Health Sector Reforms in Karnataka State

1. Health Sector Reforms inKarnataka State By Dr. H.Sudarshan Karuna Trust

2. Public Private Partnership Partnership with Voluntary Organizations: • Entrusting Management of PHCs to Vos and Private Medical Colleges • Karuna Trust is managing 15 PHCs • Goal is to manage one “Good Practicing PHC” in all the 27 Districts • Tele Medicine project – Asia Heart Foundation and Karuna trust • Tribal ANMs Project • Innovations: VHCs, Rehabilitative Services

3. Public Private PartnershipTask Force on Health and Family Welfare • The Task Force constituted by the Chief Minister GO No HFW 545 CGM 99, Bangalore dt.14-12-1999 • The terms of reference were to make recommendations for: • Improvement of Public Health; • Stabilization of the population; • Improve management and administration of the Department; • Changes in the education system covering both Clinical and Public Health. And to monitor the implementation of the recommendations.

4. Task Force on Health and Family WelfareFinal Report 12 Major Issues of Concern • Corruption • Neglect of Public • Distortions in Primary Health Care • Lack of Focus on Equity • Implementation Gap • Ethical Imperative

5. Task Force on Health and Family WelfareFinal Report 12 Major Issues of Concern • Human Resource Development • Cultural Gap and Medical Pluralism • From Exclusivism to Partnership • Ignoring the Political Economy of Health • Research • Growing Apathy in the System

6. Task Force on Health and Family WelfareFinal Report Contents • Equity in Health Care • Quality of Health Care • Primary Health Care • Secondary and Tertiary Health Care • Public Health • Mental Health and Neurosciences • Nutrition • Women and Child Health

7. Task Force on Health and Family WelfareFinal Report Contents • Population Stabilisation • Focus on Special groups • Health Promotion and Advocacy for Health • Human Resources Development for Health • Research in Health • Health Systems Management • Health Financing • Rational Drug Management

8. Task Force on Health and Family WelfareFinal Report Contents • Law and Ethics • Indian Systems of Medicine and Homoeopathy • Panchayat Raj and Empowerment of People • Strengthening of Partnership • Multisectorality and Intersectoral Co-ordination • The Karnataka State Integrated Health Policy 2001 • Vision 2020 • Implementation of the Report • Major Recommendations and Expected Outcome

9. Task Force on Health and Family WelfareFinal Report Karnataka State Integrated Health Policy 2001 • 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) • ISM&H Policy (draft) • Pharmaceutical Policy

10. Public Private Partnership For Profit – Private Sector • Out sourcing of Cleaning, Security and maintenance Services • Contracting Private Doctor and Specialists • Contracting One Super Specialty Hospital – OPEC Hospital, Raichur.

11. Decentralization • Karnataka has Decentralized Democratic System – Panchayat Raj Institutions • Involvement of ZP and Taluka Panchayats in Health • Decentralization of Administrative and Financial Powers • VHCs – IPP9 project

12. Reforms related to Human Resources • Appointment of Staff on Contractual basis • Multi-skilling of Health Personnel : CRS course • Mandatory Pre-PG rural service • Formation of District Cadres • Creation of Taluka Health Officers • Recruitment and Transfer Policy – transfers by counselling

13. Reforms in Health Financing • User Fee Vs Token Fee • Establishment of Hospital Committees • Granting Autonomy to Hospitals & Health Institutions • Health Insurance: • KT– UNDP Community Health Insurance • Yashaswini Scheme • Arogya Raksha Project

14. Health Systems Management Financial management • Optimum utilisation of allocations • 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 assets • Community Insurance for health • Liability Insurance for doctors • Test Audit

15. Re-organization & Re-structuring of Karnataka Health & Family Welfare Department

16. 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

17. 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 DMO (DS) PG in Clinical + Hos Adm DHO PG in Public Health State cadre (KHS) PG qual. compulsory Merit cum seniority District Cadre (ZP Cadre) Deputy DMO/RMO Programme Officer AMO Taluka Hospital Taluk Health Officer (THO) Taluk Community Health Centre MBBS min.qualification PGs can also enter Medical Officer PHC

