youth to perpetuate it.
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RATIONAL USE OF DRUGS
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CONTENTS
1.
Guidelines for Developing Drug Policies for Rational Drug Management
1
2.
Drugs and Cosmetics Act and other legislations.
5
3.
Drug Price Control Order - 1995
8
4.
Good Manufacturing Practices.
11
5.
Procurement, Distribution and Storage
14
6.
Rational prescribing, polypharmacy & Compliance
22
7.
Misuse of Drugs, Strategies of Drug Use, Prescription Audit.
24
8.
Guidelines for Analgesic use in Pregnancy and Lactation
25
9.
Principles of Antimicrobial Use
29
10.
Drug Interactions
33
11.
Pharmacovigilance
35
12.
Formulary
39
13.
Drugs and Therapeutic Information Services
40
14.
Self Medication
42
15.
Ethical Criteria for Medicinal Drug Information
46
16.
Quality Assurance
52
1
23>
CHAPTER 1
GUIDELINES FOR DEVELOPING DRUG POLICES FOR
RATIONAL DRUG MANAGEMENT
Health sector reform is a process aimed at improving equity, quality & efficiency in the health
sector through changes in the organization & financing of health services.
Reform is thought to be the direct response to stimuli which highlight the DEFICIENCIES of
existing models in meeting current & future needs. In health care the stimuli are: ageing populations
with different health needs; the resurgence of diseases such as tuberculosis & cholera; the
appearance of new diseases such as AIDS; increases in inequity to access to health services; the
inability of the public funds to cover all basic health needs of the population; the inability of the
current financing mechanisms to cope with the higher costs & higher demand for technically
advanced interventions. Therefore health care reform is an issue of significant consequence to a
developing country & state as for the industrialized countries.
THE ECONOMIC IMPACT OF RATIONAL DRUG MANAGEMENT
Both health and economic reforms will necessarily affect the way drugs are used—which drugs are
chosen, how frequently they are used, how many are consumed and for which reasons.
Rational drug use comprises all areas dealing with the proper selection, storage, and use of
medications for therapeutic treatment. But in truth, rational drug use begins far before this
because it is promoted by all preventive measures which can ensure health and reduce the need for
drugs. Fundamental to the appropriate use of drugs is the concept that medicines should not replace
the efforts of patients to maintain their health.
Problems in the area of drug use usually arise due to insufficient knowledge, misinformation, lack
of confidence in medical advice, forgetfulness, inadequate access to health services and drugs, or
some combination of these. The types of issues encountered cover an extensive range: Improper
drug selection and prescribing, lack of patient compliance with therapy, drug over utilization, drug
underutilization, unintended therapeutic duplication, drug interactions, disease or allergy
contraindications, improper storage resulting in reduced efficacy and possible undesirable reactions.
At best these problems result in overspending: at worst they lead to serious and undesirable health
consequences as well as to an unacceptable and unnecessary loss of resources in fiscally restrained
systems.
OBJECTIVES OF RATIONAL DRUG MANAGEMENT
The tri-fold objectives are:
♦ Equity, which comprises ensuring access to essential health services to the portions of the
population at financial and geographical disadvantage.
♦ Quality, which incorporates the effectiveness of treatment & consumer satisfaction with
services
2
23G
♦ Efficiency, which includes:
Allocative efficiency (which results in the distribution of resources across services so as to
maximize health benefits)
Administrative efficiency (the management & structure of the health system are designed to
promote most efficient use of resources)
Technical efficiency (services are provided at the lowest possible cost)
THE COST-BURDEN OF IRRATIONAL DRUG USE
1
Given the sum of choices which must be correctly made for drugs to be used appropriately, it is not
difficult to imagine that irrational drug use is a common problem. A number of studies, highlighting
inappropriate prescribing, dispensing, and use of drugs in various countries throughout the world
confirm this. Although the nature of the problems and their severity differ, it is fair to say that
irrational use is widespread.
Many economic arguments link improved prescribing and compliance with reduced pharmaceutical
expenditures. Irrational prescribing can lead to higher pharmaceutical expenditures due to the
inclusion of unnecessary or inappropriate products, unnecessarily expensive products, and
excessively high doses or long treatment periods. In many developing countries, prescriptions for
five or more drugs are not uncommon. Patient noncompliance with therapy also accounts for a
significant amount of waste. In industrialized countries, studies have shown that compliance rates
may be as low as fifty per cent, and it is difficult to imagine that the situation is better elsewhere.
But a more comprehensive view reveals that, in economic terms, this is only part of the problem.
Other expenditures which could have been avoided if the right therapy had been used need to be
considered. These include, but are not limited to, increased use of health facilities, increased drug
resistance, the spread of disease to other individuals, and lost days of work. The magnitude of these
indirect costs frequently exceeds that of the original excessive or wasteful expenditure on the drugs
themselves.
Therefore, particularly with the high levels of irrational drug use which appear to prevail, the total
costs associated with the improper use of drugs may not be fractions of overall pharmaceutical
spending, but rather multiples of it.
When true societal costs are considered, irrational drug use appears to be the largest contributor to
waste in the area of pharmaceuticals and may have a notable, negative impact on the overall
economy of a country. Since even relatively low degrees of irrational behavior can result in high
social costs, efforts to improve the use of drugs should be designated as priorities.
IMPROVING RATIONAL DRUG USE
Spending dedicated to improving rational drug use is a very useful social investment both in terms
of health and long-term cost savings. There is urgency in developing and implementing
comprehensive strategies in this area, because unless addressed, the problems associated with the
improper use of drugs can only increase in scope and negative impact due to growing population
figures and the very improvements in affordability and availability which drug polices and health
sector reform seek. It is for this reason that the incorporation of interventions to improve rational
3
drug use within a larger natRDM’KSPCional drug policy and within the health sector reform process is
essential.
STRATEGIC APPROACHES
Irrational drug use is not limited to one area of the health sector, therefore strategies should be
designed to cover both the public and private sectors as well as self-medication and prescribing
habits. What requires changing is the knowledge and behavioral patterns of the larger societal
matrix comprised of individuals, households, communities, health professionals, educational
institutions, and industry.
But because financing for interventions is necessarily limited, priority areas need to be identified
and targeted. From a health economics perspective, these areas should be those which are expected
to yield largest improvement in social benefit (or reduction of unnecessary social costs) for the
money invested. The choices will vary from country to country but some possibilities are:
•
•
•
•
•
•
interventions which make initial product selection more rational (e.g. widespread diffusion of
the essential drugs concept, formulary lists, banning of unsafe drugs, clearly visible generic
names on all packaging);
improved access to and education on drugs which, if not used or used incorrectly used, lead to
significant health and lost-work costs;
focus on drugs which are the most misused;
improved access to and education on drugs to treat serious communicable diseases:
focus on those groups in society who use the most drugs;
focus on people influencing the medication decisions of others (depending on the society,
mothers may have a significant role here).
Table 1: Tactics for Improving Rational Drug Use
Interventions_____ ___________ Examples_____________
Strategies
Educational
• Improved pharmacotherapy training
• Formal & Continuing
for physicians
education
• Newsletters
• Printed material
• One- to- one public health detailing ;
• Face to face contact
group lectures
• Media
• Radio & television_______________
Managerial
• Essential Drugs list
• Selection
• Morbidity - based quantification
• Procurement&
distribution
• Formularies and treatment guidelines;
prescribing analysis
• Prescribing&
dispensing
• Patient cost - sharing
• Financing________
Regulatory
• Advertising spending limits
• Promotion controls
• Banning unsafe drugs and irrational
• Prescribing controls
combinations
• Dispensing controls
• Limit on number of drugs per patient
RDM-KSPC
4
23*8
In addition to choosing proper activities, it is vital to make the process of implementing them as
smooth and as efficient as possible. Dialogue and cooperation of other interested parties such as
universities, consumer groups and industry are essential to ensure the complementary nature of
activities and to avoid conflicting messages which can resRDM’KSPCult in the nullification of the
invested efforts.
RATIONAL DRUG USE AND REFORM
•
•
•
•
Rational drug use begins before a drug is even selected, as it is promoted by all preventive
health measures which reduce the need for drug consumption.
Economic incentives exist in liberalized pharmaceutical markets, which can drive
overconsumption and inappropriate use of drugs.
Within health sector reform, the need to maximize the health benefits to society relative to
drug expenditures links rational drug use to economic issues.
Regardless of economic considerations, efforts to improve rational drug use are fully
warranted by ethical principles.
IMPROVING RATIONAL DRUG USE
•
•
•
Spending to improve rational drug use is a necessary social investment which should be
incorporated within health sector reform.
To be effective, efforts to improve the appropriate use of pharmaceuticals must cover the
public and private sectors.
Studies to determine the cost-effectiveness of RDM'KSPCspecific interventions used to promote
rational drug use are urgently required.
RDM-KSPC
RDM-KSPC
5
CHAPTER 2
DRUG AND COSMETICS ACT, RULES, AMENDMENTS, OTHER LEGISLATION
AFFECTING USE OF DRUGS
DRUGS & COSMETICS ACT
The act was passed in 1940 to regulate import, manufacture, distribution & sale of drugs &
cosmetics. It is implied that no adulterated, spurious &misbranded drug shall be manufactured in
India orimported into India. Similarly no misbranded &spurious cosmetic shall be manufactured in
India or imported into the country. The Act also provides for the sale & distribution of drugs only
by qualified persons. It also provides for control over manufacture, sale & distribution of
Ayurvedic, Siddha, Unani & Homeopathic Drugs. Control over manufacture is exercised by drug
inspectors. Analysis of samples is carried out at drugs control laboratory. The licensing authority
exercises control over issue of license for manufacture, sale & distribution of drugs.
D & C Act provides for establishment of Drugs Technical Advisory Board (DTAB) to advise
central & state governments on technical matters arising out of administration of the act. Drugs
Consultative Committee (DCC) aids in securing uniformity in administration of the act through out
India. DTAB consists of 18 members with representatives like Director General, Health Services,
President, PCI, MCI, IP A, IMA, Directors, CRI, CDRI, IVRI, & nominated & elected members.
DCC has one representative from each state.
Schedules: 1. Act:
a) First schedule: List of Ayurvedic, Siddha or Unani Books.
b) Second schedule: Standards to be complied with imported drugs & by drugs manufactured for
sale, sold, stocked, exhibited for sale or distributed.
1. Rule: A - List of forms used for making applications for issuing licensees, granting licensees,
sending memorandums etc. B - Fees for test or analysis by the Central Drug Laboratory or
Government Analyst. C - Biological and special products. C (I) - Other special products (The
import, manufacture and sale of schedule C and C (1) drugs governed by special provisions).
D - Class of exempted drugs, which are exempted from a certain provisions applicable to import
of drugs. E (I) - List of Ayurvedic Siddha and Unani poisonous substances. F - Provisions
applicable to Blood Bank requirements and licensing to process Blood Components. F (I) Provisions applicable to, Vaccines, Antisera and Diagnostic antigens. F (II) - Standards for
Surgical Dressings. F (III) - Standards for Umbilical Tapes. FF - Standards for Ophthalmic
Preparations. G - List of substances required to be taken only under supervision of a Registered
Medical Practitioner. The drugs to be labeled with word caution: It is dangerous to take this
preparation except under medical supervision. H - Prescription drugs which are required to be
sold by retail only on prescription of a Registered Medical Practitioner. J - List of diseases and
ailments which a drug may not claim to prevent or cure. K - List of drugs exempted, from
certain provisions applicable to manufacture of drugs. M - Good Manufacturing practices and
requirements of factory premises, plant, equipment etc. for the manufacture of drugs. M (I) Requirement of factory premises, plant, equipment etc. for manufacture of homeopathic drugs.
M (II) - Requirement of factory premises, plant, equipment for manufacture of cosmetics. M
(III) - Requirement of factory premises, plant, equipment for manufacture of Medical Devices.
N - List of minimum equipment for the efficient running of a pharmacy. O - Standards for
6
MO
disinfectant fluids. P - Life period of Drugs. P(I) - Pack sizes of Drugs. Q - List of coaltar
colours permitted to be used in cosmetics and list of colours permitted to be used in soaps. R Standards for condoms made up of rubber latex intended for single use. S - Standard for
cosmetics. T - Requirements for factory premises and hygienic conditions for manufacture of
Ayrvedic (including Siddha) and Unani drugs. U - Particulars to be shown in manufacturing and
analytical records of drugs U(I) - Particulars to be shown in manufacturing records of cosmetics.
V - Standards for patent and proprietary medicines and for patent and proprietary medicines
containing vitamins. W - List of drugs which shall be marketed under generic name only. X List of habit forming, psychotropic and other such drugs. ¥ - Requirements and guidelines on
clinical trials, for import and manufacture of new drugs.
THE DRUGS AND MAGIC REMEDIES (OBJECTIONABLE ADVERTISEMENTS) ACT 1954
1. Object:- To control the advertisements of drugs in certain cases, to prohibit the advertisement for
certain purpose of remedies alleged to possess magic qualities.
The objectionable advertisements tend to cause the ignorant and unwary to resort to self-medication
or to resort to quacks who indulge in such advertisements for treatments, which cause great harm. It
was therefore found necessary in the public interest to put a stop to such undesirable
advertisements. The bill intended for this purpose was introduced in the Parliament. The bill
contained statement of objects and reasons to the Act.
2. Legislative Background:Drug Enquiry Committee: In August 1930, Government of India appointed the Drugs Enquiry
Committee with Sir R.N.Chopra as the chairman, to enquire into the extent of quality and strength
of drugs imported, manufactured or sold in India and to recommend steps for controlling such
imports, manufacture and sale, in the interest of the public. The Chopra Committee in the Appendix
to its report had given a list of a number of samples of advertisements of patent and proprietary
medicines dealing with cures of all kinds of diseases. The Chopra Committee had also made
recommendations for a strict measure of control over proprietary medicines.
These
recommendations were made on the basis of evidence led before it and after scrutiny of many
advertisements and pamphlets in respect of drugs, which showed fraudulent practices and
extravagant claims for these drugs.
Bhatia Committee: The Bhatia Committee was set up in February 1953, with an object to look into
the control to be exercised over objectionable advertisements. The Bhatia Committee examined
large number of witnesses in different town of India, which included representatives of Chemists
and Druggists, Medical Practitioners and State Ministers for Health. The Drugs and Magic
Remedies (Objectionable Advertisements) Act, was enacted in the year 1954 after examining
recommendations of the Bhatia Committee and Drugs Enquiry Committee
3. Prohibited Advertisements:
Prohibition of advertisement of certain drugs/magic remedies for treatment of certain diseases
and disorders- Subject to the provisions of this Act, no person shall take any part in the publication
of any advertisement referring to any drug in terms which suggest or are calculated to lead to the
use of that drug for (a) The procurement of miscarriage in women or prevention of conception in women; or
(b) The maintenance or improvement of the capacity of human beings for sexual pleasure or
(c) The correction of menstrual disorder in women or
7
(d)
the diagnosis, cure, mitigation, treatment or prevention of any disease, disorder or
condition specified in the Schedule, or any other disease, disorder or condition (by
whatsoever name called) which may be specified in the rules made under this Act:
Provided that no such rules shall be made except(i) in respect of any disease, disorder or condition which requires timely treatment in
consultation with a registered medical practitioner or for which there are normally no
accepted remedies, and
(ii) after consultation with the Drugs Technical Advisory Board constituted under the Drugs
and Cosmetics Act, 1940 (23 of 1940) and, if the Central Government considers necessary,
with such other persons having special knowledge or practical experience in respect of
Ayurvedic or Unani systems of medicines as that Government deems fit.
4. Prohibition of misleading advertisements relating to drugs-
Subject to the provisions of this Act, no person shall take any part in the publication of any
advertisement relating to a drug if the advertisement contains any matter which
(a) directly or indirectly gives a false impression regarding the true character of the drug; or
(b) make a false claim for the drug; or
(c) is otherwise false or misleading in any material particular.
