Health Sector Reforms in Karnataka State

Health Sector Reforms in

Karnataka State

By

Dr. H.Sudarshan

Karuna Trust

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

• 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.

Public Private PartnershipTask Force on Health and Family

Welfare

12 Major Issues of Concern

1. Corruption

2. Neglect of Public

3. Distortions in Primary Health Care

4. Lack of Focus on Equity

5. Implementation Gap

6. Ethical Imperative

Task Force on Health and Family Welfare

Final Report


Final Report

12 Major Issues of Concern

7. Human Resource Development

8. Cultural Gap and Medical Pluralism

9. From Exclusivism to Partnership

10. Ignoring the Political Economy of Health

11. Research

12. Growing Apathy in the System


Final ReportContents

1. Equity in Health Care

2. Quality of Health Care

3. Primary Health Care

4. Secondary and Tertiary Health Care

5. Public Health

6. Mental Health and Neurosciences

7. Nutrition

8. Women and Child Health



9. Population Stabilisation10. Focus on Special groups11. Health Promotion and Advocacy for Health12. Human Resources Development for Health13. Research in Health14. Health Systems Management 15. Health Financing16. Rational Drug Management



17. Law and Ethics18. Indian Systems of Medicine and Homoeopathy19. Panchayat Raj and Empowerment of People20. Strengthening of Partnership21. Multisectorality and Intersectoral Co-ordination22. The Karnataka State Integrated Health Policy 200123. Vision 202024. Implementation of the Report25. Major Recommendations and Expected Outcome

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

•


Final Report

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.

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

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

Reforms in Health Financing

• User Fee Vs Token Fee• Establishment of Hospital Committees• Granting Autonomy to Hospitals & Health

Institutions• Health Insurance: 1. KT– UNDP Community Health Insurance2. Yashaswini Scheme3. Arogya Raksha Project

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

Health Systems Management

Re-organization & Re-structuring of

Karnataka Health & Family Welfare Department

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

Health Systems Management

State cadre (KHS)PG qual. compulsory Merit cum seniority

Medical Officer PHC

Deputy DMO/RMO

Taluk Health Officer(THO)

AMO Taluka Hospital

DHOPG in Public Health

DMO (DS)PG in Clinical + Hos Adm

Programme Officer

MBBS min.qualificationPGs can also enter

District C

adre (ZP

Cadre)

Taluk

Medical Public Health

Community Health Centre

Dist. Med StoreDist. Maint UnitDist. LaboratoryDist. HMIS Unit

CHART NO. 2

DEPARTMENT OF HEALTH & FAMILY WELFARE –

ORGANISATIONAL STRUCTURE: PROPOSED

DISTRICT LEVEL

Lady Medical Officer Medical Officer

Staff Nurse

Pharmacist Lab Tech Sr. HA (Female)

Sr. HA(Male)

SDC Driver* Aya

JHA(F)

TBA

VHW

AWW

JHA (M) JHA(F)

JHA(F)

JHA (M) JHA(F)

JHA(F)

JHA(M) JHA(F)

* Driver for PHCs which have vehicles

CHART NO. 3



DISTRICT LEAVEL, PRIMARY HEALTH CENTRE

Taluk Health OfficerDPH Qualification

Senior Health Assistant(Male & Female)

BHE's(Shift from PHC to Taluk Level)

Refractionists(Shift from PHC to Taluk Level)

ASO(Statistics person must

for HMIS)

FDC Driver

CHART NO. 4



DISTRICT LEVEL

TALUK HEALTH OFFICE

DHO

Prog Co-ordinator

RCH-PO

Vector -PO

TB - PO

FW - PO

LEP+STD/HIV

Blindness PO

HP- PO

Nutri

IEC

DSO

Entm Statis

District Hospital

District Laboratory

MicrobiologistPathologistBiochemist

Dt. Maint UnitCivil works

Vehicle maintenance

Equipment maint

Dt. Medical Store

Dt. HMIS Unit

DMO

Mental-PO

CVS-PO

Opth-PO

Onco-PO

AMOs

CHART NO. 7



STRUCTURE AT DISTRICT HEALTH OFFICES – DHO & DMO

DIRECTORPUBLIC HEALTH

Add. DirectorAIDS

(KSPC)

Project DirectorRCH & PHC

Add. DirectorHealth Promotion

AD (CMD)State Survey Off

Chief Acc. Officer

AD-BMPUrban PHCs

JDAIDS

JDRCH

JDPHC

JDIEC

JDNut

JD-Vect Borne Dis

JDTB

JDLeprosy

JDVaccine

JDLab

DDKFD

DDDis Surv

CHART NO. 9



STATE LEVEL

DIRECTORMEDICAL

JDMedical

JDGMS

JD-Hosp North

JD-Hosp South

JD-Trau-Eme Med

JDOphthal(MINTO)

