Dr. H.Sudarshan Karuna Trust karunatrust ktrust@vsnl

1. 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@vsnl.net

2. 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)

3. 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.

4. Health Status of Karnataka

5. 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.

6. 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

7. Inequity • 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. • 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. • 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.

9. IDENTIFICATION OF REGIONAL BACKWARDNESS BASED ON THE AGGREGATE DEVELOPMENT INDEX

10. 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.

11. 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

12. 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

13. 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.

14. 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.

15. 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.

16. 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

17. 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

18. 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

19. Women and Child Health Women’s 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

20. 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

21. 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

22. Human Resource Development for Health • Moratorium on new Medical, ISM&H, 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

23. Human Resource Development for Health Training • State Institute of Health & Family Welfare - as an institute of excellence. • Regional, District & ANM training centres under SIH&FW Research in Health • Establish – Research Board • Centre for Population and Health Research - Upgradation

24. 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.

25. 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.

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

28. 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.

29. 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.

30. 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.

31. 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

32. 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

33. CHART NO. 1 DEPARTMENT OF HEALTH & FAMILY WELFARE – ORGANISATIONAL STRUCTURE: PROPOSED DISTRICT LEVEL Clinical Stream Public Health Stream Ob&G Paed Gen Surg Fam Phy Need based temporary contract appointments GDMO AMO THO Need based temporary contract appointments Taluk Need based on numbers Inservice PG Inservice PG Public Health Medical (clinical) MO (PHC) PHC (MO) MBBS + PG MBBS MBBS

34. 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

35. 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

36. 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

37. 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)

38. 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)

39. 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

40. 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

41. 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

42. 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)

43. 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

44. 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

45. 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

46. 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

47. 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)

48. 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

50. 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) • ISM&H Policy (draft) • Pharmaceutical Policy