5. Exemption:
any signboard or notice displayed by a registered medical practitioner on his premises
indicating that treatment for any disease, disorder or condition specified in Section 3, the
Schedule or the rules made under this Act, is undertaken in those premises; or
(b) any treatise or book dealing with any of the matters specified in Section 3 from a bonafide
scientific or social standpoint; or
(c) any advertisement relating to any drug sent confidentially in the manner prescribed under
Section 16 only to a registered medical practitioner; or
(d) any advertisement relating to a drug printed or published by the Government; or
(e) any advertisement relating to a drug printed or published by any person with
(f) the previous sanction of the Government granted prior to the commencement of the Drugs
and Magic Remedies (Objectionable Advertisement) Amendment Act, 1963 (42 of 1963);
Provided that the Government may, for reasons to be recorded in writing, withdraw the sanction
after giving the person an opportunity of showing cause against such withdrawal.
(a)
6. Penalty:- Punishment which may extend to six months or with fine or both.
NARCOTIC DRUGS AND PSYCHOTROPIC SUBSTANCES ACT, 1985
Objective:- An Act to consolidate and amend the law relating to Narcotic Drugs, to make stringent
provisions for the control and regulation of operations relating to Narcotic Drugs and Psychotropic
substances and for matters connected therewith.
PHARMACY ACT 1948
1. Objective:- An Act to regulate the profession of Pharmacy.
8
CHAPTER 3
DRUGS (PRICE CONTROL) ORDER-1995
1. Objective:- To regulate the selling price of bulk drugs and formulations.
2. Legislative background:-When the demand exceeds supplies, there will be a tendency to
indulge in hoarding and black marketing. During the sixties when Pharmaceutical industry had
not progressed and essential drugs were in short supply, the Government of India notified
“drug” to be an essential commodity within the meaning of Essential Commodities Act 1955 in
order to regulate the price at which they can be bought or sold. That is how Drugs (Price
Control) order came to be introduced. The first order was notified in the year 1966. Thereafter,
as the Pharmaceutical Industry progressed and keeping in tune with the “Drug Policy” of the
Government, the Price Control order has been substituted from time to time. 1966 Order was
replaced by 1970 order, 1979 order replaced 1970 order, 1987 order replaced 1979 order and
1995 order replaced 1987 order and is in force with effect from 1.1.95.
3. Criteria for Price Control:- In the modified drug policy announced in the year 1994 the
criteria for span of Price Control is envisaged as under:
The criterion of including drugs under price control will be the minimum annual turnover
i)
of Rs.400 lakhs.
ii) Drugs of popular use, in which there is a monopoly situation, will be kept under price
control. For this purpose, if for any bulk drug, having an annual turnover of Rs. 100 lakhs
or more there is a single formulator having 90% or more market share in the Retail Trade
(as per ORG) a monopoly situation would be considered as existing.
iii) Drugs in which there is sufficient market competition viz. at least 5 bulk drug producers
and at least 10 formulators and none having more than the 40% market share in the Retail
Trade (as per ORG) may be kept outside the price control. However, a strict watch would
be kept on the movement of prices as it is expected that their prices would be kept in check
by the forces of market competition. The Government may determine the ceiling levels
beyond which increase in prices would not be permissible.
iv) Government will keep a close watch on the prices of medicines, which are taken out of
price control. In case, the prices of these medicines rise unreasonably, the Government
would take appropriate measures, including re-clamping of price control.
v) For applying the above criteria, to start with, the basis would be the data up to 31st March
1990 collected for the exercise of the Review of the Drug Policy. The up dating of the data
will be done by the National Pharmaceutical Pricing Authority.
vi) Genetically engineered drugs produced by recombinant DNA technology and specific
cell/tissue targeted drug formulations will not be under price control for 5 years from the
date of manufacture in India.
4. In pursuance of the drug policy announced in the year 1994 Drugs (Price Control) order 1995
was introduced with effect from 1.1.95, wherein, 76 (seventy six) bulk drugs identified for price
control have been included in the First schedule to the Order and hence these are termed as
“Scheduled Bulk Drugs “ and formulations based on these bulk drugs are termed as “Scheduled
formulations”. Basically, the Drugs (Price Control) order -1995 is aimed to control the sale
price of “scheduled bulk drugs” and “scheduled formulations”.
9
5. Government of India has constituted National Pharmaceutical Pricing Authority (NPPA) for
the purpose of Price fixation and related issues.
6. Fixation of maximum sale price of Bulk Drugs.
1. NPPA after making such enquiry as it deems fit, fix from time to time by notification in the
Official Gazette maximum sale price at which such bulk drug shall be sold.
2. While fixing the maximum sale price NPPA shall take into consideration.
Post tax return of 14% on net worth or
a)
b) A return of 22% on capital employed or
In respect of new plant an internal rate of 12% based on long term marginal costing,
c)
or
d) Where production is from basic stage post tax return of 18% on net worth or a return
of 26% on capital employed.
7. Fixation of retail price of formulations:
1. Formula for calculation of Retail Price.
R.P.= (M.C.+C.C.+P.M.+P.C.) x (1 + MAPE/100) + ED.
“R.P.” means retail price;
“M.C.” means material cost and includes the cost of drugs and other pharmaceutical aids
used including overages, if any, plus process loss thereon specified as a norm from time to
time by notification in the Official Gazette in this behalf;
“C.C.” means conversion cost worked out in accordance with established procedures of
costing and shall be fixed as a norm every year by notification in the Official Gazette in this
behalf;
“P.M.” means cost of the packing material used in the packing of concerned formulation,
including process loss, and shall be fixed as a norm every year by notification in the Official
Gazette in this behalf;
“P.C.” means packing charges worked out in accordance with established procedures of
costing and shall be fixed as a norm every year by notification in the Official Gazette in this
behalf;
“MAPE” (Maximum Allowable Post-manufacturing Expenses) means all costs incurred by
a manufacturer from the stage of ex-factory cost to retailing and includes trade margin and
margin for the manufacturer and it shall not exceed one hundred per cent for indigenously
manufactured Scheduled formulations;
“E.D.” means excise duty:
Provided that in the case of an imported formulation, the landed cost shall from the basis for
fixing its price along with such margin to cover selling and distribution expenses including
interest and importer’s profit which shall not exceed fifty per cent of the landed cost.
Explanation:-For the purpose of this proviso, “landed cost” means the cost of import of
formulation inclusive of customs duty and clearing charges.
10
2^4
2. Fixation of Ceiling Price:
NPPA has power to fix Ceiling Price of scheduled formulations. Ceiling Price is the price
fixed keeping in view the cost or efficiency or both of major manufacturers of such
formulations and such price shall operate as the ceiling price for all such packs including
those sold under generic name and for every manufacturer of such formulation.
With a view to enable the manufacturers of similar formulations to sell in pack size different
to the pack size for which ceiling price has been notified, the manufacturer shall work out
the price on pre-rate basis and shall intimate the price of formulation pack to the NPPA and
such formulation packs shall be released for sale only after the expiry of sixty days after
such intimation. The Government may by order revise the price so intimated, which shall be
binding on the manufacturer.
3. Individual price fixation of scheduled formulations.
1. The retail price of a scheduled formulation of a manufacturer shall until the retail price
thereof is fixed under the provisions of 1995 order, shall continue to the price fixed
under the earlier order.
2. Where the Government fixes or revises the price of any bulk drug and a manufacturer
utilizes such bulk drug in his scheduled formulations he shall, within thirty days of such
fixation or revision, make an application for the NPPA for price revision.
3. The retail price once fixed shall not be increased by any manufacturer except with prior
approval of NPPA.
4. Manufacturers seeking price approval shall apply for NPPA within a period of two
months decision by the NPPA has to be taken.
5. No new packs shall be introduced without price approval.
6. Registered small-scale industries are exempted from individual price approval.
4. Miscellaneous provisions:
1. Government of India (NPPA) has power to recover overcharged account.
2. Retail price to be printed on the label of both scheduled and non-scheduled formulations
with the words “Retail price not to exceed Rs
Local taxes extra”
~
'
or distributor shall issue price list to the dealers, State
3. “
Every manufacturer,
importer
Drug Controllers and NPPA covering both scheduled and non-scheduled formulations.
4. Refuse to sell without valid reason is the offence.
5. Violation of DPCO is punishable under Essential Commodities Act 1955, the
punishment being imprisonment or not less than three months which may extend to
seven years and shall also liable to fine. The Court, may, on any account or special
reason impose a sentence of imprisonment for a term not less than three months.
6. Government of India has power to fix Ceiling Price of even non-scheduled formulations
if it is of the opinion that there is need to fix the price to contain abnormal increase in the
price.
11
CHAPTER 4
GOOD MANUFACTURING PRACTICES
In the drug industry at large, quality management is defined as the aspect of management function
that determines and implements the "quality policy", i.e., the overall intentions and direction of an
organization regarding quality, as formally expressed and authorized by top management.
The basic elements of quality management are:
an appropriate infrastructure or "quality system", encompassing the organizational structure,
procedures, processes, and resources; and
systematic actions necessary to ensure adequate confidence that a product (or service) will
satisfy given requirements for quality. The totality of these actions is termed ’’quality
assurance”.
Within an organization, quality assurance serves as a management tool. In contractual situations,
quality assurance also serves to generate confidence in the supplier.
In drug manufacture and supply the terminology may differ. In particular, the term "quality system"
is rarely used, and it is "quality assurance" that usually embraces such elements as organizational
structure, procedures, and processes.
The concepts of quality assurance, GMP, and quality control are interrelated aspects of
quality management They are described here in order to emphasize their relationship and their
fundamental importance to the production and control of pharmaceutical products.
Quality assurance
’’Quality assurance” is a wide-ranging concept covering all matters that individually or
collectively influence the quality of a product. It is the totality of the arrangements made with the
object of ensuring that pharmaceutical products are of the quality required for their intended use.
Quality assurance therefore incorporates GMP and other factors, including those outside the scope
of this guide such as product design and development.
The system of quality assurance appropriate to the manufacture of pharmaceutical products should
ensure that:
(a) pharmaceutical products are designed and developed in a way that takes account of the
requirements of GMP and other associated codes such as those of good laboratory practice
(GLP) and good clinical practice (GCP);
(b) production and control operations are clearly specified in a written form and GMP
requirements are adopted;
(c) managerial responsibilities are clearly specified in job descriptions;
(d) arrangements are made for the manufacture, supply, and use of the correct starting and
packaging materials;
(e) all necessary controls on starting materials, intermediate products, and bulk products and other
in-process controls, calibrations, and validations are carried out;
(f) the finished product is correctly processed and checked, according to the defined procedures;
12
(g)
(h)
(i)
pharmaceutical products are not sold or supplied before the authorized persons have certified
that each production batch has been produced and controlled in accordance with the
requirements of the marketing authorization and any other regulations relevant to the
production, control and release of pharmaceutical products;
satisfactory arrangements exist to ensure, as far as possible, that the pharmaceutical products
are stored by the manufacturer, distributed, and subsequently handled so that quality is
maintained throughout their shelf-life;
there is a procedure for self-inspection and/or quality audit that regularly appraises the
effectiveness and applicability of the quality assurance system.
GOOD MANUFACTURING PRACTICES FOR PHARMACEUTICAL PRODUCTS (GMP)
Good manufacturing practice is that part of quality assurance which ensures that products are
consistently produced and controlled to the quality standards appropriate to their intended use and
as required by the marketing authorization. GMP rules are directed primarily to diminishing the
risks, inherent in any pharmaceutical production, that cannot be prevented completely through the
testing of final products. Such risks are essentially of two types: cross-contamination (in particular
by unexpected contaminants) and mix-ups (confusion) caused by false labels being put on
containers. Under GMP:
all manufacturing processes are clearly defined, systematically reviewed in the light of
experience, and shown to be capable of consistently manufacturing pharmaceutical products
of the required quality that comply with their specifications;
(b) critical steps of manufacturing processes and any significant changes made to the processes
are validated;
(c) all necessary facilities are provided, including:
(i) appropriately qualified and trained personnel;
adequate premises and space;
(ii)
(iii)
suitable equipment and services;
(iv)
correct materials, containers, and labels;
approved procedures and instructions;
(v)
suitable storage and transport; and
(vi)
adequate personnel, laboratories, and equipment for in-process controls
(vii)
under the responsibility of the production management;
(d) instructions and procedures are written in clear and unambiguous language, specifically
applicable to the facilities provided;
(e) operators are trained to carry out procedures correctly;
(0 records are made (manually and/or by recording instruments) during manufacture to show that
all the steps required by the defined procedures and instructions have in fact been taken and
that the quantity and quality of the product are as expected; any significant deviations are fully
recorded and investigated;
(g) records covering manufacture and distribution, which enable the complete history of a batch to
be traced, are retained in a comprehensible and accessible form;
(h) the proper storage and distribution of the products minimizes any risk to their quality;
(i) a system is available to recall any batch of product from sale or supply;
0) complaints about marketed products are examined, the causes of quality defects investigated,
and appropriate measures taken in respect of the defective products and to prevent recurrence.
(a)
13
24T
Quality control
Quality control is the part of GMP concerned with sampling, specifications, and testing and with the
organization, documentation, and release procedures which ensure that the necessary and relevant
tests are actually carried out and that materials are not released for use, nor products released for
sale or supply, until their quality has been judged to be
satisfactory. Quality control is not
confined to laboratory operations but must be involved in all decisions concerning the quality of the
product.
Rationale for New Drugs
Unjustifiable
Me-too product
With nothing extra
to offer
Debatable
Undeniable
Proved benefits over existing
No increase in
Marginally more
safety or efficacy. Effective, but
But better
more expensive
acceptability
Spurious Drug: Means a drug:
a) Imported/manufactured under a name which belongs to another drug; or
b) Which is an imitation of or is a substitute for another drug or resembles another drug in a
manner to deceive or bear upon its label or container the name of another drug unless plainly or
conspicuously marked so as to reveal its true character and its lack of identity with such other
drugs; or
c) The label or container bears the name of an individual or company purporting to be the
manufacturer of drug, which individual or company is fictitious or does not exist; or
d) Which has been substituted wholly or in part by another drug or another substance; or
e) Which purports to be the product of a manufacturer of whom it is not truly a product.
14
CHAPTER 5
PROCUREMENT, DISTRIBUTION AND STORAGE
Drug supply system management
Procurement is the process of acquiring supplies from private or public suppliers, or through
purchases from manufacturers, distributors or international agencies, or through bilateral aid
program. Procurement includes most of the decisions, and actions that determine which drugs are
obtained and in what quantities, what is paid for them and whether they are of satisfactory quality.
Drug procurement policies should be aimed at influencing both the private and public sector.
Distribution and storage covers the activities needed to ensure that drugs arrive in the right place at
the right time, in good condition and with minimal wastage of resources. It also includes inventory
control and providing the information necessary to forecast drug needs.
The importance of drug supply system as a component of national drug policy
There needs to be good coordination between these central elements of the supply system. Failures
at any point of the drug supply system can lead to shortages, or to waste. Both the health and the
economic consequences can be serious.
A well-coordinated supply system will ensure that available resources are used effectively to
maximize access, to obtain good value for money and to avoid waste. A supply system which works
will increase confidence and participation in health services.
Drug supply arrangements vary greatly in the extent to which public and private sectors play a role
in financing, distributing and dispensing drugs. It is important that policies serve the needs of both
the private and public sectors.
Variations in the needs and capacities of different countries mean that each country will have to
select which policies are most appropriate to their needs.
Organizing the drug supply system- Who has responsibility for the supply system and how it
should be structured are important choices. There are several options, and which one is chosen will
depend on existing structures, the balance between public and private sectors, and other factors.
PROCUREMENT
The pharmaceutical procurement system is a major determinant of drug availability and total health
costs.
Expert technical assistance in quantification may be useful in initial phases of the procurement
program, with local officials participating to gain an understanding of the methodology.
An effective procurement process ensures the availability of the right drugs in the right quantities, at
reasonable prices and at recognized standards of quality. Drugs may be acquired through purchase,
donation, or manufacture.
15
In the public sector, the first step in the procurement process is to prepare estimates of the types and
quantities of pharmaceutical products that will be required annually, biannually, or quarterly to
satisfy the needs of the health services. Ideally, estimates of types and quantities should be based on
up-to-date health information and should take into consideration the available financial resources. In
practice, therefore, the estimates are usually based on past drug use, and may be re-evaluated and
revised through inventory control and utilization surveys. Drug procurement should be adapted to
the needs of the public and the private sectors. The public sector should follow the national essential
drugs list.
