Seminar on the 11th Five Year Plan of Karnataka: Perspectives Issues in health care in Karnataka and recommendations

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Seminar on the 11th Five Year Plan of Karnataka
PerspectivesIssues in health care in Karnataka
and recommendations

• Dr. H.Sudarshan
• Karuna Trust
• www.karunatrust.org
• ktrust_at_vsnl.net

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STRENGTHS AND ACHIEVEMENTS

• Among the key States in India, Karnataka
• is above the national average (HDI rank 7).
• has a wide network of Health Care Institutions
• Strong political will and concern for health
• has committed and dedicated officials and
  bureaucrats increasing openness and receptive
  bureaucrats and technocrats.
• has several health professional educational
  institutions and Rajiv Gandhi University of
  Health Sciences
• has eradicated of smallpox, plague in humans, and
  recently guineaworm infestation.
• has made substantial progress in the control of
  Vaccine Preventable Diseases (Polio, Diphtheria,
  Whooping cough, Tetanus, Measles)

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STRENGTHS ACHIEVEMENTS

• Externally Aided Projects - infrastructure made
  available efficient and effective work culture.
• The Community Mental Health initiative in Bellary
  
• Partnership with Voluntary Organisations
• Making available anti-tubercular drugs
• Bringing out Human Development Report (HDR)
• Growing sensitivity to Health care needs and
  addressing the formidable challenges of Equity in
  Health and Development.

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Health Status of Karnataka
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Progress

• Increased Life expectancy at birth from 26 years
  in 1947 to 66.3 years for women and 65.1 for men
  in 1997
• Institutional deliveries have improved to 66.9
  from 38.4 in 1992-93 (NFHS)
• Decline in crude birth rage from 41.6 to
  22.7/1000 population from 1961 to 1997
• Control to a considerable extent of Vaccine
  Preventable Diseases such as polio, diphtheria,
  whooping cough, tetanus and to a smaller extent
  measles.

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Progress

• Improved infrastructure at secondary care and
  tertiary care through external aid
• Improved coverage of community mental health
  services through the District Mental Health
  Program
• Partnership with Non-profit voluntary
  oganizations in primary health care and district
  level
• Karnataka State Integrated Health Policy document

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Inequity

1. Monitor inequities in health based on social,
   economic and health care services, disaggregated
   with respect to age, gender, socio economic
   status, geographical regions and others.
2. The Health System must improve availability and
   access to quality health care (particularly
   primary health care and public health) in the
   underserved talukas / districts and for the poor
   and vulnerable population.
3. In the large and undivided districts like
   Gulbarga and Belgaum the districts should be
   divided into two and a post of Additional DHO /
   DMO should be created with Additional team of
   Programme Officers. An Additional Director should
   be made responsible for the Northern Districts.

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IDENTIFICATION OF REGIONAL BACKWARDNESS BASED ON
THE AGGREGATE DEVELOPMENT INDEX
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Quality of Health Services

• Effective implementation of the Health
  Establishment Bill for ensuring proper standards
  in the private health care system. Have minimum
  acceptable standards worked out by independent
  committees for health care institutions at
  different levels and locations and for public
  health measures.
• The Joint Directors, Medical and Public Health,
  will be designated as the persons in charge of
  Quality Assurance. The Administrative Medical
  Officer in charge of each hospital will be
  responsible for ensuring quality of care in each
  institution.
• The professional bodies may be encouraged to have
  accreditation of their member institutions. The
  Indian Medical Association, Karnataka State
  Branch may take the initiative.

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Primary Health Care

• Prompt filling up of vacancies essential staff
  to stay in headquarters
• Construction and renovation of PHC Quarters in a
  definite time frame
• Lady Medical Officers/ Staff Nurse/
  Nurse-obstetrician and Nurse-Practitioner
• Male Health Workers choices
• Speedy transport for emergencies and mobility for
  staff

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Primary Health Care

• Fully functional laboratories
• Village Health Committees and PHC Committees
• Round the clock Services
• Functional Referral System
• Re-organisation / restructuring of SCs, PHUs
  PHCs

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Urban Primary Health Care

• Have Urban Primary Health Centres, one for 50,000
  population in cities and towns, converting the
  existing resources such as health centers, urban
  family welfare centers and maternity homes.
  While these Urban Primary Health Centres will be
  the responsibility of the local body (Corporation
  or Municipality), technical guidance will be
  provided by the Directorate of Health and Family
  Welfare Services.