JD-CVS & Diabet

JD-Dent Health

JD-MH(NIMHANS)

JD-Onco(KIDWAI)

Addl DirectorMedical

Addl DirectorNCD CAO

CHART NO. 10



STATE LEVEL

DIRECTORExt. Aided Projects

DIRECTORProcurement & Maint

AD (SPC)Planning & Monitor

Joint DirectorPlanning

Joint DirectorHMIS

Joint DirectorProcurement

JD-Bio-Medical Equip Maintenance

Superintendent EngCivil

DD-Law & Ethics(Forensic Medicine)

Civil Engineering. Staff

as in KHSDP

Secretary PWD

CHART NO. 11



STATE LEVEL

DIRECTORISM&H

Directorate level

JDMed Edu

JDISM&H

Admin Officer

AccountsOfficer

Ast DrugControll

PrincipalsCol & Hosp

DDAyurveda

DDUnani

DDHomoeo

DDNat & Yog

3 Drug-Inspectors

Physician Gr IDistrict Hospital

Dt. ISM&H Officer

Phy Gr IIHosp & Disp

DDPharmacy

Div DDs?

Aided Col & Hos

CHART NO. 12


ORGANISATIONAL STRUCTURE : PROPOSED

DIRECTORATE OF ISM&H

PRINCIPAL SECRETARY

Governing BoardDirector

Selection PostSIHFW

(Autonomous)

Commissioner /DGHS

Directorate

Joint DirectorTraining

Joint DirectorResearch

(Social Scientist)

SpecialistsCommunication

Health MgtRCH/NCD

Deputy DirectorCourse Content

Deputy DirectorTraining

Principals RHFWTC/DTCANM Training Centres

CHART NO. 13


ORGANISATIONAL STRUCTURE : PROPOSED

STATE INSTITUTE OF HEALTH & FAMILY WELFARE (AUTONOMOUS)

DRUGS CONTROLLER

ADDITIONAL DRUGS CONTROLLER

Enforcement Division Drugs Testing Laboratory Pharmacy Education

Head Quarters

Drugs Price Control Cell

Bl bank & Intellig

Circle & Dt. Off

Superintendent (Admn) -1Superintendent (Lab) -1Other Technical -7Officers Junior Chemists -30

Govt. College of Pharmacy

Board of Examining Authority

Dy. Drugs Controller - 8Asst. Drugs Controller -19Drugs Inspector -56

Principal & Chairman - 1Member Secretary - 1Professor - 6Asst. Professor - 8Lectures (Pharmacy Lect) -17(Non Pharmacy) - 5

CHART NO. 14

DEPARTMENT OF HEALTH & FAMILY WELFARE – ORGANISATIONAL STRUCTURE

DRUG CONTROL DEPARTMENT

SECRETARYMEDICAL EDUCATION

DirectorMedical Education

Autonomous TeachingHospitals/Institutions

DEANBMC

DEANMMC

ADMed Edu

DEANGDC

*DirRIO

Vice PrlBMC

Vice PrlMMC

SuprHos 1

SuprHos 2

SuprHos 3

SuprHos 4

SuprHos 5

SuprHos 6

SuprHos 7

JDME

Vice PrlGDC

CHART NO. 15



DEPARTMENT OF MEDICAL EDUCATION

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)

Autonom Hosp.

Drug Controller

SIHFW

Pop & Health Research

CAOFinance

CVOVigilance

DirectorPublic Health

DirectorMedical

DirectorEAP

DirectorProcurement / Maintenance

NGO Cell

PRINCIPAL SECRETARY

Commissioner / DGHS

Commission on Health

Dir. ISM&H

Secretary (ME)

Autonomous Teaching Hospital / Institute

Director (ME)

Joint DirectorSpecial Groups

Additional DirectorPlanning

Additional DirectorN. Karnataka

CHART NO. 8



STATE LEVEL

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.


Final Report

Good Governance Karnataka Health Department

byDr.H. Sudarshan

Vigilance Director(Health,Education & Social Welfare)

The Epidemic of Corruption in Health ServicesCorruption in Hospitals

a. Corruption in service delivery by the following:

• Ayaas/ward boys

• Contract workers

• Technicians

•Administrative Staff

• Nurses

• Pharmacist

• Doctors

• Specialists

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

The Epidemic of Corruption in Health Services

Corruption in Hospitals


Corruption in Hospitals

b. For the following Services

• Admission

• Issuing Medical certificates

• Laboratory

• X-ray, Scanning

• Transporting patients

• Referrals

• Medical & Surgical

emergency services

• Elective Surgeries

• Deliveries

• Postmortem

• Blood Transfusion

Epidemic of Corruption in Health Services

Drugs 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

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

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.


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


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.

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

THANK YOU

Health Sector Reforms in Karnataka State

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