Procurement should include a quality assurance system covering registration, quality control,
control of imports, effective drug inspection and the application of the WHO Certification Scheme
on the Quality of Pharmaceutical Products Moving in International Commerce.
The procurement cycle involves the following steps:
• review drug selections
• determine quantities needed
• reconcile needs and funds
• choose procurement method
• locate and select suppliers
• specify contract terms
• monitor order status
• receive and check drugs
• make payment
• distribute drugs
• collect consumption information.
The major procurement methods are open tender , restricted tender, competitive negotiation, and
direct procurement, which vary with respect to their effect on price, delivery times, and workload of
the procurement office.
Key principles of good pharmaceutical procurement include
• procurement by generic name;
• limitation of procurement to the essential drugs list
• procurement in bulk;
• format supplier qualification and monitoring;
• competitive procurement;
• sole-source commitment;
• order quantities based on reliable estimate of actual need.
• reliable payment and good Financial management;
• transparency and written procedures;
• separation of key functions;
• product quality assurance program;
• annual audit with published results;
• regular reporting of procurement performance indicators.
16
Alternative systems for supplying drugs to public health systems include the central stores system,
autonomous supply agency system, direct delivery system, prime vendor system and private
pharmacy system. All involve pharmaceutical procurement.
Procurement may proceed under different models - annual purchasing, scheduled purchasing, or
or
perpetual purchasing. Different combinations of these models may be used at different levels of the
system or for different drugs. Whichever combination of supply systems and purchasing model is
used, most public-sector drug procurement involves group purchasing, whereby one procurement
office, whether public or private, negotiates contracts for members of a group with similar needs
and interests.
The focus is on identifying-and controlling excess costs in the selection, procurement, distribution,
and use of drugs. Several analytical tools are available that help quantify costs and identify areas
where costs can be reduced; the information provided is also essential in designing and monitoring
interventions to control costs.
When funds are not available to purchase all the drugs listed in estimates, it is necessary to reduce
the list according to health system resources. The following tools, can help with prioritization:
VED (vital, essential, desirable) analysis classifies drugs in two or three categories, according to
how critical the drug is for treating commonly encountered diseases. Priority is given to vital drugs.
V: vital drugs are potentially lifesaving, have significant withdrawal side effects (making regular
supply mandatory), or are crucial to providing basic health services;
E: essential drugs are effective against less severe but nevertheless significant forms of illness but
are not absolutely vital to providing basic health care;
D: desirable drugs are used for minor or self-limited illnesses, are of questionable efficacy, or have
a comparatively high cost for a marginal therapeutic advantage
Assignment to the desirable category does not mean that the drug is no longer on the system's
formulary or essential drugs list,' in many cases, drugs for minor illnesses are included on the
essential drugs list but may be considered a lower priority for procurement than other drugs.
The classification of drugs should not be a one-time exercise. As the national formulary or essential
drugs list is updated, and as public health priorities change, the VED categories should be reviewed
and updated. Any new drugs added to the list should be categorized appropriately, and category
assignments for older drugs should be reviewed and changed if needed)
In El Salvador, there are three categories in the Cuadro Basico (formulary) for the ministry of
health: category 1, essential medicines; category 2, basic medicines; and category 3, complementary
medicines.
The main objective is an ongoing system to give priority to essential, lifesaving drugs as opposed to
expensive nonessential items.
Therapeutic category analysis applies cost-effectiveness, cost benefit, and/or cost-minimization
methods to help select the best drugs for treating common diseases.
17
*■>
ABC analysis assembles data from recent or projected procurements to determine where money is
actually being spent, allowing managers to focus first on high-cost items when considering ways to
reduce procurement costs.
ABC value analysis examines the annual consumption of drugs and expenditures for procurement
by dividing the drugs consumed into three categories. Class A includes 10 to 20 percent of items,
which account for 75 to 80 percent of expenditures. Class B items represent 10 to 20 percent of
items and 15 to 20 percent of expenditures. Class C items are 60 to 80 percent of items but only
about 5 to 10 percent of expenditures. ABC analysis can be used to
•
•
•
•
measure the degree to which actual consumption reflects public health needs and morbidity;
reduce inventory levels and costs by arranging far more frequent purchase or delivery of smaller
quantities of class A items.
seek major cost reductions by finding lower prices on class A items, where savings will be more
noticeable;.
assign import and inventory control staff, to ensure that large orders of class A items are
handled expeditiously.
Therapeutic category analysis considers the utilization and financial impact of various therapeutic
categories of drugs and then compares cost and therapeutic benefit to select, the most cost-effective
drugs in each major therapeutic category. This can be done to select drugs for a formulary or
procurement list.
Price comparison analysis compares drug prices paid by different supply systems, as one measure
of procurement efficiency. The analysis can also compare supply system acquisition and selling
prices with local private-sector prices to gauge the cost effectiveness of in-house pharmaceutical
services and to assess price elasticity for cost recovery.
Total variable cost analysis compiles information on variable costs associated with purchasing and
inventory management, to help managers consider options for change in terms of their impact on
total variable costs.
Lead-time analysis is a systematic approach to tracking procurement lead times, determining the
points at which lead time can be reduced, and adjusting safety stock appropriately. Payment time
should also be analyzed (when delayed payment to suppliers is feasible).
Expiry date analysis examines levels of stock on hand and their expiry dates and compares this
information with average rates of consumption to assess the likelihood of wastage (and to develop
appropriate countermeasures).
Hidden cost analysis examines supplier performance to identify any hidden costs incurred because
of problems such as late, deliveries and short shipments. Hidden costs may make one supplier
considerably more expensive than a competitor that offers a higher unit price but better
performance.
18
QUANTIFICATION
Accurate estimates of drug requirements are needed to avoid stock outs of some drugs and
overstocks of others. In addition, suppliers are most apt to compete for an estimated quantity supply
contract if they believe that the quantities specified are reasonably accurate.
The most accurate way to quantify pharmaceutical needs is to start with accurate past consumption
data from all units being supplied. These data should be tempered by known or expected changes in
morbidity patterns, seasonal factors, service levels, prescribing patterns, and patient attendance.
Unfortunately, in many countries, consumption data are incomplete or do not reflect real need
because the supply pipeline has never been full. In such cases, the morbidity-based and adjusted
consumption techniques may be needed for procurement quantifications.
Quantification involves estimating the quantities of specific drugs needed for a procurement. Most
quantification exercises also estimate the financial requirements to purchase the drugs. Normally
used to forecast needs for an annual or semiannual procurement. They are not usually used to
calculate routine order quantities in an established supply system that uses scheduled purchasing
(periodic orders) or perpetual purchasing(orders placed whenever need arises).
It is the responsibility of the procurement office to produce a reasonably accurate estimate of drug
requirements for each tender, but much of this responsibility can be decentralised. Quantification
can consume considerable time in programs that are decentralized but involve multiple layers of
review.
Distribution and storage
The distribution and storage system plays an important role in determining whether people have
access to good-quality drugs when they need them. It includes inventory control as well as
requisition and delivery to the point of use. It also includes collecting information on consumption.
It is necessary to devise and implement a system that results in the
the safe
safe distribution
distribution of
of good
good-
quality drugs at the lowest possible cost and that reaches the majority of the population, especially
in remote areas of the country. Such a system is often best based on a combination of private and
public sector initiative. An effective distribution system will:
• maintain supply;
• keep drugs in good condition;
• minimize overstocking;
• minimize losses due to expiry;
• minimize losses due to theft;
• provide information on consumption and requirements in order to forecast future needs.
Access and distribution of quality drugs
Access through private sector
When developing a national policy it is important to take retailers and wholesalers in the private
sector into account since they can play a role in maximizing access. In most countries the majority
of the population are serviced by private retailers. More over, in a fully private system, patients buy
drugs directly from private pharmacies. It may be difficult to ensure that everyone has access to
drugs.
19
353
The role of the private sector (private drug outlets) is growing, but this sector is mainly concentrated
in urban and population centers. This will always affect affordability and equitable access. It may be
necessary to create intermediate and peripheral storage facilities managed by appropriately trained
personnel in order to improve access to essential drugs, especially in more remote areas. When
setting levels of payment to cover distribution costs for wholesalers and retailers, it is most
important to take into account the need to keep drug prices affordable to the entire population.
Quality when transporting drugs it is important to pay attention to quality requirements, particularly
maintenance of the cold chain, and attention to the maximum temperatures permitted for some
products. Distribution and storage in both the public and private sectors should be monitored to
ensure the quality of drugs at all levels of the distribution network.
Drug donations Drugs are frequently donated by international organizations. Inappropriate drug
donations have caused problems, particularly in emergency situations. The guidelines aim to
promote core principles in drug donation:
•
•
•
•
it should give maximum benefit to recipient, and it must be based on their needs;
donations should respect the wishes and authority of the recipient country;
there is no double standard in quality;
there should be an effective communication between donor and recipient.
Disposal of unwanted or expired drugs
If the supply system is working well disposal is hardly needed, but it is important to get rid of
excess or expired stock or unwanted donations safely.
Table : Examples of measures for controlling drug expenditures
Examples_____
Explanation/comments________________________
Bulk purchasing
• Includes tenders
• Includes pooled procurement__________________
Capping of expenditure
• Ceiling of pharmaceutical expenses
• Limits expenditures allowed per treatment episode
Drug selection
• Positive lists, such as essential drugs lists, are
formulated based on criteria for inclusion (public
health needs, therapeutic value, cost)
• Negative lists focus on excluding certain products
Marketing and advertisement restrictions
• Advertising and promotion can make up a sizable
portion( 15-25%) of ex-factory drug costs and are
intended to influence consumption patterns.
Limitations are intended to reduce price and
rationalize consumption______________________
Price control___________
_______________ (refer to section)
Promotion of rational use
_______________ (refer to section)_______________
Use of generic products
_______________ (refer to section)_______________
User fees and co-payments
• May discourage excessive consumption but may
have negative consequences on affordability and
equity
20
Competitive mechanisms in public drug supply
Ideally, drug supply systems should be able to provide drugs, in the most cost efficient manner, to
all areas of a country, with minimal stock outs and shortages There exist five different options for
the distribution of pharmaceuticals to government hospitals, health centers, and clinics.
Table: Comparison of systems for public drug supply
Responsibility
Examples
Description
Contracting
Storage &
Monitoring &
(Current and past)
suppliers
delivery
drug quality
Central
Medical CMS
CMS
CMS, DRA
Numerous
Stores(CMS)
countries
in
Drugs procured and
Africa, Asia and
distributed
by
elsewhere
centralized government
unit._______
Autonomous
supply Autonomous
Autonomous
DPO,
Benin,
Haiti,
agency
agency
agency
Autonomous
India
(Tamil
Bulk drug procurement
agency, DRA nadu),
Sudan,
and
distribution
Uganda, Zambia
managed
by
autonomous or semi
autonomous agency
Direct Delivery system
DPO
Supplier
DPO, DRA
bile, Indonesia,
• Decentralized
Peru, Thailand
approach
• Tenders
establish
the supplier and
price for each item
• Drugs delivered by
supplier to districts,
major facilities
Prime vendor system
DPO
3rime vendor
DPO, prime South
• DPO
establishes
vendor, DRA Afri ca, (Northern
contracts with drug
Transvaal),United
suppliers
and
State
of
separate
contract
America(many
with a single prime
state and local
vendor
lealth services)
Prime
vendor
warehouses
and
distributes drugs to
district, major facilities
Fully private supply
Procurement and distribution by DRA
Private wholesalers and private enterprises
pharmacies manage all
aspects of drugs supply
with
government
facilities
1
21
3.^
Notes CMS— Central medical stores; DRA— national drug regulatory authority
DPO = drug procurement office (MOH or other govt, office);
With central medical stores, the state both owns and manages the entire drug supply system. Many
countries have adopted this approach but have found the management of such a system difficult.
One option to which they have turned is the establishment of autonomous or semi-autonomous
supply agencies which, in theory, can manage distribution with more efficiency and focus on public
health objectives.
Where centralized distribution proves to be difficult or undesirable, direct delivery systems may be
able to better deliver pharmaceuticals to health facilities. However, the management demands for
this may also be great. Alternatively, the management can be contracted out to another party, a
prime vendor, who is responsible for receiving drugs from suppliers and for stocking health
facilities. These last two mechanisms are usually only feasible where a well-developed private
sector exists.
Table: Benefits of and concerns associated with decentralization in health_________________
Possible benefits______________________ Concerns______________________
• Improved public sector efficiency in the • Who will be accountable for meeting national
provision of health services
policies?
• Stimulation of local participation in • Increased costs: administrative(more layers) and
their own health care provision
those associated with the transition.
• Improved quality of care through better • Inter-regional inequalities (poor regions may no
response to local needs.
longer be subsidized by more affluent regions).
• Long -term central versus local rivalries.
• Knowledge and management techniques may be
more limited at local level than central level.
• Health budgets may be reduced to meet other
local needs
Decentralization is not an easy solution to the problems of health care systems. While it can be a
result of organizational reform, it should not be viewed as a goal in its own right. Decentralization
is, however, an option which can be undertaken in a larger reform context to foster the improved
implementation of health and drug policies which, themselves, are aimed at better achieving health
objectives.
Each component of a national drug policy - including selection, supply, quality assurance, storage
and distribution, and rational use - has economic effects.
22
CHAPTER 6
RATIONAL PRESCRIBING, POLYPHARMACY AND COMPLIANCE
The ultimate goals of studying and intervening in drug use practices include
•
•
improvement of quality of health care through effective and safe use of pharmaceuticals;
improvement of cost effectiveness of health care through economic and efficient use of
pharmaceuticals.
Before attempting to intervene to change drug use practices, underlying reasons for problem
behaviors must be understood. Interdisciplinary collaboration involving health and social science
experts is of utmost importance in this task.
Strategies to improve rational prescribing can be characterized as educational, managerial,
and regulatory.
Educational strategies include
• training of prescribers (formal and continuing education, supervisory visits, group lectures,
seminars, workshops);
• printed materials (clinical literature and newsletters, treatment guidelines, drug formularies,
flyers, leaflets):
• approaches based on face-to-face contact (educational outreach, patient education, influencing
opinion leaders).
• prescribing and dispensing approaches (structured drug order forms, standard diagnostic and
treatment guidelines, course-of-therapy packaging);
• financing (price setting, capitation-based budgeting).
Regulatory strategies include
• drug registration;
• limited drug lists;
• prescribing restrictions;
• dispensing restrictions.
An intervention should be focused on a fspecific problem behavior and targeted at the facilities or
people that have the greatest need for improvement.
Interventions should be carefully selected with regard to efficacy, feasibility for implementation in
the existing system, and cost. Before wide-scale implementation of an intervention, it is imperative
to evaluate its effectiveness and cost in the existing health setting.
Programs to ensure rational use of drugs should be an integral part of health and medical care
services. The responsibility for promoting rational use of drugs
~ belongs to decision-makers,
administrators, and clinicians. It is also the responsibility of health care professionals, consumers,
educators and pharmaceutical companies.
Polypharmacy defeats the purpose of rational use of drugs. Drug use indicators can be used for
self-audit & feedback.
23
Compliance or adherence to treatment is the degree to which patients adhere to medical advice &
take medicines as directed. Compliance depends not only on acceptance of information about the
health threat itself but also on the practitioner’s ability to persuade the patient that the treatment is
worthwhile & on the patient’s perception of the practitioner’s credibility , empathy, interest &
concern.
The usual reasons for non compliance are:
• Did not know the purpose of the prescription medication.
• Shared prescription medication with another.
• Stored medication improperly.
• Used outdated prescription medication.
• Used a duplicate prescription
• Overused medication.
The consequences of non compliance are:
• Lack of complete efficacy or treatment failure as in tuberculosis or sexually transmitted
diseases.
• Recurrence or relapse of infection /disease.
• Development of microbial resistance e.g.. Nonadherence with antibiotic therapy.