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Secondary and Tertiary Care

• Mismatch of specialists, technicians and
  equipment.
• Administrative Medical Officer to be trained in
  Hospital Administration
• Social Workers and Dharmashalas
• Equipment Maintenance - reduction in down time
• Bio safety
• Develop Emergency Medicine Trauma Care Centres
  good communication system, ambulance services
  with trained paramedics.

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Secondary and Tertiary Care

• Integrate District Hospital Lab and District
  Public Health Lab
• Standardisation and quality systems of labs,
  Imaging and other diagnostic services
• One Standardised Blood Bank per district
• Increase voluntary and related blood donation and
  rational use of blood.

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Public Health

• Nutrition - children, adolescents, women
• Water availability, purification, standards,
  testing
• Sanitation
• Waste management general waste, hazardous
  waste, biomedical waste
• Collection, segregation at source, disposal
• Pollution control Air, water and soil

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Public Health

• Communicable Diseases
• Vector borne disease control by vector control
  bioenvironmental, Chemical only when essential
  (Malaria, JE, Filaria, Dengue, KFD)
• Disease Surveillance District Surveillance Units
• KFD Prevention, ELISA Testing adequate
  vaccines
• TB early case detection, complete treatment,
  close monitoring. DTOs
• Vaccine Preventable Diseases complete coverage
  with cold chain Hepatitis B, vaccine production
  in collaboration with Animal Husbandry Dept.
• Food water borne diseases food inspection,
  Rapid Action Force
• HIV/AIDS and STDs Integration with general
  health services, Voluntary Testing in all
  districts, Continuum of care, Preventive Education

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Public Health

• Non Communicable Diseases
• Need for District Disease Control Programs for
  Diabetes cardiovascular diseases Rheumatic
  fever Respiratory diseases Cancer Blindness
  Oral health Mental health Neurological
  disorders
• Tobacco control
• Alcohol and health
• Disaster management health aspects
• Accidents head injuries helmets
• Occupational health

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Women and Child Health

• Womens health
• Gender issues access to care, privacy, gender
  segregated data.
• Empowerment of women for health
• Violence female foeticide, infanticide,
  domestic violence, sexual abuse
• Child
  Health
• Additional birth attendant
• Indira Gandhi Institute - apex body
• Diarrhoea Oral Rehydration Therapy, Acute
  Respiratory Infections
• Health education, services for adolescents

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Women and Child Health

• Reproductive and Child Health Programme
• CNA approach
• Quality of FRUs, Emergency Obstetric Care
• ASHA Dai training and dai kits
• Population Stabilisation
• Unmet needs to be met
• Quality of services, regular follow up, choice of
  contraceptives, safe contraceptives
• Raising age at marriage, registration of
  marriages
• Spacing
• Adolescent life skill education
• Committee on social development and population
  issues

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Focus on Special Groups

• Persons with disability
• Prevention, early detection, medical treatment
  and rehabilitation , CBR approach
• Coordination with associated departments and
  agencies
• Tribal People
• Survey of health status
• Tribal ANMs, flexible norms
• Traditional healing systems
• Elderly persons
• Policy for the elderly
• Geriatric care facilities
• Health insurance and pensions

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Human Resource Development for Health

• Moratorium on new Medical, ISMH, Nursing,
  Dental, Pharmacy and Physiotherapy colleges
• Repairs to colleges, hospitals and hostels.
• Fill up Vacancies in teaching hospitals.
• Medical colleges to take up 3 PHCs for training
  and providing health services.
• Corruption in examination
• Teacher training, Performance Appraisal
• Non-teaching staff of Medical College Hospitals
  to be under the control of Dept. of Medical
  Education

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Human Resource Development for Health

• Training
• State Institute of Health Family Welfare - as
  an institute of excellence.
• Regional, District ANM training centres under
  SIHFW
• Research in Health
• Establish Research Board
• Centre for Population and Health Research -
  Upgradation

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Rational Drug Management

• Optimization of Drug procurement
  quantification, procedures
• Establishment of Standard Treatment Guidelines,
  Essential Drug List and State Formulary.
• Govt. Medical Stores/District Stores
  reorganisation
• Drugs Control Department Strengthening for
  effective supervision.