18. Lady Medical Officer Lady Medical Officer Medical Officer Medical Officer Lady Medical Officer Medical Officer Staff Nurse Staff Nurse Pharmacist Pharmacist Lab Tech Lab Tech Sr. HA (Female) Sr. HA (Female) Sr. HA (Male) Sr. HA (Male) SDC SDC Driver* Driver* Aya 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

19. 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

20. CHART NO. 7 DEPARTMENT OF HEALTH & FAMILY WELFARE – ORGANISATIONAL STRUCTURE: PROPOSED STRUCTURE AT DISTRICT HEALTH OFFICES – DHO & DMO DHO DMO District Hospital District Laboratory Microbiologist 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 LEP+STD/HIV AMOs Dt. HMIS Unit Blindness PO Nutri HP- PO IEC

21. 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

22. 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)

23. 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

24. CHART NO. 12 DEPARTMENT OF HEALTH & FAMILY WELFARE – ORGANISATIONAL STRUCTURE : PROPOSED DIRECTORATE OF ISM&H DIRECTOR ISM&H Directorate level JD Med Edu JD ISM&H Admin Officer Accounts Officer Ast Drug Controll 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. ISM&H Officer Phy Gr II Hosp & Disp

25. 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

26. 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

27. 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)

28. 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. ISM&H 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

29. Task Force on Health and Family WelfareFinal Report 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.

30. Good Governance Karnataka Health Department by Dr.H. Sudarshan Vigilance Director (Health,Education & Social Welfare)

31. The Epidemic of Corruption in Health Services Corruption in Hospitals • Corruption in service delivery by the following:

32. The Epidemic of Corruption in Health Services Corruption in Hospitals • Various forms of Corruption by Doctors and Para Medical Staff: • Private practice • Nursing Homes (owned by spouses, relatives & business partners) • Referrals to Private Hospitals • Owning Pharmacies • Blood Banks • Excess of assets over income

33. The Epidemic of Corruption in Health Services Corruption in Hospitals • For the following Services

34. Epidemic of Corruption in Health ServicesDrugs Control Department • Lokayukta ride on Drugs control Department – wide spread corruption - mamools • Manufacturing License: Inspection of units for fresh & renewal - less than 20% • Drugs collected during inspections – Low • 2268 samples declared “Not of standard Quality” including 126 spurious drugs – very few prosecutions • No action initiated on those who supplied spurious drugs to Health department

35. Epidemic of Corruption in Drugs Control Department • Indiscriminate issue of Loan licenses & product permissions to Loan Licensee • 50% of the Medical shops do not have qualified pharmacists – hardly 14 prosecutions • Violation of DPCO – people of Karnataka have paid nearly 100 crores in excess • Complaints given by public & institutions were not attended. • Trading of blood by Unlicensed Blood Banks & chemists, HIV infected blood sold

36. Corruption in Procurement of Drugs • Purchase of Non Essential Drugs – Nemisulide Tabs 18% of budget • IV fluids scam – Bypassing HAL and buying from PDPL • Decentralized Corruption in Procurement of drugs by Zilla Panchayaths – buying spurious and substandard drugs from unlicensed manufacturers – excess price.

37. The Epidemic of Corruption in Health Services Corruption in Civil Works: Construction of PHCs, CHCs, Taluka & District Hospitals and Repairs. Corruption in Administration:at offices of District Health, Directorate & Secretariat for the following • Recruitment & Postings, • Transfers & Promotions • Sanctioning Leave, Medical reimbursement • Monitoring Private Practice & Absenteeism • Suspension and Reinstating

38. The Epidemic of Corruption in Health Services Corruption in Medical Education • Sanctioning New Colleges - Medical, Nursing & ISM&H • Increasing seats of Nursing Colleges • Admissions • Examination: bribes for examiners-Undergraduate & PGs • Recruitment of Teaching Staff • Registration in KMC.

39. Reforms for Good Governance in Health • Proactive Lokayukta • Consumer Forum • Transparency Act • Right to Information Bill • Training in Health & Hospital management • Leadership training • HMIS & e-Governance • Hospital & Health Committees

40. THANK YOU