• Increased risk of transmission of communicable diseases from incompletely cured patients.
• Increased health care costs due to readmission’s or reconsultations, lost work timings, travel
costs etc.
As adherence cannot be dictated, it is important to understand why drug defaulting occurs. The next
step is to develop the communication skills needed to interact with patients so those problems may
be identified & resolved. It is equally important to remove barriers to good communication. Finally,
it is important to assist the patient to a position of autonomy supported by problem solving and self
management skills. All this will lead the patient from being compliant to concordant wherein there
is frank exchange of information, negotiation and a spirit of cooperation. Treating a patient as a
decision-maker is a fundamental step away from compliance model. The reason being that the price
of compliance was Dependence whereas the price of concordance will be greater Responsibility- in
the doctor's case, for the quality of the evidence, diagnosis, treatment and explanation; in the
pharmacist's case for patient education & communication along with dispensing: and in the patient's
case for the consequences of his/her choices.
I
24
2^2
CHAPTER 7
MISUSE OF DRUGS, STRATEGIES OF DRUG USE, PRESCRIPTION AUDIT
The actual use of pharmaceuticals is influenced by a wide range of factors, including drug
availability, provider experience, economic influences, community belief systems and complex
interactions among these factors.
In order to prevent misuse of drugs, it is essential to ensure therapeutically sound & cost effective
use of drugs by health professionals and consumers.
Improving drug use by prescribers, dispensers and the general public helps to reduce morbidity and
mortality, and to contain drug expenditure. The challenge is how best to ensure therapeutically
sound & cost effective use of drugs, at all levels of the health system, in both the public & private
sectors, by both health professionals and consumers. The three major components are:
Rational drug use strategy & monitoring: Policies & regulations related to RUD
Rational drug use by health professionals: Develop standard Treatment guidelines, Essential
drugs list, formulary, educational programs, and other effective mechanisms to promote rational
drug use by all health professionals.
Rational drug use by consumers: establish effective systems to provide independent & unbiased
drug information to the general public and to improve drug use by consumers.
Drug utilization Review and feedback
Drug utilization review (DUR) is a tool to identify problems in the medication use process: drug
prescribing, dispensing, administration and monitoring. As problems are identified, strategies
are developed and implemented to improve the use of drugs. If actions are successful, the result
will be improved patient care and more efficient use of resources.
Drug and therapeutic committees play an important role in iimproving prescribing practices.
Their role has expanded in some settings from selecting drugs for formularies to
•
•
reviewing drug requisitions and revising them to fit budget allocations;
determine which drugs should be made available to each type of health facility (if this is not
determined at the national level.);
• developing standard treatment norms for the common illnesses treated in the area or
institution;
• establishing prescribing limitations aimed at controlling irrational drug use(for example,
limiting certain antibiotics to use only under the recommendation of a consultant)
• Limiting the amount dispensed at one time to curb abuse of particular drugs and reduce
waste;
• Reviewing antibiotic resistance patterns and revising guidelines for antibiotic use;
• Stimulating drug education activities among hospital staff;
• Supervising and monitoring prescribing practices.
25
CHAPTER 8
GUIDELINES FOR ANALGESIC USE IN PREGNANCY AND LACTATION
PREGNANCY AND ANALGESICS
Drugs can have harmful effects on the fetus at any time during the pregnancy, their nature
depending on the timing of exposure. During the first 2 weeks of development, the embryo is
thought to be resistant to any teratogenic effects of drugs. The critical period of embryonic
development, when the major organ systems develop, starts at about 17 days post conception and is
complete by 60 to 70 days. Exposure to certain drugs during this period (17 to 70 days) can cause
major birth defects. However, some drugs can interfere with functional development of organ
systems and the central nervous system in the second and third trimesters and produce serious
consequences.
All drugs should be avoided if possible, in the first 12 weeks of pregnancy. If drugs are to be
prescribed then the benefits to the mother must be considerable.
CATEGORISATION OF DRUGS IN PREGNANCY
This is based on Medicines in Pregnancy. The Australian categorization consists of the following.
Category A
Drugs which have been taken by a large number of pregnant women and of childbearing age
without any proven increase in the frequency of malformations or other direct or indirect harmful
effects on the fetus having been observed.
Category Bl
Drugs which have been taken by only a limited number of pregnant women and women of
childbearing age, without an increase in the frequency of malformation or other direct or indirect
harmful effects on the human fetus having been observed. Studies in animals* have not shown
evidence of an increased occurrence of fetal damage.
Category B2
Drugs which have been taken by only a limited number of pregnant women and women of
childbearing age, without an increase in the frequency of malformation or other direct or indirect
harmful effects on the human fetus having been observed. Studies in animals* are inadequate or
may be lacking, but available data show no evidence of an increased occurrence of fetal damage.
Category B3
Drugs which have been taken by only a limited number of pregnant women and women of
childbearing age, without an increase in the frequency of malformation or other direct or indirect
harmful effects on the human fetus having been observed. Studies in animals* have shown evidence
of an increased occurrence of fetal damage, the significance of which is considered uncertain in
humans.
Category C
Drugs which, owing to their pharmacological effects, have caused or may be suspected of causing,
harmful effects on the human fetus or neonate without causing malformations. ’’These effects may
be reversible. Accompanying texts should be consulted for further details.
26
&QO
Category D
Drugs which have caused, are suspected to have caused or may be expected to cause, an increased
incidence of human fetal malformations or irreversible damage. These drugs may also have adverse
pharmacological effects. Accompanying texts should be consulted for further details.
Category X
Drugs which have such a high risk of causing permanent damage to the fetus that they should not be
used in pregnancy or when there is a possibility of pregnancy._____________
Table, Analgesic lisp
nrp<ynanov*
use in pregnancy
______ Drug_____
Category
_______ Drug
Category
Acetazolamide
B3
Methyl sergide
C
_____ aciclovir
B3
Metoclopramide
A
Allunopurinol
B2
_____ Mexiletine
Bl
Amitriptyline
C
_____ Midazolam
C
_____ Aspirin_____
C
Misoprostol
X
____ Auranofin
B3
____ Morphine
C
Azithroprine
D
_____ Naloxone
Bl
_____ Baclofen____
B3
____ Naproxen
C
Bromocriptine(oral)
A
Nitrous Oxide
A
Bupivacaine
A
Nortriptyline
C
Carbamazepine
D
Oxycodone
C
Clonazepam
C
Paracetamol
A
_____ Codeine_____
A
Penicillamine
D
Colchicines
B2
Pentazocine
C
Cyclophosphamide
D
_____ Pethidine
C
_____ Danazol_____
D
Phenylbutazone
C
Desipramine
C
____ Phenytoin
D
Diazepam
C
____ Piroxicam
C
Diclofenac
c
_____ Pizotifen
Bl
_____ Doxepin_____
c
Prednisolone
A
Ergotamine
c
Probenecid
B2
Famciclovir
Bl
Prochlorperazine
C
____ Fentanyl_____
C
Promethazine
C
Hydroxychloroquine
D
Propantheline
B2
Hyoscine
B2
Propranolol
C
butylbromide
Ibuprofen_____
C
Sodium valproate
D
Indomethacin
c
Sulindac
C
Ketamine_____
A
Sulphasalazine
A
Ketoprofen
C
Sulphinpyrazone
B2
Ketorolac____
C
Sumatriptan
B3
Mebeverine
B2
Temazepam
C
Methadone
C
Tenoxicam
c
Methotrexate
D
Valaciclovir
B3
Note: For drugs in the Bl, B2 and B3 categories, human data are lacking or inadequate and sub
categorisation is therefore based on available animal data. The allocation of a B category does not
T1
3Ci
I
imply greater safety than the C category. Drugs in category D are not absolutely contraindicated
in pregnancy (eg antiepileptics). Moreover, in some cases the 'D' category has been assigned on
the basis of'suspicion'.
LACTATION AND ANALGESICS
The benefits of breastfeeding are sufficiently important to recommend that breastfeeding should be
discontinued or discouraged only when there is substantial evidence that the drug taken by the
mother will be harmful to the infant and that no therapeutic equivalent can be given.
Most drugs are only excreted to a minimal extent in breast milk and in most cases the dosage to
which the infant is ultimately exposed is very low and is well below the therapeutic dose level for
infants. For this reason, there are few drugs which are totally contraindicated whilst breastfeeding.
The pharmacokinetics of many drugs ingested by breastfeeding women is such that administration
of the drug at or immediately after the infant feeds will result in the lowest level of drug in the milk
at subsequent feeding in most cases. For long-acting drugs, medication is best taken by the mother
just prior to the longest sleep of the infant. In most situations drugs cross the placenta more
efficiently than into breast milk.
Acetazolamide
Allunopurinol
Amitriptyline
Aspirin
Azithroprine
Bupivacaine
Carbamazepine
Codeine
Colchicines
Cyclophosphamide
Diazepam
Ergotamine
Halothane_____
Ibuprofen_____
Indomethacin
Ketamine_____
Methotrexate
Metoclopramide
______ Table , Analgesic use and lactation_________________________
Compatible with breastfeeding____________________________________
No data available.______________________________________________
Compatible with breastfeeding in doses up to 150 mg per day.___________
Compatible with breastfeeding in occasional doses. Avoid long - term
therapy, if possible. Monitor infant for side effects(haemolysis, prolonged
bleeding time and metabolic acidosis).___________________________
Avoid breastfeeding____________________________________________
Compatible with breastfeeding.____________________________________
Compatible with breastfeeding. Monitor infant for side effects (Jaundice,
drowsiness, poor suckling, vomiting and poor weight gain)._____________
Compatible with breastfeeding in occasional doses. Avoid repeated doses,
if possible. Monitor infant for side effects (apnoea, bradycardia and
cyanosis).___________________________________
Avoid if possible, animal data suggest it can alter the composition of
breast milk.___________________________________________________
Avoid breastfeeding._____________________________
Compatible with breastfeeding in single dose. Avoid repeated doses, if
possible. Monitor infant for drowsiness. Short - acting benzodiazepines
preferred._____________________________
Avoid if possible. Monitor infant for side effects (ergotism)._____________
Compatible with breastfeeding.________ ___________________________
Compatible with breastfeeding.___________________________________
Avoid possible. Monitor infant for convulsions._______________________
Compatible with breastfeeding._________________________
Avoid brestfeeding_______________
Avoid if possible. Insufficient data on long-term side effects. Increases
breast milk production
28
Table , Analgesic use and lactation
Morphine
Naloxone
Nitrous Oxide
Paracetamol
Penicillamine
Pethidine
Phenytoin
Prednisolone
Promethazine
Propranolol
Sodium valproate
Sulphasalazine
Compatible with breastfeeding in occasional doses. Avoid repeated doses,
if possible. Monitor infant for side effects(apnoea, bradicardia and
cyanosis)._________
No data available.
Compatible with breastfeeding.
Compatible with breastfeeding.
No data available._______________
Compatible with breastfeeding in occasional doses. Avoid repeated doses,
if possible. Monitor infant for side effects(apnoea, bradicardia and
cyanosis). Side effects occur more commonly than with morphine._____
Compatible with breastfeeding. Monitor infant for side effect(cyanosis and
methaemoglobinaemia.
Compatible with breastfeeding.
Compatible with breastfeeding in single dose. Avoid repeated doses, if
possible. Monitor infant for drowsiness._____
Compatible with breastfeeding. Monitor infant for side effects
(bradycardia, hypoglycaemia and cyanosis).
Compatible with breastfeeding. Monitor infant for side effects (Jaundice)
Avoid if possible, especially if infant is premature or less than 1 month
old. Monitor infant for side effects (bloody diarrhoea, haemolysis and
jaundice). Avoid in glucose - 6- phosphate - dehydrogenase - deficient
infants.
29
3.G3
CHAPTER 9
PRINCIPLES OF ANTIMICROBIAL USE
General principles
This is intended to provide a general statement of acceptable approaches to the use of antimicrobial
drugs both in hospital practice and in the community. In hospitals, the choice of which drugs are
used may be influenced by such local factors as trends in susceptibility of current isolates, cost of
the drugs and in some instances traditional preference or familiarity.( Each hospital's drug
committee should produce its own antimicrobial policies within the overall framework suggested.
)Acquisition of resistance to antimicrobials is more common in hospitals than in the community due
to the selective pressure exerted by high drug levels in the biosphere of the former together with
facilitated transfer of organisms between staff and patients. Nonetheless, the same principles apply
in both settings. Restraint in prescribing and adherence to the principles discussed below are equally
necessary in both hospital and community. Problems of distance, access to specialized care or
continuity of contact encountered in remote areas may dictate recommendations at variance with
those generally appropriate.
Much viral and self-limiting bacterial disease does not benefit from the use of antimicrobials.
Exposure of the patient to the risk of adverse effects due to a drug is thus clearly unwarranted. Such
prescribing practices are costly and help create conditions favoring the proliferation of resistant
organisms in that patient and throughout the community.
Choice of an antimicrobial agent
When an antimicrobial is indicated, the choice of agent should be based on factors such as spectrum
of activity in relation to the known or suspected causative organism, safety, previous clinical
experience, cost, and the potential for selection of resistant organisms and associated risk of super
infection. The relative importance of each of these factors will be influenced by the severity of the
illness and whether the drug is to be used for prophylaxis, empirical therapy or therapy directed by
identification of one or more pathogens. A history of allergy or other adverse response to the drug
under consideration should always be sought and taken into account.
Prophylactic antimicrobial therapy should be restricted to situations in which it has been shown
to be effective or where the consequences of infection are disastrous. Most surgical prophylaxis
should be parenteral and commence just before the procedure. A single dose is usually adequate for
operations lasting less than 2 hours. The aim is to achieve high plasma and tissue levels at the time
that contamination is most likely, ie during the operation..
Empirical antimicrobial therapy should be based on local epidemiological data on potential
pathogens and their patterns of antimicrobial susceptibility. Where appropriate, specimens for Gram
stain, culture and susceptibility testing should be obtained before commencing antimicrobial
therapy. A Gram stain, eg of sputum, or direct antigen detection methods, eg in meningitis, may
allow specific therapy to be commenced even before the pathogen has been cultured.
Directed antimicrobial therapy It is important to review the empirical regimen when culture results
have identified the organisms present and their susceptibility to antimicrobials. It must be
remembered that organisms found to be present are not necessarily responsible for the clinical
30
condition. Laboratory data must be interpreted in the context of the overall clinical picture.
Antimicrobial therapy directed at specific organisms should include the most effective, least toxic,
narrowest spectrum agent available. This practice reduces the problems associated with broad
spectrum therapy, viz selection of resistant micro-organisms and super infection and will usually be
the most cost-effective.
Choice of parenteral, oral or topical antimicrobial formulations: Parenteral administration of
antimicrobials is generally more expensive than equivalent oral therapy but may be necessary due to
poor bioavailability of the drug or inability of the patient to take oral medication. Intravenous
therapy via a central line may be necessary to avoid causing phlebitis when an irritant concentration
of a drug is administered. It is important that topical antimicrobial therapy be restricted to a few
proven indications, eg eye infections, because of the capacity of most topical agents to select
resistant micro-organisms and to cause sensitization.
Antimicrobial combinations should be avoided unless indicated: to extend the spectrum of cover,
eg empirical therapy of suspected mixed infections such as pelvic inflammatory disease; to achieve
a bactericidal effect (synergy), eg in enterococcal endocarditis; or to prevent the emergence of
resistant micro-organisms, eg in the therapy of tuberculosis.
ANTIMICROBIAL USE IN HOSPITALS
The importance of each hospital adhering to a defined antimicrobial policy is internationally
accepted. The aim is to minimize the selection of antimicrobial-resistant micro-organisms and to
promote effective and economical prescribing. Successful implementation of antimicrobial policies
requires that hospital drug committees should formulate prescribing strategies appropriate for their
institution; audit antimicrobial use;
Prescribing strategics:
Hospitals should classify antimicrobial preparations into 3 groups:
unrestricted, restricted and excluded. The primary aim of such policies is not to prevent access to
useful drugs but rather to require doctors to justify their use of certain antimicrobials and have their
decisions subject to peer review.