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Law and Ethics

• Effective implementation of Human Organ
  Transplant Act, 1994 and Prenatal Diagnostic
  Techniques Act, 1994
• Renew Registration of health professionals every
  5 years
• Enact comprehensive law for Private Health
  Institutions Promote accreditation.
• Enact comprehensive Public Health Act.
• Take effective steps to stop quackery.

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Indian Systems of Medicine and Homoeopathy

• ISMH hospitals to be renovated, upgraded and
  relocated at CHC, Taluka and District Hospitals
  of Modern System
• Appoint District Level ISMH Officers.
• The issue of disparity in stipend/ salary between
  doctors/ internees of ISMH and modern medicine
  should be examined on a priority basis.
• Upgradation of the Government ISMH Pharmacy.

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Panchayat Raj and Empowerment of People

• Enhance the role of PRI in health management.
• Formulation of Health component of the District
  Development Plan.
• Monitoring of Health activities of ZPs by
  Commissioner.
• System to ensure better involvement and
  co-ordination between health officials and PRI.

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Strengthening Public Private Partnership

• Oversight Role of Health Department
• GIS Mapping of all the Public Private
  Providers.
• Involving Private General Practitioners in PHC
• Association of Voluntary organisations in
  formulation, implementation and monitoring of
  health programmes.
• Involve VOs in managing PHCs, District Health
  Management State Resource Center
• Simplification of grant-in-aid rules /
  procedures.
• Creation of a NGO cell under the Commissioner to
  promote partnership between the public, private
  and voluntary organisations.

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Multi Sectorality Intersectoral Co-ordination

• Establishment of mechanisms for intersectoral
  co-ordination at all levels.
• Set up a High Power Committee with Chief
  Secretary as Chairman for intersectoral
  co-ordination.

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Health Systems Management

• Division on the basis of functional
  responsibilities
• Public Health
• Medical (Curative)
• District Cadres
• Constitution of Karnataka Health Services (KHS)
• Reformulation of
• Cadre/Recruitment/Structures/Rules

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Health Systems Management

• Enhancement of internal system for vigilance,
  discipline
• Manpower management Appraisal system, Transfer
  Policy, filling of key vacancies
• Private Practice - Two choices
• Delegation of powers
• Externally Aided Projects
• HMIS - GIS
• Planning and Monitoring
• Commission on Health

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CHART NO. 1 DEPARTMENT OF HEALTH FAMILY WELFARE
ORGANISATIONAL STRUCTURE PROPOSED DISTRICT
LEVEL
Clinical Stream
Public Health Stream
ObG Paed Gen Surg
Fam Phy
Need based temporary contract appointments
AMO
GDMO
THO
Need based temporary contract appointments
Taluk
Need based on numbers
Inservice PG
Inservice PG
Public Health
Medical (clinical)
MBBS PG
PHC (MO)
MO (PHC)
MBBS
MBBS
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CHART NO. 2 DEPARTMENT OF HEALTH FAMILY WELFARE
ORGANISATIONAL STRUCTURE PROPOSED DISTRICT
LEVEL
Public Health
Medical
Dist. Med Store Dist. Maint Unit Dist.
Laboratory Dist. HMIS Unit
State cadre (KHS) PG qual. compulsory Merit cum
seniority
DHO PG in Public Health
DMO (DS) PG in Clinical Hos Adm
District Cadre (ZP Cadre)
Deputy DMO/RMO
Programme Officer
Taluk Health Officer (THO)
AMO Taluka Hospital
Taluk
Community Health Centre
MBBS min.qualification PGs can also enter
Medical Officer PHC
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Lady Medical Officer
Medical Officer
Lady Medical Officer
Medical Officer
 
 
Lady Medical Officer
Medical Officer


 
 
 
 
Staff Nurse
Pharmacist
Lab Tech
Sr. HA (Female)
Sr. HA (Male)
SDC
Driver
Aya
Staff Nurse
Pharmacist
Lab Tech
Sr. HA (Female)
Sr. HA (Male)
SDC
Driver
Aya
Staff Nurse
Pharmacist
Lab Tech
Sr. HA (Female)
Sr. HA (Male)
SDC
Driver
Aya
 