Unrestricted: No restrictions should be placed on antimicrobials which are safe, effective and
relatively cheap, eg benzyl penicillin.
Restricted: Drugs may be restricted because of concern regarding emergence of antimicrobial
resistance, cost-containment or safety. Many degrees of restriction are possible: limited supplies
available on one prescription, use only in defined situations, authority to prescribe limited to certain
medical staff or special units, and supply only after consultation and approval from a clinical
microbiologist, infectious diseases physician or other clinician nominated by an appropriate
committee. A mechanism must exist whereby an initial dose of a restricted antimicrobial can be
given in an emergency, after which approval is sought.
Excluded: Agents in this category would include preparations considered to have no useful
advantage over diugs already held, or drugs superseded by newer releases, eg numerous penicillins,
cephalosporins, tetracyclines and sulphonamides. These agents would only be obtained for use
under special circumstances. All new antimicrobial agents should be automatically placed in the
excluded category until the appropriate hospital committee has considered their role in therapy. A
31
written request and justification from a hospital clinician should be required before a drug is
considered for reclassification by the appropriate committee.. Hospital laboratories should limit the
range of antimicrobials for which susceptibility tests are reported routinely. Susceptibilities to
restricted antimicrobials should only be reported if the organism isolated is resistant to non
restricted antimicrobials.
Antimicrobial audits
Reviews of antimicrobial usage by product and by clinical unit, with occasional audits of
prescribing habits, may suggest specific educational campaigns.
Educational responsibilities Educational functions of hospital drug committees should include the
provision of information on antimicrobial use, supplemented by local decisions and data on new
antimicrobials as these become available. Drug committees should encourage the provision of
information to clinicians on current antimicrobial susceptibility patterns of organisms from their
patients.
Forces influencing prescribing
Prescribing habits have been shown to be influenced by education, peer influences, physician
characteristics, activities of the pharmaceutical industry such as advertising and drug detailing,
control and regulatory measures and demands from patients and society. It is the task of the hospital
drug committee to augment influences that foster rational prescribing and to counter those that have
the opposite effect.
ANTIMICROBIAL USE IN THE COMMUNITY
Decisions to be made in the community setting are less complex than in hospital but prescribers
should have an 'antimicrobial policy' appropriate to their practice. Use of empirical regimens
without preceding culture will frequently be appropriate but the risks of this should be appreciated
and given due weight. The most common adverse consequence is use of an antimicrobial in a viral
disease when none is indicated. However other undesirable consequences could be that; an
inappropriate antimicrobial may be chosen with consequent treatment failure; and in serious
disease, eg endocarditis, treatment even with an inappropriate
antimicrobial
may
prevent
subsequent identification of the organism and its susceptibility as a guide to definitive treatment.
Geographical variation in susceptibility of organisms to antimicrobials may be considerable and
advice from a pathologist on current local isolates, eg the proportion of Escherichia coli from urine
cultures susceptible to candidate treatments, may be useful in deciding on empirical therapy of
urinary tract infection. Selective reporting of susceptibilities by community laboritories may be
desirable. Auditing of the pattern of antimicrobial use by the individual prescriber or by a whole
practice and comparison of the result with standard recommendations such as those in this book
may be instructive.( In Australia, prescribers can obtain data on their own prescribing from those
centrally accumulated by the reimbursement authority.) Use of this information for continuing
education would be of value.
The problems posed by pathogenic organisms resistant to established and to new antimicrobial
agents is increasing globally. We must learn from the experience in some Asian and East European
communities where unregulated use of antimicrobials has been associated with frightening increases
in resistance of major human pathogens. Adherence to the principles of antimicrobial use, is
increasingly important. Restraint in the use of new and often powerful antimicrobials is the best
32
&6G
way to ensure their continuing efficacy. Most conditions requiring antimicrobial treatment can be
managed using established drugs.
The B-lactams and aminoglycosides are still important, and new agents in the former group
continue to appear. Fluoroquinolones increase in number and in use, and newer macrolides have
achieved recent prominence. Brief orientating comments are made below on these categories as
well as on antiviral, antifungal and some other agents.
BETA-LACTAMS
Penicillins, cephalosporins including cephamycins, monobactams and carbapenems are structurally
related and share bactericidal activity primarily directed at the bacterial cell wall. Most B-lactams
are relatively safe, except in those patients hypersensitive to them. The various combinations of a Blactam with an inhibitor of B- lactamase have important clinical applications.
penicillins: Narrow-spectrum penicillin
These are mainly active against Gram-positive organisms but are inactivated by B-lactamases
produced by staphylococci and many other organisms.
Benzylpenicillin (penicillin G) is administered parenterally. It remains the treatment of choice for
many infections.
Procaine penicillin is an intramuscular preparation designed to extend the half-life of
benzylpenicillin. It provides blood levels for up to 24 hours but these are adequate only against
highly susceptible organisms.
Benzathine penicillin is given intramuscularly and provides low levels of benzylpenicillin for
up to 4 weeks.
Phenoxymethyipcnicillin (penicillin V) is acid stable and thus may be given orally, although food
impairs absorption. It is intrinsically less active than benzylpenicillin.
Antistaphylococcal penicillins
Methicillin, cioxacillin, dicloxacillin, and flucloxacillin are stable to B-lactamase produced by
staphylococci. They are microbiologically similar but methicillin has greater toxicity and is no
longer used therapeutically. Flucloxacillin and dicloxacillin are more reliably absorbed by the oral
route than cloxacillin and may cause less gastrointestinal upset.
Flucloxacillin is generally well tolerated but has recently been found to be associated with
cholestatic jaundice in some patients. This may occur after oral or intravenous administration. It can
manifest up to 6 weeks after treatment and may last for months. It is more commonly seen in elderly
patients. This propensity should not prevent use of flucloxacillin to treat staphylococcal disease of
sufficient severity to warrant use of this generally superior drug. However it should not be used for
less serious infections. It is not yet clear whether the other isoxazolyl penicillins, cloxacillin and
dicloxacillin, have a similar adverse effect. In this book (flu)cloxacillin refers to cloxacillin and
flucloxacillin. Methicillin-resistant Staphylococcus aureus (MRSA) should be regarded as clinically
resistant to all B-lactams irrespective of laboratory reports of susceptibility.
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bi
CHAPTER 10
DRUG INTERACTIONS
A drug-drug interactions may be defined as the pharmacological or clinical response to the
administration of a drug combination different from that anticipated from the known effects of the
two agents when given alone. The clinical result of a drug-drug interaction may manifest as
antagonism (i.e., 1+ 1 < 2), synergism (i.e., 1+ 1 >2) or idiosyncratic (i.e., a response unexpected
from the known effects of either agent.
Incidence of Drug Interactions
The clinical effects of any interactions, no matter how well documented, do not occur in every
patient or at the same degree of intensity. The incidence and degree of severity of an interaction
depend on both patient-related factors and information about the effects of the interaction (e.g.
dose-dependency, route). Patient-related factors (e.g. disease process, impairment of organ function)
must be individually assessed.
Onset: How rapidly the clinical effects of an interaction can occur determines the urgency with
which preventive measures should be instituted to avoid the consequences of the interaction. Two
levels of onset are used:
Rapid: the effect will be evident within 24 hours of administration of the interaction drug.
Immediate action is necessary to avoid the effects of interaction.
Delayed: The effect will not be evident until the interacting drug is administered for a period of
days or weeks. Immediate action is not required.
Severity: The potential severity of the interaction is particularly important in assessing the risk
versus benefit of therapeutic alternatives. With appropriate dosage adjustments or modification of
the administration schedule, the negative effects of most interactions can be avoided. Three degrees
of severity are defined:
Major: The effects are potentially life threatening or capable of causing permanent damage.
Moderate: The effects may cause deterioration in a patient’s clinical status. Additional treatment,
hospitalization or extension of hospital stay may be necessary.
Minor: The effects are usually mild; consequences may be bothersome or unnoticeable, but should
not significantly affect the therapeutic outcome. Additional treatment is usually not required.
A drug interaction pair typically consists of the:
•
•
Object drug
Precipitant drug
The activity of the “object” drug is altered; the drug causing this change is the “precipitant” drug.
34
Types of Drug Interactions
Drug interactions are frequently
pharmacodynamic.
characterized
as
being
either
pharmacokinetic
or
PHARMACOKINETIC
Pharmacokinetic interactions are those in which one drug alters the rate or extent of absorption,
distribution or elimination (metabolism or excretion) of another drug. This is most commonly
measured by a change in one or more kinetic parameter, such as maximum serum concentration,
area under the concentration-time curve, half-life, total amount of drug excreted in urine, etc.
PHARMACODYNAMIC
Pharmacodynamic interactions are those in which one drug induces a change in a patient’s response
to a drug without altering the object drug’s pharmacokinetics. That is, one may see a change in drug
action without altered plasma concentration, (e.g increase in the toxicity of digoxin produced by
potassium-wasting diuretics.) Pharmacological interaction, that is, concurrent use of two or more
drugs with similar or opposing pharmacological actions (e.g. use of alcohol with an antianxiety drug
and a hypnotic or antihistamine) are a form of pharmacodynamic interactions.
In order to avoid the incidences of such interactions, unbiased, up-to -date drug & therapeutic
information is an absolute must for the prescribers.
35
CHAPTER 11
PHARMACOVIGILANCE
An adverse drug reaction (ADR) has been defined by the World Health Organisation as "a response
to a drug which is noxious and unintended and which occurs at doses normally used in man for the
prophylaxis, diagnosis or therapy of disease or for the modification of a physiological function".
Medicinal products are very safe, that is, the benefits are much greater than the risks. Not all the
risks from drugs, better called medicinal products, are known when such a product is first marketed.
Since there is no programme of testing prior to the marketing of a medicinal product that will find
all the risks of its use in everyday clinical situations, we must learn by experience.
The history of international pharmacovigilance goes back as much as thirty years. At this moment,
under the WHO Collaborating Centre for International drug Monitoring, there are 58 official
member countries (those with a formally recognized national ADR monitoring centre) and 6
associate member countries (those with strong pharmacovigilance capacity but no formally
recognised ADR monitoring centre) participating in the programme.
WHY PHARMACOVIGILANCE?
The information collected during the pre-marketing phase of a medical drug is inevitably
incomplete with regard to possible adverse reactions
• tests in animals are insufficiently predictive of human safety
• in clinical trials patients are selected and limited in number, the conditions of use differ from
those in clinical practice and the duration of trials is limited
• information about rare but serious adverse reactions, chronic toxicity, use in special groups
(such as children, the elderly or pregnant women) or drug interactions is often incomplete or not
available.
WHY PHARMACOVIGILANCE IS REQUIRED IN KARNATAKA ALSO?
Pharmacovigilance is needed in every Place (country), because there are differences between
countries (and even regions within countries) in the occurrence of adverse drug reactions and other
drug-related problems. This may be because of differences in:
• drug production
• distribution and use (e.g. indications, dose, availability)
• genetics, diet, traditions of the people
• pharmaceutical quality and composition (excipients) of locally produced
• pharmaceutical products
• the use of non-orthodox drugs (e.g. herbal remedies) which may pose special toxicological
problems, when used alone or in combination with other drugs.
Data derived from within the country or region may have greater relevance and educational value
and may encourage national regulatory decision-making.
36
2*0
AIMS:
Pharmacovigilance is concerned with the detection, assessment and prevention of adverse
reactions to drugs. Major aims of pharmacovigilance are:
2. Early detection of hitherto unknown adverse reactions and interactions
3. Detection of increases in frequency of (known) adverse reactions
4. Identification of risk factors and possible mechanisms underlying adverse reactions
5. Estimation of quantitative aspects of benefit/risk analysis and dissemination of information
needed to improve drug prescribing and regulation.
The ultimate goals of pharmacovigilance are:
•
•
•
the rational and safe use of medical drugs
the assessment and communication of the risks and benefits of drugs on the market
educating and informing of patients.
HOW TO START A PHARMACOVIGILANCE CENTRE:
A new pharmacovigilance centre can start operating very quickly. The development of a
pharmacovigilance system, however, from the first and uncertain stage to becoming an established
and effective organisation, is a process that needs time, vision, dedication, expertise and continuity.
Whatever the location of the centre, pharmacovigilance is closely linked to drug regulation.
Governmental support is needed for national co-ordination. Pharmacovigilance is nobodyOs
individual privilege. Good collaboration, co-ordination, communications and public relations are
needed for coherent development and for the prevention of unnecessary competition or duplication.
BASIC STEPS IN SETTING UP A PHARMACOVIGILANCE CENTRE:
1. Make contacts with the health authorities and with local, regional or national institutions and
groups, working in clinical medicine, pharmacology and toxicology outlining the importance of
the project and its purposes.
2. Design a reporting form and start collecting data by distributing it to hospital departments,
family practitioners, etc.
3. Produce printed material to inform health professionals about definitions, aims and methods of
the pharmacovigilance system.
4. Create the centre: staff, accommodation, phone, word processor, database management
capability, bibliography etc.
5. Take care of the education of pharmacovigilance staff with regard, for example, to:
♦ Data collection and verification
♦ Interpreting and coding of adverse reaction descriptions
♦ Coding of drugs
♦ Case causality assessment
♦ Signal detection
♦ Risk management.
6. Establish a database (administrative system for the storage and retrieval of data;).
7. Organise meetings in hospitals, academia and professional associations, explaining the
principles and demands of pharmacovigilance and the importance of reporting.
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8. Promote the importance of reporting adverse drug reactions through medical journals, other
professional publications, and communications activities.
9. Maintain contacts with international institutions working in pharmacovigilance, e.g. the WHO
Department of Essential Drugs and Medicines Policy (Geneva) and the Uppsala Monitoring
Centre, Sweden
REPORTING FORM:
A case report in pharmacovigilance can be defined as: A notification relating to a patient with an
adverse medical event (or laboratory test abnormality) suspected to be induced by a medicine.
A case report should (as a minimum to aim at) contain information on the following elements:
1. The patient: age, sex and brief medical history (when relevant). In some countries ethnic origin
may need to be specified.
2. Adverse event: description (nature, localisation, severity, characteristics), results of
investigations and tests, start date, course and outcome.
3. Suspected drug(s): name (brand or ingredient name + manufacturer), dose, route, start/stop
dates, indication for use (with particular drugs, e.g. vaccines, a batch number is important).
4. All other drugs used (including self-medication): names, doses, routes, start/stop dates.
5. Risk factors (e.g. impaired renal function, previous exposure to suspected drug, previous
allergies, social drug use).
6. Name and address of reporter (to be considered confidential and to be used only for data
verification, completion and case follow-up).
Reporting should be as easy and cheap as possible. Special free-post or business reply reporting
forms, containing questions 1-6 mentioned above, can be distributed throughout the target area to
healthcare professionals at regular intervals (for example, four times a year).
It may take the yearly distribution of hundreds of thousands of forms to harvest only some hundreds
of case reports.
REPORTING BY WHOM?
Professionals working in healthcare are the preferred source of information in pharmacovigilance,
for example family practitioners, medical specialists and pharmacists. Dentists, midwives, nurses
and other health workers may also administer or prescribe drugs and should report relevant
experiences.
In addition pharmacists and nurses can play an important role in the stimulation of reporting and in
the provision of additional information (for example, on co-medication and previous drug use).
Pharmaceutical manufacturers, being primarily responsible for the safety of their products, have to
ensure that suspected adverse reactions to their products are reported to the competent authority. If
adverse reactions are reported directly by patients to the national or local centre, it is useful to
consider the possibility of communication with their physicians for additional information and data
verification.
STIMULATION OF REPORTING
The reporting of adverse reactions needs continuous stimulation. It is important to achieve the
development of a positive attitude towards pharmacovigilance among healthcare professionals so
that adverse reaction reporting becomes an accepted and understood routine. In summary, the
following may stimulate reporting:
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♦ Easy access to pre-paid reporting forms and other means of reporting
♦ Acknowledging the receipt of adverse drug reaction reports by personal letter or phone call
♦ Providing feedback to reporters in the form of articles in journals, adverse drug reaction
bulletins or newsletters
♦ Participation of the centres staff in pre- and postgraduate education and scientific meetings
♦ Collaboration with local drug or pharmacovigilance committees
♦ Collaboration with professional associations
♦ Integration of pharmacovigilance in the (further) development of clinical pharmacy and clinical
pharmacology in a country.