 

 
 
 
JHA (F)
JHA (F)
JHA (F)
JHA (F)  
JHA (F)  
JHA (F)  
JHA (F)
JHA (F)
JHA (F)
JHA (F)  
JHA (F)  
JHA (F)  
 
JHA (F)
JHA (F)
JHA (F)
JHA (F)  
JHA (F)  
JHA (F)  
JHA (M)
JHA (M)
JHA(M)
JHA (M)
JHA (M)
JHA(M)
JHA (M)
JHA (M)
JHA(M)
 
 
TBA
TBA
 
TBA
VHW
VHW
VHW
 
 
 
AWW
AWW
AWW
Driver for PHCs which have vehicles
Driver for PHCs which have vehicles
Driver for PHCs which have vehicles
 
 
 
 
 
 
 
 
 
CHART NO. 3 DEPARTMENT OF HEALTH FAMILY WELFARE
ORGANISATIONAL STRUCTURE PROPOSED DISTRICT
LEAVEL, PRIMARY HEALTH CENTRE
 
 
 
 
 
 
Medical Officer
Lady Medical Officer
 
 
Staff Nurse
Pharmacist
Lab Tech
Sr. HA (Female)
Sr. HA (Male)
SDC
Driver
Aya
 
 
 
JHA (F)
JHA (F)
JHA (F)
JHA (F)
JHA (F)
JHA (M)
JHA (M)
JHA (F)
JHA(M)
 