CONTINUITY
Continuity in accessibility and service is a basic feature of a successful pharmacovigilance centre.
The centre therefore needs a permanent secretariat, for phone calls, mail, maintenance of the
database, literature documentation, co-ordination of activities, etc. Secretarial continuity may be
achieved through collaboration with related departments, provided there is sufficient capacity.
39
a?3
CHAPTER 12
FORMULARY
A formulary manual contains summary drug information. It is not a full textbook, nor does it
usually cover all drugs on the market. Instead, it is a handy reference that contains selected
information that is relevant to the prescriber, dispenser, nurse, or other health worker. A formulary
is drug centered, as it is based on monographs for individual drugs or therapeutic groups.
Formularies may or may not contain evaluate statements or comparisons of drugs. Some
formularies also include comparative price information, which can help guide prescribing decisions.
A national formulary manual is based on the national list of essential drugs. The production of a
formulary is one step in an ongoing process. The development process of these publications is a
continual effort, not limited to the one time production . The process involves gaining acceptance of
the concept, preparing the text based on the wide consultation and consensus building,
implementing an introductory campaign and training activities, and undertaking regular reviews and
updates.
To maintain the credibility of the information, a system for regular updates and for incorporation of
accepted amendments into the next edition is essential.
Limited drug lists have been used since the early 1970s to control costs & promote rational use in
public and private sector pharmaceutical programs. Limited drug lists can be the main mechanism
to prevent the use of dangerous, ineffective & unnecessarily expensive drugs.
Intended to be a ready reference for doctors and contains information which includes the category
of the drug, its indications cautions to be observed when using the drug, contraindications, side
effects, drug interactions and dosage forms available. Additional notes on use of the drugs will be
provided wherever necessary to use the drugs more rationally and avoid complications in therapy.
Thus the prescribing doctor will have a publication providing him objective unbiased information
about the drugs that will be prescribed.
Hospital formulary: In many countries, especially those with highly developed health systems,
hospitals develop their own formulary manuals. The advantage is that the formulary can be tailored
to fit the particular requirements of the hospital & to reflect departmental consensus on first choice
treatments from the national list of essential drugs. Additional information presented in hospital
formularies may include details of recommended hospital procedures, hospital antibiotic policy,
guidelines for laboratory investigations and patient management. Hospital formularies usually
reflect consensus on the treatment of first choice and thus are not always distinct from treatment
guideline
40
CHAPTER 13
DRUGS AND THERAPEUTIC INFORMATION SERVICES
Access to clinically relevant, up-to date, user- specific, independent, objective and unbiased drug
information is essential for appropriate drug use. Prescribers dispensers, and users of medicines all
need objective information. A health care system can provide access to the highest quality
medicines, but if those medicines are not properly used, they may have negligible benefits or even
adverse effects. Although access to good drug information does not guarantee appropriate
di ug use, it is certainly a basic requirement for rational drug use decisions.
The factors influencing drug use are many and interrelated. No single approach is likely to work.
Rather, a variety and combination of strategies tailored to the needs of the different groups in
society and the different working enviromnents of health workers will be needed.
Objective drug information
A medicinal product must be accompanied by appropriate information. The quality of information
accompanying the drug is as important as the quality of the active substance. Information about
drugs and drug promotion can greatly influence the way in which drugs are used. Monitoring and
control of both these activities are essential parts of any national drug policy.
Criteria that should apply to the development of objective information are that it should be: based
on agreed standards; available, accessible and understandable to users; flexible and provided in a
variety of forms; relevant to user needs, recognizing the multicultural nature of societies;
independent, unbiased and withi no advertising; developed with user input; and pilot tested for
usefulness and acceptability.
The primary role of a DRUG INFORMATION CENTRE is to keep up - to- date with
pharmacological and therapeutic literature and disseminate relevant information when it becomes
available. A secondary role of the center is to give clear and definitive information on essential
drugs and promote their rational use.
Source of Drug Information :
Information sources fall into three classes. Primary sources are the foundation on which all other
drug information is based. These include journal publications on drug - related subjects, such as
reports of clinical drug trials, case reports and pharmacological research. Secondary’ sources
function as a guide to or review of the primary literature. Secondary sources include review articles,
meta analysis, indexes (Index Medicus) abstracts (International Pharmaceutical Abstracts), and
combinations of abstracts and full - text reprints.
Tertiary or general sources present documented information in a condensed format. Examples
include formulary , manuals, standard treatment manuals, text books, general reference books, drug
bulletins, and drug compendia. It is advisable to obtain the most current edition available when
using secondary or tertiary sources.
All information sources have limitations, and drug information provides should use them with care.
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cS'T S'
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A DIG should provide a variety of services, from responding to patients’ and doctors’ queries to
proactive efforts suchi as publishing newsletters or drug bulletins, participating in clinical activities,
and organizing formulary and treatment guidelines committees. DIG staff are also likely to be
involved in training health professionals and regularly evaluating the performance of the centre’s
staff. Although DICs tend to be small units, it is important that each one have a well - developed
amiual plan.
Proactive outreach
Health care professionals in both the public and private sectors often have little time or funds to
spend on drug information resources. A DIG can fill this gap, but the service must be effectively
marketed.
Drug information for health personnel
I
I
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I
Comparative, independent, reliable and objective information is also needed for appropriate
therapeutic decisions. This can be provided in the following ways:
• Utilizing the services of the drug information center
• Through participation in the development of treatment guidelines and drug formularies, the
formation of drug and therapeutic committees, involvement in teaching and clinical meetings,
surveys of practice, and outreach services by staff from the drug information center.
• By circulating the drug information bulletin or newsletter. It can offer objectively written
articles focusing on drug use and appropriate prescribing practices.
• By disseminating independent scientific literature on the rational use of drugs and on therapeutic
advances including material from peer-reviewed medical journals.
• By the organization of training programs, symposia, and lectures for the various groups of
health personnel.
• By the development of treatment guidelines and educational material on the appropriate use of
drugs by community health workers or paramedical personnel.
Drug information for consumers
Information similar to prescriber information, but in language that is understandable for the non
health professional, should be provided to consumers. In many countries this is done through patient
information sheets and drug labeling. These should be regulated to ensure accuracy. Other
information may be provided in the form of brochures, through campaigns and, most importantly,
through patient counseling. In populations with a low level of literacy, additional ways of
presenting information can be used.
Drug Bulletins
The development, production and dissemination of newsletters or drug bulletins that address
relevant drug information issues often help develop the market for a DIG. These periodicals should
promote rational drug therapy and appear at regular intervals, ranging from weekly to quarterly,
depending on their purpose and on the capacity of the DIG. Drug bulletins should provide
impartial assessments of drugs and practical recommendations, based on a comparison of treatment
alternatives and on the consensus of the main specialists in the field.
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•
•
•
•
•
the use of drugs for indications that could be handled by non-drug alternatives; in such cases
there can be increased risk and needless expenditures;
poly pharmacy or the multiple use of drugs, which increases the risks of adverse reactions,
including drug interactions;
drug and prescription hoarding, as people share medicines from previous illnesses, often
with a deficient understanding of the action, and risks, of these medicines;
preference for injectables, and the reuse of disposable syringes, which increases the risk of
HIV and other infections;
inappropriate use of antibiotics and other anti-infectives, which results in drug resistance,
contributing to higher morbidity and mortality.
The Alma Ata declaration clearly stares that ’’People have the right and duty t participate
individually and collectively in the planning and implementation of their health care”._ But,
public education is seldom allocated the necessary human and financial resources and is frequently
treated as a marginal activity or one which should only be tackled when the other elements of drug
policy have been dealt with. There is a need to increase the priority given to public education.
The overall aim of public education in drug use is to provide individuals and communities with
information, and to foster skills and confidence, which will enable them to use medicines in an
appropriate, safe, and judicious way.
Educational campaigns are unlikely to be effective if conducted primarily from a top-down and
biomedical perspective without an understanding of the socio-cultural framework within which
decisions are taken.
At an individual level the benefits of improved public understanding include:
• a better appreciation of the limits of the role of medicines within health care and less belief in the
idea that all ills require pharmaceutical treatment;
• an improved balance of power between consumers/patients and health professionals;
• a more critical attitude to advertising and other commercial information, which often fails to give
balanced information about drugs;
• a better understanding of how to take medicines when needed.
Drug use should be seen within the overall context of a society, community, family and
individual. Public education on drugs should recognize and take into account cultural diversity and
the influence of social factors such as poverty, disadvantage and power relations that can influence
drug use.
It is important to integrate public education in the appropriate use of drugs within comprehensive
national pharmaceutical and health policies.
• public education should encourage informed decision-making by individuals, families and
communities on the use of drugs and non-drug solutions;
• public education on drugs should be based on the best available scientific information on
drugs, their efficacy and side effects;
• public education should be accompanied by supportive legislation and controlled drug use
to make informed choices on drag use easier;
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NGOs, community groups and consumer organizations have an important role to play in
public education programmes and should be involved in the planning and implementation
of education activities;
• communications training and a reorientation of health care providers’ attitudes is necessary if
prescribers are to make an effective contribution to public education on drug use in their
interaction with the community;
• * public education should be based on sound educational principles which take into account
community perception and needs, decision-making processes in families, and the constraints
that communities face in their daily lives.
•
I
Constraints and facilitating factors
The outcome of public education activities can 1be influenced both positively and negatively by
many factors. The nature and extent of these influences» can vary from country to country according
to the level of development and health care infrastructure.
Constraining factors include: a lack of policies on both drug use and public education; commercial
interests; professional interests; weak infrastructures; resource availability; as well as economic,
social and cultural influences.
Facilitating factors include: increased awareness <of the need' for drug education;? improvements in
health infrastructures; and the expanding coverage of the world’s population by mass media.
Improving public understanding about medicines will not resolve all of these issues but, together
with other activities to implement national drug policies, it will contribute to the development of
solutions.
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CHAPTER 15
ETHICAL CRITERIA FOR MEDICINAL DRUG PROMOTION
Introduction (Optional for our purpose)
1. Following the WHO Conference of Experts on the Rational Use of Drugs held in Nairobi in
November 1985, WHO prepared a revised drug strategy which was endorsed by the Thirty-ninth
World Health Assembly in May 1986 in resolution WHA39.27. This strategy includes, among other
components, the establishment of ethical criteria for drug promotion based on the updating and
extension of the ethical and scientific criteria established in 1968 by the Twenty-first World Health
Assembly in resolution WHA21.41. The criteria that follow have been prepared in compliance with
the above on the basis of a draft elaborated by an international group of experts.
Objective
2. The main objective of ethical criteria for medicinal drug promotion is to support and encourage
the improvement of health care through the rational use of medicinal drugs.
Ethical criteria
3. The interpretation of what is ethical varies in different parts of the world and in different
societies. The issue in all societies is what is proper behavior. Ethical criteria for drug promotion
should lay the foundation for proper behavior concerning the promotion of medicinal drugs,
consistent with the search for truthfulness and righteousness. The criteria should thus assist in
judging if promotional practices related to medicinal drugs are in keeping with acceptable ethical
standards.
Applicability and implementation of criteria
4. These criteria constitute general principles for ethical standards which could be adapted by
governments to national circumstances as appropriate to their political, economic, cultural, social,
educational, scientific and technical situation, laws and regulations, disease profile, therapeutic
traditions and the level of development of their health system. They apply to prescription and nonpre_scription medicinal drugs (’’over-the-counter drugs"). They also apply generally to traditional
medicines as appropriate, and to any other product promoted as a medicine. The criteria could be
used by people in all walks of life; by governments; the pharmaceutical industry (manufacturers and
distributors); the promotion industry (advertising agencies, market research organizations and the
like); health personnel involved in the prescription, dispensing, supply and distribution of drugs;
universities and other teaching institutions; professional associations; patients' and consumer
groups; and the professional and general media (including publishers and editors of medical
journals and related publications). All these are encouraged to use the criteria as appropriate to their
spheres of competence, activity and responsibility. They are also encouraged to take the criteria into
account in developing their own sets of ethical standards in their own field relating to medicinal
drug promotion.
5. The criteria do not constitute legal obligations; governments may adopt legislation or other
measures based on them as they deem fit. Similarly, other groups may adopt self-regulatory
measures based on them. All these bodies should monitor and enforce their standards.
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Promotion
6. In this context, "promotion" refers to all informational and persuasive activities by manufacturers
and distributors, the effect of which is to induce the prescription, supply, purchase and/or use of
medicinal drugs.
7. Active promotion within a country should take place only with respect to drugs legally available
in the country. Promotion should be in keeping with national health policies and in compliance with
national regulations, as well as with voluntary standards where they exist. All promotion-making
claims concerning medicinal drugs should be reliable, accurate, truthful, informative, balanced, upto-date, capable of substantiation and in good taste. They should not contain misleading or
unverifiable statements or omissions likely to induce * medically unjustifiable drug use or to give
rise to undue risks. The word "safe" should only be used if properly qualified. Comparison of
products should be factual, fair and capable of substantiation. Promotional material should not be
designed so as to disguise its real nature.
8. Scientific data in the public domain should be made available to prescribers and any other
person entitled to receive it, on request, as appropriate to their requirements. Promotion in the form
of financial or material benefits should not be offered to or sought by health care practitioners to
influence them in the prescription of drugs.
9. Scientific and educational activities should not be deliberately used for promotional purposes.
Advertising
(a) Advertisements in all forms to physicians and health related professionals
10. The wording and illustrations in advertisements to physicians and related health professionals
should be fully consistent with the approved scientific data sheet for the drug concerned or other
source of information with similar content. The text should be fully legible.
11. Some countries require that advertisements should contain full product information, as defined
by the approved scientific data sheet or similar document, for a given period from the date of first
promotion or for the full product life. Advertisements that make a promotional claim should at least
contain summary scientific information.
12. The following list, based on the sample drug information sheet contained in the second report of
the WHO Expert Committee on the Use of Essential Drugs and appended for ease of reference, can
serve as an illustration of the type of information that such advertisements should usually
contain, among others:
• the name(s) of the active ingredient(s) using either international nonproprietary names (INN)
or the approved generic name of the drug;
• the brand name;
• content of active ingredient(s) per dosage form or regimen;
• name of other ingredients known to cause problems;
• approved therapeutic uses;
• dosage form or regimen;
48
•
•
•
•
•
side-effects and major adverse drug reactions;
precautions, contra-indications and warnings;
major interactions;
name and address of manufacturer or distributor;
reference to scientific literature as appropriate.
13. Where advertisements are permitted without claims (reminder advertisements), they ought to
include at least the brand name, the international nonproprietary name or approved generic name,
the name of each active ingredient, and the name and address of the manufacturer or distributor for
the purpose of receiving further information.
(b) Advertisements in all forms to the general public
14. Advertisements to the general public should help people to make rational decisions on the use of
drugs determined to be legally available without a prescription. While they should take account of
people's legitimate desire for information regarding their health, they should not take undue
advantage of people's concern for their health. They should not generally be permitted for
prescription drugs or to promote drugs for certain serious conditions that can be treated only by
qualified health practitioners, for which certain countries have established lists. To fight drug
addiction and dependency, scheduled narcotic and psychotropic drugs should not be advertised to
the general public. While health education aimed at children is highly desirable, drug
advertisements should not be directed at children. Advertisements may claim that a drug can cure,
prevent, or relieve an ailment only if this can be substantiated, They should also indicate, where
applicable, appropriate limitations to the use of the drug.
15. When lay language is used, the information should be consistent with the approved scientific
data sheet or other legally determined scientific basis for approval. Language which brings about
fear or distress should not be used.
16. The following list serves as an illustration of the type of information advertisements to the
genera] public should contain, taking into account the media employed:
• the name(s) of the active ingredients(s) using either international nonproprietary names
(INN) or the approved generic name of the drug;
• the brand name;
• major indication(s) for use;
• major precautions, contra-indications and warnings;
• name and address of manufacturer or distributor.
Information on price to the consumer should be accurately and honestly portrayed.