TBA
VHW
 
AWW
Driver for PHCs which have vehicles
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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CHART NO. 4 DEPARTMENT OF HEALTH FAMILY WELFARE
ORGANISATIONAL STRUCTURE PROPOSED DISTRICT
LEVEL TALUK HEALTH OFFICE
Taluk Health Officer DPH Qualification
BHE's (Shift from PHC to Taluk Level)
Refractionists (Shift from PHC to Taluk Level)
ASO (Statistics person must for HMIS)
Senior Health Assistant (Male Female)
FDC
Driver
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CHART NO. 5 DEPARTMENT OF HEALTH FAMILY WELFARE
ORGANISATIONAL STRUCTURE PROPOSED DISTRICT
LEVEL, STRUCTURE AT DISTRICT HEALTH OFFICE
DISTRICT HEALTH OFFICER
Health Officer Corporation/Municip
Entomologist
Urban Primary Health Centres
Programme Co-ordinator
District Surveillance Officer
Statistical Officer
RCH programme officer
Family Welfare Programme Officer
Vector Borne Dis Programme Officer
Tuberculosis programme officer
Lep/HIV/STD programme officer
Blindness-programme officer
Health Promotion programme officer
Dt. Nutrition Officer
IEC (DHEO)
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CHART NO. 6 DEPARTMENT OF HEALTH FAMILY WELFARE
ORGANISATIONAL STRUCTURE PROPOSED STRUCTURE
AT DISTRICT MEDICAL OFFICE
District Medical Officer (DMO)
District Hospital RMO/DS/Superintendent
Ophthalmic Programme Officer (MINTO)
Administration Medical Officers CHC/Taluk Hosp.
Mental Health Programme officer (NIMHANS)
CVS / Diabetes Programme Officer
Oncology Programme Officer (KIDWAI)
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CHART NO. 7 DEPARTMENT OF HEALTH FAMILY WELFARE
ORGANISATIONAL STRUCTURE PROPOSED STRUCTURE
AT DISTRICT HEALTH OFFICES DHO DMO
DHO
DMO
District Hospital District Laboratory Microbiolo
gist Pathologist Biochemist
Prog Co-ordinator
DSO
Mental-PO
RCH-PO
Entm
Statis
CVS-PO
Dt. Maint Unit Civil works Vehicle
maintenance Equipment maint
Vector -PO
Opth-PO
TB - PO
Onco-PO
FW - PO
Dt. Medical Store
LEPSTD/HIV
AMOs
Dt. HMIS Unit
Blindness PO
Nutri
HP- PO
IEC
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CHART NO. 8 DEPARTMENT OF HEALTH FAMILY WELFARE
ORGANISATIONAL STRUCTURE PROPOSED STATE LEVEL
Autonom Hosp.
PRINCIPAL SECRETARY
Commission on Health
Secretary (ME)
Drug Controller
Autonomous Teaching Hospital / Institute
Commissioner / DGHS
Dir. ISMH
SIHFW
Director (ME)
Pop Health Research
Director Procurement / Maintenance
CAO Finance
CVO Vigilance
Director Public Health
Director Medical
Director EAP
NGO Cell
Additional Director Planning
Additional Director N. Karnataka
Joint Director Special Groups
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CHART NO. 9 DEPARTMENT OF HEALTH FAMILY WELFARE
ORGANISATIONAL STRUCTURE PROPOSED STATE LEVEL
DIRECTOR PUBLIC HEALTH
Add. Director AIDS (KSPC)
Add. Director Health Promotion
AD (CMD) State Survey Off
Chief Acc. Officer
Project Director RCH PHC
AD-BMP Urban PHCs
JD AIDS
JD RCH
JD PHC
JD IEC
JD Nut
JD-Vect Borne Dis
JD TB
JD Leprosy
JD Vaccine
JD Lab
DD KFD
DD Dis Surv
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CHART NO. 10 DEPARTMENT OF HEALTH FAMILY
WELFARE ORGANISATIONAL STRUCTURE
PROPOSED STATE LEVEL
DIRECTOR MEDICAL
Addl Director NCD
CAO
Addl Director Medical
JD Medical
JD GMS
JD-Hosp North
JD-Hosp South
JD-Trau-Eme Med
JD Ophthal (MINTO)
JD-CVS Diabet
JD-Dent Health
JD-MH (NIMHANS)
JD-Onco (KIDWAI)
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CHART NO. 11 DEPARTMENT OF HEALTH FAMILY
WELFARE ORGANISATIONAL STRUCTURE
PROPOSED STATE LEVEL
DIRECTOR Ext. Aided Projects
DIRECTOR Procurement Maint
AD (SPC) Planning Monitor
Secretary PWD
Superintendent Eng Civil
Joint Director Procurement
JD-Bio-Medical Equip Maintenance
Joint Director Planning
Joint Director HMIS
DD-Law Ethics (Forensic Medicine)
Civil Engineering. Staff as in KHSDP
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CHART NO. 12 DEPARTMENT OF HEALTH FAMILY
WELFARE ORGANISATIONAL STRUCTURE
PROPOSED DIRECTORATE OF ISMH
DIRECTOR ISMH
Directorate level
JD Med Edu
JD ISMH
Admin Officer
Accounts Officer
Ast Drug Controll
Principals Col Hosp
Aided Col Hos
DD Ayurveda
DD Unani
DD Homoeo
DD Nat Yog
3 Drug-Inspectors
DD Pharmacy
Div DDs ?
Physician Gr I District Hospital Dt. ISMH Officer
Phy Gr II Hosp Disp
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CHART NO. 13 DEPARTMENT OF HEALTH FAMILY
WELFARE ORGANISATIONAL STRUCTURE
PROPOSED STATE INSTITUTE OF HEALTH FAMILY
WELFARE (AUTONOMOUS)
PRINCIPAL SECRETARY
Director Selection Post SIHFW (Autonomous)
Commissioner / DGHS
Governing Board
Directorate
Joint Director Training
Joint Director Research (Social Scientist)
Specialists Communication Health Mgt RCH/NCD
Principals RHFWTC/DTC ANM Training Centres
Deputy Director Course Content
Deputy Director Training
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CHART NO. 14 DEPARTMENT OF HEALTH FAMILY
WELFARE ORGANISATIONAL STRUCTURE DRUG CONTROL
DEPARTMENT
DRUGS CONTROLLER
ADDITIONAL DRUGS CONTROLLER
Drugs Testing Laboratory
Pharmacy Education
Enforcement Division
Head Quarters
Drugs Price Control Cell
Bl bank Intellig
Circle Dt. Off
Superintendent (Admn) -1 Superintendent (Lab)
-1 Other Technical -7 Officers
Junior Chemists -30
Govt. College of Pharmacy
Board of Examining Authority
Principal Chairman - 1 Member Secretary
- 1 Professor
- 6 Asst. Professor -
8 Lectures (Pharmacy Lect) -17 (Non Pharmacy)
- 5
Dy. Drugs Controller - 8 Asst. Drugs
Controller -19 Drugs Inspector -56
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CHART NO. 15 DEPARTMENT OF HEALTH FAMILY
WELFARE ORGANISATIONAL STRUCTURE
PROPOSED DEPARTMENT OF MEDICAL EDUCATION
SECRETARY MEDICAL EDUCATION
Autonomous Teaching Hospitals/Institutions
Director Medical Education
AD Med Edu
DEAN GDC
DEAN BMC
DEAN MMC
Dir RIO
Vice Prl BMC
Vice Prl MMC
Supr Hos 1
Supr Hos 2
Supr Hos 3
Supr Hos 4
Supr Hos 5
Supr Hos 6
Supr Hos 7
JD ME
Vice Prl GDC
PROFESSORS HOD BMC / MMC
ASSOCIATE PROFESSORS ASSISTANT
PROFESSORS LECUTRERS REGISTRARS / TUTORS /
DEMONSTRATORS/ RESIDENTS
Regional Institute Ophthalmology (RIO) could be
made into an Autonomous Institution
DD (ME)
DD (DE)
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Financial Management