Medical representatives
17. Medical representatives should have an appropriate educational background. They should be
adequately trained. They should possess sufficient medical and technical knowledge and integrity to
present information on products and carry out other promotional activities in an accurate and
responsible manner. Employers are responsible for the basic and continuing training of their
representatives. Such training should include instruction regarding appropriate ethical conduct
taking into consideration the WHO criteria. In this context, exposure of medical representatives and
49
223
trainees to feed-back from the medical and allied professions and from independent members of the
public, particularly regarding risks, can be salutary,
18. Medical representatives should make available to prescribers and dispensers complete and
unbiased information for each product discussed, such as an approved scientific data sheet or other
source of information with similar content.
19. Employers should be responsible for the statements and activities of their medical
representatives. Medical representatives should not offer inducements to prescribers and
dispensers. Prescribers and dispensers should not solicit such inducements. In order to avoid over
promotion, the main part of the remuneration of medical representatives should not be directly
related to the volume of sales they generate
Free samples of prescription drugs for promotional purposes
20. Free samples of legally available prescription drugs may be provided in modest quantities to
prescribers, generally on request.
Free samples of non-prescription drugs to the general public for promotional purposes
21. Countries vary in their practices regarding the provision of free samples of non-prescription
drugs to the general public, some countries permitting it, some not. Also, a distinction has to be
made between provision of free drugs by health agencies for the care of certain groups and the
provision of free samples to the general public for promotional purposes. The provision of free
samples of non-prescription drugs to the general public for promotional purposes is difficult to
justify from a health perspective. If this practice is legally permitted in any country, it should be
handled with great restraint.
Symposia and other scientific meetings
22. Symposia are useful for disseminating information. The objective scientific content of such
meetings should be paramount, and presentations by independent scientists and health professionals
are helpful to this end. Their educational value may be enhanced if they are organized by scientific
or professional bodies.
23. The fact of sponsorship by a pharmaceutical manufacturer or distributor should clearly b stated
in advance, at the meeting and in any proceedings. The latter should accurately reflect the
presentations and discussions. Entertainment or other hospitality, and any gifts offered ti members
of the medical and allied professions, should be secondary to the main purpose o the meeting and
should be kept to a modest level.
24. Any support to individual health practitioners to participate in any domestic or international
symposia should not be conditional upon any obligation to promote any medicinal product.
Post-marketing scientific studies, surveillance and dissemination of information
25. Post-marketing clinical trials for approved medicinal drugs are important to ensure it rational
use. It is recommended that appropriate national health authorities be made aware any such studies
and that relevant scientific and ethical committees confirm the validity the research. Intercountry
and regional cooperation in such studies may be useful. Substantiated information on such studies
50
should be reported to the appropriate national health authorities and disseminated
as soon as
possible.
p™fo”arke,in8
StUdieS and
»> l» -isused as a disguised fonu of
27. Substantiated information on Ihazards associated with medicinal drugs should be reported to the
appropriate national health authority
as a priority, and should be disseminated internationally as
soon as possible.
Packaging and labeling
Zd±d^„,X“e package “* “ =d°
Information for patients: package inserts, leaflets and booklets
-j? ~
criteri! enuSLS
m
sis—
d f°r promotlonal Purposes, they should comply with the ethical
approved package inserts
this documem. ,pp":’pnate- S“cl'maBnaI sh»uld ako “mply with the ethical criteria enunciated in
Promotion of exported drugs
51
Appendix
Sample Drug Information Sheet
Various types of information are ineeded
’ ' ’by prescribers and consumers to ensure the safe and
effective use of drugs. The following list is a sample that should be adjusted to meet the needs and
abilities of the prescriber.
1. International Nonproprietary Name (INN) of each active substance.
2. Pharmacological data: a brief description of pharmacological effects and mechanism of action.
3. Clinical Information:
(a) Indications: whenever appropriate, simple diagnostic criteria should
be provided.
(b) Dosage regimen and relevant pharmacokinetic data:
• average and range for adults and children;
• dosing interval;
• average duration of treatment;
• special situations, e.g., renal, hepatic, cardiac, or nutritional insufficiencies that
require either increased or reduced dosage.
(c) Contra-indications.
(d) Precautions and warnings (reference to pregnancy, lactation, etc )
(e) Adverse effects (quantify by category, if possible).
(f) Drug interactions (include only if clinically relevant; drugs used for
self-medication should be included).
(g) Over dosage:
• brief clinical description of symptoms;
• non-drug treatment and supportive therapy;
• specific antidotes.
4.
Pharmaceutical information:
(a) Dosage forms.
(b) Strength of dosage form.
(c) Excipients.
(d) Storage conditions and shelf-life (expiry date).
(e) Pack sizes.
(f) Description of the product and package.
(g) Legal category (narcotic or other controlled drag, prescription or
non-prescription).
(h) Name and address of manufacturer(s) and importer(s).
Reference: 1. Essential drugs Monitor, WHO action Program on
essential Drugs, Issue No. 17,
1994, Pg-16-17.
52
CHAPTER 16
QUALITY ASSURANCE
The importance of ensuring drug quality
•
Poor quality drugs can have serious health consequences for users. Drugs may be formulated
in the wrong dosages. Also, drugs that have been stored in poor conditions or have become
contaminated may be used. Sometimes drugs may contain toxins.
Poor drug quality-causes money to be wasted, because ineffective treatments or adverse
packaged and^stored^rop^by.1^
COnSiderable Wasta8e oc^ 'f drugs are not
•
If people do not have confidence in tlthe quality of the drugs they receive, they will lose
confidence in the drug policy and healthh services as a whole.
Challenges
Responsibilities of various actors in pharmaceutical quality assurance
The following points are particularly important:
•
•
Manufacturers should adhere to and implement GMP
The Drug
Regulatory
Authority
Tncrt^
+•
-c
' h;iaS cruc*ai resP°nsibilities in quality assurance, namely:
o Inspecting manufacturers to ensure that they comply with GMPo Using the WHO certification scheme to ensure the quality of imported productso supervising the operation of the national quality control laboratory;
o ensuring that drugs are appropriately evaluated and registered;
53
o inspecting wholesalers, retailers and other points of distribution to ensure that
product quality is maintained in the distribution chain until products reach the
consumer.
♦ Those involved in procurement should ensure that drugs are carefully selected, purchased
from reliable sources, inspected at the time of receipt, and stored and transported properly.
The necessary laboratory testing must be requested, and mechanisms to report quality defects
and a recall procedure must be in place.
• Those involved in final distribution must ensure the proper storage of products, and their
appropriate handling, packaging and dispensing.
54
322
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GOVERNMENT OF KARNATAKA
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TASK FORCE ON HEALTH AND FAMILY WELFARE
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ALCOHOL USE AND MISUSE IN KARNATAKA
0
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By
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Dr. Vivek Benegal
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NIMHANS
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Bangalore.
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6
T
Alcohol Use and Misuse
in Karnataka:
I
A Position Paper submitted to the Karnataka Task Force on Health and Family Welfare
f
35 o
DIMENSIONS OF THE ALCOHOLISM EPIDEMIC.IN KARNATAKA: THE CASE FOR URGENT ACTION
Vivek Benegal, A Shantala, Pratima Murthy, N Janakiramaiah
Deaddiction Centre, National Institute of Mental Health and Neurosciences, Bangalore
INTRODUCTION
SJid bUfbl'C pe^ePtion' as wel1 as in the m,nds of Health planners, there is this strongly held and often
stated but nevertheless mythical belief that there are two distinct classes of drugs The licft variety (imolicitlv
safer), and the illicit variety (implicitly dangerous).
y (,mPllc,t|y
Icon^mic buX
’
deSPite accumulatin9 knowledge challenging this belief. Few recognize that it is the
Pa'd drU9S' alCOhO'
tObaCC°' WhiCh impose the heaviest health care and
THE PROBLEM AT HAND
1. Availability of Beverage Alcohol in Karnataka
EZE’mSSS’iJs!8’
deri' “’"a ”“ds“e E"e Dep“,”ni G»«™“
Rise in Beverage Alcohol Production in Karnataka from 1988 -1999
3000
□ IML [corr.] i
2500
□ Arrack
2000- x
i
U)
■ Beer
2
!
m
1500
5
1000
500
i
0
1988-89 1989-90 1990-91 1991-92 1992-93 1993-94 1994-95 1995-96 1996-97 1997-98
a.
1998-99 1999-00
Iirnh^0'
in Produc‘ion and sales has been in the spirits / arrack segment and low
cohol content beverage sales and production has shown far less growth. There is a covert
pressure to consume high alcohol content beverages in preference to low alcohol content
do with tkh%beer and W'ne' The ,rratlOnal and ineclual taxation of spirits and beers has a lot to
Pr'Ce °f,1 qUarter lcontains 6 unitsl of whisky the lowest price range is Rs 20 iRs 8 in
1988], the pnce of 1 sachet of arrack [3 units] is Rs. 8 [Rs. 3 in 1988], whiie the price of one boWe
of the cheapest beer [2 units] is Rs. 38 [Rs. 11 in 1988], [1 unit = 12 gms of absolute alcohol! Th s
'years °U ° 8 166%
PnCeS' 15°% f°r Wh'Sky and 246% rise for beer P'ices over 10
i
4
from the equivalent of 9 bottles (750 ml.) of whisky per year in 1988-89 to 20 bottles in 19982. Patterns of alcohol consumption in Karnataka state
The findings in section 2 are derived from data from an (ongoing
M
;house to house survey looking at alcohol and tobacco use in
randomly selected representative samples of rural and urban society in Karnataka
a.
I
i
Men drink far more than women, but women’s drinking is rising
The overall prevalence of alcohol use is lower than in non-temperance cultures. Males are still the
predominant consumers, however women are increasingly using and abusing alcohol
There is a large sex difference with reference to drinking behaviour with very few female users The
prevalence of alcohol use among women has never been studied in detail. 24% of all males and 5% of
all females had ever used alcohol in a Bangalore study done in 1983 [Mohan and Sundaram 1983]
However an indirect measure of this difference can be gauged from the male.female ratio of’s/ l in
TiToc! S®®king help.for alcoho1 related neuropsychiatric problems at the NIMHANS De-addiction centre
(1995). What is striking however is the four-fold increase in women registering with alcohol related
problems, at the same facility, over the last 10 years. This is likely to be only the tip of the ice-berg.
Depending on the area sampled the prevalence of alcohol use varies. Centers near to alcohol sales
outlets have a larger number of users. Figures vary from 20% of all males to 5% of all males (studies
conducted in Chottanahally, 10 kms from Malavalli and in Nuggehalli, 10 kms from Pandavapura in
Mandya district). The prevalence rates in an urban slum at Bagalur, Bangalore are about 27% of ail
males and 2% of all females.
b.
People start drinking earlier than ever and develop problems earlier
The average age at which males start regular drinking has dropped to 23 years [1998] from 25 years in
1988. The mean age at which they develop alcohol dependence is now approximately 29 years, down
from 35 years in 1988. This is a significant drop over the last 10 years.
c.
One out of two people who drink develops problem drinking [drinking in quantities sufficient to
cause significant medical problems]
Most of the persons who drink have problems related to drinking. Irrespective of the high or low
prevalence rates in that geographical location, the proportion of the drinkers having heavy enough
alcohol consumption to result in medical problems, vary from 68% to 46% of all users. More than 50% of
all people who drink alcohol appear to have problem drinking patterns, i.e. either drinking more than 2
drinks per day [one drink = 30 ml. “peg”' of spirits = ’/a bottle of beer] or drinking more than 5 drinks at
any given setting. These patterns of drinking usually lead to significant medical problems and contribute
to significant cumulative economic loss to the state in terms of forgone industrial production
1
d. People with heavy use of alcohol develop early health problems
This high proportion of problem drinkers have more frequent health visits at hospitals and clinics due to
alcohol related physical illnesses. Among the patients admitted at the district general hospital at
Mandya, 54% of the male patients and 16% of the female patients were alcohol users and 52% of these
male users had problem drinking. Among the patients attending the general practitioners clinics at
Malavalli, 50% of the male patients were using alcohol and 54% of these users had problem drinking
Similarly, studies done at a large general hospital in Bangalore (Savitha Sri et al, 1997) revealed that
40% of all males and 6.6% of all females admitted for medical and surgical problems had oroblem
drinking.
’
K
I
e.
I
Early alcohol related health damage is under recognized by primary care physicians
Inspite of these high prevalence rates of alcohol problems in their patients only 1.4% to 2 3% of the
patients were asked about alcohol use by their doctors where as none of the patients were advised to
stop alcohol use. Although a large proportion of the patients were consulting for what appeared to be
clearly alcohol related problems, the medical professionals attending to them, did not pick them up The
2.9 SI
6
j-
The thrust of the interventions for alcohol and drug misuse has hitherto been focused on al
chronic and habitual users in b] urban centers, whereas there is clear evidence that the oroblem
is larger and more serious in rural Karnataka.
prooiem
k.
The focus of intervention needs to change from tertiary prevention [treating people after thev
have become dependent and have developed severe health and social problems] to primary and
detecti^Anri Ven l0n [preventing Pe°Ple who have not started drinking from starting and early
probl
j
d early mtervention for people who are drinking at levels likely to start causing
3.
Alcohol dependence and the social cost
4 /o of the adult male population based upon data from the door to door survey done at Sakalvara (Benegal et al, 1997).
ThO™Coh0liC indi''iduals and their immediate families suffer significant economic and health burden
There are more than 5 lakh alcohol dependent individuals in the state. Their average daily individual
"" °f abS0'Ute a'C°h01 equivalent per day ie' equivalem to 255 bottles of
The average monthly expenditure on alcohol [Rs 1938.40+1649.82] of patients with alcohol dependence is more
lh "n a!- aVera9ve m°nothly earnins [Rs 1660±1704) which again, is likely to be reduced because of
hhT
"I' slckrness & unemployment. They contribute very little or nothing to family and are likely *o
incur heavy loans [average Rs 8388+ 2145 per year],
y
ely 0
familvXeHn bfUbden °f k 6 individual w^h alcohol dependence alters the structure and functioning of the
In vn
K M her mambers of the fami|y to take up financial responsibilities inappropriate to their roles
-g.. young children, widowed mother, sister's husband etc.) This sets up a chain of longer term
-es tn
tShOpCdirArtfrr eXample’ whefn children lose out on education and subsequent social upliftment not to speak of
the direct consequences of failure and frustration in such a role change).
’
P
Alcohol related Profits and Losses [1997]
i
_______
1000
500
846
■70
V)
<u
o
0
co
O'
-500
d
40-
1-963.5
■ Health Budget
□ Excise
-1000
-352.9
□ P ayments
■ Health costs
-1500 K--------------------------------- -----------
Expenditure
I
I
I
Income
593
Budget
□ Industrial loss
8
Existing Regulations against Sales and Retail are not effectively used:
Prohibited sales of alcoholic beverages to children below 18 years
b) Restricted sales at retail shops between 9 a.m. and 9 p.m.
c) Prohibited sales of alcoholic beverages in pubs, hotels etc. between 2.30 p.m to 5.30p.m and
afterlOp.m
d) Prohibited setting up retail outlets within 1 km radius of schools, places of worship etc .
e) Attempts to regulate the sales and consumption of alcohol along the state highways.
0 Restrictions against drinking and driving or operating heavy machinery
Advertising: The norms regarding advertising of beverage alcohol are also insufficiently enforced.
B] Demand Reduction: Demand reduction strategies, which have proved to be relatively more effective
than supply reduction strategies the world over, have received little attention in Karnataka. Admittedly these
require planners to take a long range view. Prevention efforts in the workplace, life skills training to children
and adolescents, building up grassroot initiatives against alcohol misuse have ocurred sporadically and
never as a part of a larger, well planned initiative.
Also treatment and prevention efforts in the state have targeted the urban sector and largely ignored the
large rural sector.
I
5. Some strategies towards effective action
The Deaddiction Centre, National Institute of Mental Health and Neurosciences, Bangalore in collaboration
with the World Health Organisation, is involved in developing a model programme for delivery of services for
prevention of Drug and Alcohol Problems in the community. Mandya district has been identified for the
development of the project. The project is for two years (1999-2001).
The project involves:
A] Sensitization and training of medical officers in employment with the State Government [Sub - PHC’s,
Public health centres, District Hospital] and local medical practitioners [with assistance from the local Indian
Medical Association] in concepts of substance abuse and its management through brief workshop
interactions, in order to enable them to carry out early detection and brief interventions, offer detoxification
where necessary and refer to secondary and tertiary centers if required. [These training sessions are brief,
lasting for 1-2 hours and usually one session is enough, with provisions of booster sessions after a year or
more].
An early result of this activity is that after one month of the training session for the medical officers at
Mandya General Hospital, monitoring revealed that the recognition rate of patients with alcohol related
problems had risen to 67%. Also all the patients thus identified had been offered brief interventions.
B] Training of peer educators through workshop interactions in order to equip them to run self help groups,
acquire techniques of motivation enhancement and imparting relapse prevention and life skills training C]
Sensitization of local community and community leaders to promote a primary prevention initiative.
C] Involvement of NGO’s involved locally in development projects and local, industry to incorporate the
model of early detection and brief intervention as well as in disseminating the public health aspects of
harmful alcohol use.
6. Summary Recommendations for an Action Plan
Demand Side measures
a) Sensitization and training of medical officers in employment with the State Government [Sub PHC’s, Public health centres, District Hospital] and local medical practitioners [with assistance from
the local Indian Medical Association] in concepts of substance abuse and its management through
brief workshop interactions, in order to enable them to carry out early detection and brief
interventions, offer detoxification where necessary and refer to secondary and tertiary centers if
required. This can be done through brief Continuing Medical Education Programmes.
29^
10
3.
Budgetary provisions should be made to fund long term interventions for drug and alcohol misuse.
4.
Non governmental organizations similarly working in divergent areas of human development need to be
encouraged to network among themselves and with governmental and non governmental aaencies
working with drug abuse, since this is a shared concern with broad ramifications and long term
consequences.
y
5.
The Government needs to work towards a rational Alcohol Policy governing Sales Production
Taxation, Regulations governing retail. Penalties covering harmful Use, Advertising,' etc. In this
regard certain draft documents and discussions regarding an International Alcohol Policy which
have also been debated amongst stakeholders in India may be a helpful guide. Disincentives to the
use of spirits (as opposed to beers and wines) should be actively considered.
6.
'n Dhe area of Alcoho1 and Drug Misuse is a rapidly progressing area though sadly neglected
i “is"be “ln 10 pursui"9 such “eB,ch,”s p°",n,ia'fcr
Programmes
1.
pr°9,rta7lrre for Ear|y Detection and Early Intervention of Alcohol and Drug related problems
~
2.
A similar sensitization programme can also be easily imparted to educational workers and help
Providers (teachers, anganwadi workers, field level staff of N.G.O's running developmental programmes
) so that a prevention message can be built into their programmes and so that they can also act as early
ueieciion agents.
3.
Workplace prevention programmes for alcohol and drug misuse can be promoted after dialogue with
industry as early evidence has shown it to be especially effective and financially viable.
9
4.
Tde government especially the Excise Department and concerned N.G.O’s need to work with the
xvs prap°“a p>5.
The Temperance Board which has funds earmarked for the purpose may be urged to oroduce
educational and publicity material for use in primary prevention, in collaboration with agencies9having
experience in such communication. In this regard, it is now universally accepted that “scare tactics" and
solitary attempts at raising drug awareness are ineffective and often dangerously counter-active.
6.
Following from the above, there is a crying need to include “Alternatives and Life Skills Education” in the
schoo curricula in association with some awareness programmes addressing alcohol and drug use
sexuality and high risk behaviours. All such educational inputs needs to emphasize healthy alternatives
and teach children strategies to cope with negative moods, adversity and day to day problems
12
THE SOCIAL COST OF ALCOHOLISM (KARNATAKA)
Vivek Senegal1 , Ajay Velayudhan 2 and Sanjeev Jain 3
1. Assistant Professor of Psychiatry, Deaddiction Centre, National Institute of Mental Health and
Neuro Sciences, Bangalore, 560 029 India [vbenegal@nimhans.kar.nic.in]
2. Consultant Psychiatrist, Moulana Hospital, Perintalmanna , 679 322 Kerala, India
3. Additional Professor, Department of Psychiatry, National Institute of Mental Health and Neuro
Sciences, Bangalore, 560 029 India [sjain@nimhans.kar.nic.in]
i
I
Running Title: Social Cost of Alcoholism
I
39 G
INTRODUCTION
India is traditionally perceived to be a 'dry' culture, but alcohol use in some form has always existed in
the country.The view of
alcohol as impure and polluting, that many middle class Indians have, was
predominantly influenced by Western temperance campaigners in the 19th century. A view which acquired
greater popularity during the Nationalist movement - and was shaped into a generally held belief that drinking
alcohol was alien to Indian culture.
This influenced the founding fathers of the new Indian Republic into declaring Prohibition as one of the
Directive principles of the constitution. From the early 1950's the Government of India has periodically sought
to persuade the State Governments to adopt a uniform prohibition policy. Attempts to impose prohibition in
various states have periodically been made and predictably lifted as the budgetary deficit and the extra cost of
enforcing prohibition made the effort financially non-viable. Consequently, the economic aspect of beverage
alcohol as a major source of indirect tax revenue has always been the centre-point of the policy makers'
thinking. Little thought has gone into examining the economic consequences of alcohol use and the costs
borne by society as a result of it.
Alcohol policies especially those relating to production, consumption and taxation have varied widely
across the states. However there has been no systematic recording of data pertaining to alcohol use and
research in various aspects of alcoholism, particularly in the perspective of public health, has been minimal. It
is not possible at the outset therefore to arrive at a reliable composite estimate of the costs due to alcoholism in
the entire country. It would be prudent to gather data from individual states and cumulatively build up country
wide statistics.
Despite the gaps in epidemiologic data, a beginning has to be made in auditing the costs due to
alcohol misuse in India, based on two major compulsions :
1) The epidemiologic data, albeit crude and incomplete, shows evidence of a rapid and significant rise in
alcohol production, consumption and related morbidity, which is only likely to increase further in the light of the
drastic social and economic changes taking place in the country
2) Alcohol policy and legislation in India is based on political compulsions rather than the interests of public
health. Part of the reason is that there has been little attempt to examine the‘economic and social burden
generated by alcohol misuse to provide a sound guide for policy makers.
REVIEW OF LITERATURE
Epidemiologic Data
During the past twenty five years several field surveys of general psychiatric morbidity as well as
alcohol use have been carried out in different parts of the country. It is difficult to generalize the figures
derived from them, at a national level because of various methodologcal problems (Mohan & Sharma
I
j
I
I
1985).
Estimating prevalence of alcohol use in the general population, some of the recent studies
16
absolute alcohol peruser per year in 1990-91 to 2.15 litres of absolute alcohol per user per year in 199697 (if alcohol consumption is restricted to alcohol using males in the age group of 15 - 65 years).
Excise tax on alcoholic beverage production and sales forms the second highest source of
government revenue (greater than 20%) . In 1985, Karnataka state earned about Rs 50 crores from
excise on liquor. This rose to Rs. 846.67 crores in 1996-97 and is estimated to net Rs. 946 crores in
1997-98.
Social Costs
The term 'social' costs has been defined as the sum of private and external costs.Costs falling on
third parties are termed 'external' costs (Wagstaff, 1987).
Private costs
Private costs comprise the direct costs borne by the individual consuming the hazardous
substance.These include the costs related to loss in income due to absenteeism, reduced efficiency
unemployment and the amount spent on buying alcohol. Personal loans incurred are also added to this
figure.
External costs
Health costs:
Treatment facilities for substance abuse are organised under the governmental, private and
voluntary (non governmental organisation) sectors. The health ministry of the government of India has set
up a series of "drug management centres" mainly attached to psychiatric hospitals or general hospital
psychiatry units. The ministry of welfare has provided financial support to set up detoxification centres
with short-term inpatient facilities for 15 to 60 persons, counselling centres, and after care homes for
longer term care and rehabilitation. Most of these provide care for those with predominant alcohol
problems (Isaac 1992).
i
AIMS
r
Estimation of the cost of alcohol dependence to the individual patient and the cost borne by the
state in treating a patient with alcohol dependence syndrome.
METHODOLOGY
I
I
I
Data regarding production, sales, consumption and taxation of alcoholic beverages in the state
was collected from the available records of the state excise department.
It
Only 6.3% of the patients were admitted for the first time. It was the second admission for 57.3%
patients and 37.4% had three or more admissions. The mean number of admissions was 2.06 (1.71) over
the last two years, the mean stay in hospital being 38.42 (21.83) days (Table 4).
Only 25%
of the
subjects paid for their treatment, the rest received treatment free of cost. The mean hospital bill was Rs
520.72 (1681.33)
Consequently the responsibility for financial support of the family had been taken over by the
spouse or other relatives in 88.6 percent. In 24 % of the sample the responsibility for family support had
been taken up by non-traditional sources of support e.g. widowed mother, wife's biological family,
married sisters and friends 9.7 percent of the families had to send one or more children below the age of
15 years to work to supplement the family finances (Table 5).
7.3% percent of marriages had broken down. 15 percent of all the alcoholics had lost a job within
the last year or had been forced to take up lower paying jobs.
Table 6 describes the social cost of alcoholism at the individual level. Private costs amount to Rs.
11086.88. External costs amount to Rs. 18,798.82. The social cost of alcohol dependence is thus Rs.
29,885.80 per patient per month .
DISCUSSION
The primary finding of this study is that the monthly expenditure on alcohol of patients with alcohol
dependence is more than their monthly earnings. Their monthly earnings are likely to be reduced because
of absenteeism, sickness and unemployment. As they tend to spend more than what they earn, they are
more likely to incur loans.
The economic burden of having an individual with alcohol dependence alters the structure and
functioning of the family thereby forcing persons to take up responsibilities inappropriate to their roles eg.,
young children, widowed mother, sister's husband etc. This in turn sets up a chain of longer term loss to
society, for example, when children lose out on education and subsequent social upliftment, not to speak
of the direct consequences of failure and frustration in such a role change.
Projecting the data obtained at the micro level, we have estimated the social cost of alcoholism in
1
the state of Karnataka given that there are 5 lakh alcohol dependent individuals as deduced from the
3.79% prevalence of alcohol dependence syndrome in the state . External costs include health
care
provided by the health care system of the state for detoxification and counselling. The cost per person per
day in NIMHANS has been calculated at Rs. 600( including etablishment costs, salaries and consumables)
by the NIMHANS administration. With a mean of 38.42 days per admission and a mean of 2.06
admissions over 2 years, the cost of health care in a year assuming all alcohol dependent individuals in
the state undergo at least one admission in a year is Rs. 1129.39 crores (this figure has been adjusted
-
for those who pay for their own treatment). Costs of alcohol related medical and surgical problems (data is
5_9
21
political, of the liquor traders. In many places they from cartels and syndicates to monopolise the trade in
specific geographic areas. It is widely believed that liquor traders have close links with major political
parties and are able to infulence the liquor policies of the government.
Side by side, following liberalization of the Indian economy, transnational corporations are
currently trying to create markets for their beverages in India, using aggressive worldwide marketing
strategies. As experience in other developing economies has shown:
1. The diffusion of European style commercial alcoholic drinks adds to and modifies older patterns of
drnking, more than it substitutes, thus tending to increase total consumption and drinking situations.
2.
While considerable short term economic benefits accrue from the growth of alcoholic beverage
industries, in forms of profit, employment and taxes; at the same time, however, there is a gradual rise of
long-term social and economic costs as a result of alcohol consumption.
3. Attempts by the government to restrict the transnational companies by licensing, joint ventures, sales
of technology and similar means are usually ineffectual as these means are shown to be as effective for
the corporations as outright legal ownership in exercising influeance. (McBride and Mosher, 1985).
With the evidence at hand, and the current social political and economic situation in India, it is not
difficult to extrapolate to a situation, where the prevalence of alcohol use will rise to resemble that of 'wet'
cultures. This in turn will lead to a sharp increase in alcohol related morbidity and the costs accruing from
them. In order to promote rationalizing of health care as opposed to rationing it, informed health planning
is necessary.
Much more research is needed on the public health aspects of alcohol for confidence to be placed
on cost estimates emerging from the available information. Cost calculation should not be based merely
concentrating on a minority of alcohol misusers, with severe enough problems to have come to the
attention of health professionals. Moderate drinkers may contribute significantly to the overall social cost
in the community. Our figures are extremely crude and conservative and must be interpreted cautiously.
The epidemiological evidence on which these costs are based require to be improved. Nevertheless
even those conservative estimates suggest that alcohol related problems to the society are of great
magnitude. The costs are heavy and place a severe burden on the society's scarce resources, more so in
the context of a developing economy.
§oO
TABLE 1: SOCIO DEMOGRAPHIC PROFILE OF THE SUBJECTS
Mean Age In Years
i
Occupation
38.43 (8.26)
Percentage
White Collar
12.3
Blue Collar
32.7
Manual Labourers
46.9
Unemployed
18.1
T
Marital Status
Married
84.4
Unmarried
8.3
Separated/Divorced
7.3
I
TABLE 2: PATTERNS OF CONSUMPTION
Duration Of Dependence In Years
7.71 (6.71)
Daily Consumption Of Absolute Alcohol In Ml.
Type Of Beverage
223.74 (111.57)
Percentage
Spirits
69
i
Arrack
27.4
Locally Brewed
2.7
Beer
0.9
t1
3ol
4
TABLE 5: SUPPORT SYSTEMS — FINANCIAL
NATURAL
PERCENTAGE
SPOUSE/CHILD
20.8
PARENTS
12.5
SIBLINGS
10.4
OTHERS
10.4
NONE
46.6
1
UNNATURAL
NIL
6.2
WIDOWED MOTHER
3.1
MARRIED SISTER
6.3
WIFE’S FAMILY
9.4
FRIENDS
5.2
NONE
69.8
CHILDREN < 15 YEARS, EARNING
9.7
i
3o9-
TABLE 7: SOCIAL COSTS OF ALCOHOLISM (PROJECTED TO THE POTENTIAL 5 LAKH
ALCOHOLICS IN THE STATE )
Income
Rs. Crores
Health care provided by state for
Excise revenue from
- alcoholics
581.5
- alcohol users
264.5
Total excise revenue
1147.48
alcoholics
846.00
Alcohol related medical/surgical
problems
Direct payments for
health services
Rs. Crores
Expenditure
(incomplete)
0.15
18.09
Forgone production/ loss of
864.09
productivity due to sickness,
absenteeism,
unemployment
Deficit requiring to
Distress to family and friends
be filled up from
Social costs of material damage &
general
974.72
taxation pool
691.18
na
criminal activities
na
Costs of reducing external costs
na
1838.81
1838.81
i
Integration of EAP's in Health Service Delivery
Karnataka
CONCEPTUAL FRAME WORK (2)
* Objectives ?
Focus ?
Regions ?
p-1
I—.
L
I
Processes
or
programmes
Complementarity,
Supplementarity,
Overlap,
Duplication
Ownership /
Leadership
L
I
«»•
Budgets
Partnerships /
Linkages
Evaluating /
Monitoring
ri
n
n
VII
Integration of EAP's in Health Service Delivery
Karnataka
CONCEPTUAL FRAMEWORK (3)
(
Add
Quantity
Add Value
(Improve /
Diversity)
Add Quality
!_________
J
b Innovations
- ve
Distort
-T’
Relationship
to Existing
Health Care
System
■ ve
Undermine
*
System
Development
■ ve
Confuse or
complicate^
Integration of EAP’s in Health Service Delivery
Karnataka
CONCEPTUAL FRAMEWORK (4)
Whose
Agenda ?
-•y irijr
Who Drives?
a) State need
b) Funding partners
c) External Consultants
Sustainabili
a) System
b) Financial
I
Some
Issues
for Integration
Duplication
a) HMIS
b) IEC
c) Training / CME
Financial Issues
a) Budgets
b) Financial System
r Accountabili
a) Corruption
I
b) Political
Interference
!
I
(
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