• Optimum utilisation of existing allocation
• Increase in Health Budget from 4 to 7
• National Health Accounts and State Health
  Accounts SDP 0.9 to 2 -3
• Delegation of financial powers
• Release of funds - timely issue of sanction
• No budgetary cuts for Health Services
• Adequacy of funds for maintenance of essential
  needs repairs, maintenance and efficient use of
  asset
• Test Audit

49
Health Insurance

• Social Security
• ESI State Central
• Yashaswini Health Insurance
• Community Health Insurance of Karuna Trust
• Universal Health Insurance of GOI
• World Bank Assisted Project - KHSDRP

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Karnataka State Integrated Health Policy

• Vision, Mission Goals
• Comprehensive Health Policy which includes
• Health Policy
• Population policy
• Drug policy
• Nutrition policy
• Education for Health Sciences Policy
• Blood banking policy
• Policy on Control of Nutritional Anaemia
• AIDS Prevention Control Policy (draft)
• ISMH Policy (draft)
• Pharmaceutical Policy

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Vision 2020
Indicators 2001 (Source / Year) 2020
Infant Mortality Rate 58/1000 live births 25/1000 live births
Under 5 Mortality Rate 69/1000 live births 35/1000 live births
Crude Birth Rate 22.3/1000 population 13/1000 population
Crude Death Rate 7.7/1000 population 6.5/1000 population
Maternal Mortality Rate 195/ 1 lakh live births 90/ 1 lakh live births
Life Expectancy at Birth
Male 61.7 years 70.0 years
Female 65.4 years 75.0 years
Total Fertility Rate 2.13 1.6
Percentage of Institutional Deliveries 51.1 75
Percentage of Safe deliveries 59.2 gt95
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VISION 2020
Indicators 2001 2020
Newborns with Low Birth Weight 35 10
Percentage of mothers who received ANC 86.3 100
Percentage of eligible couples protected 59.7 70
Percentage of children fully immunised 60 gt90
Anaemia among children (6-35 months) 70.6 40.0
Nutritional Status of children
Severe under nutrition 6.2 2.0
Moderate under nutrition 45.4 25.0
Mild under nutrition 39.0 43.0
Normal 9.4 30
Sex (Gender) ratio 964F/1000M 975F/1000M
Sex (Gender) ratio, 0-6 years 949/1000M 970F/1000M
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Reforms for Good Governance in Health Services

• Proactive Lokayukta Ombudsman for PRI and
  active Monitoring institutionalize the reforms
• Vigilance cell in Health Department Strengthen
  and Capacity building Expertise
• E-Governance HMIS Program and HRM,
  computerize transfers, recruitment, promotions,
  e-procurement, Web site for transparency and
  accountability
• Integrity Pact black listing and debarring
• Effective Management and Supervision by
  Administrators and senior staff Field visits

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Reforms for Good Governance in Health Services

• Training in Health Hospital Management
  Effective Monitoring of Stay at the HQ, Private
  practice, absenteeism, Decision Making Problem
  solving
• Leadership Training
• Health staff Welfare Salaries, benefits,
  non-monetary incentives, grievance reddressal
  mechanism.
• Hospital Health Committees Citizens Charter,
  Report card system
• Public grievance redressal at various levels

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THANK YOU