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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

Public Private Partnership Task 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.

Task Force on Health and Family Welfare

Final Report
12 Major Issues of Concern Corruption Neglect of Public Distortions in Primary Health Care Lack of Focus on Equity Implementation Gap Ethical Imperative

1. 2. 3. 4. 5. 6.

10. 11. 12. 8. . 9.Task Force on Health and Family Welfare Final 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 7.

6. 7. 5. 3. 2.Task Force on Health and Family Welfare Final Report Contents 1. 8. 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 . 4.

Task Force on Health and Family Welfare Final Report Contents 9. 16. 11. 10. 14. 12. 13. 15. 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 .

22. 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 . 18. 23.Task Force on Health and Family Welfare Final Report Contents 17. 24. 19. 20. 21. 25.

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 .Task Force on Health and Family Welfare Final Report Karnataka State Integrated Health Policy 2001 • Vision.

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

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 Insurance 2. Yashaswini Scheme 3. Arogya Raksha Project .

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 .

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

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 .

compulsory Merit cum seniority District Cadre (ZP Cadre) Deputy DMO/RMO Programme Officer AMO Taluka Hospital Taluk Community Health Centre Taluk Health Officer (THO) Medical Officer PHC MBBS min. Med Store Dist. Laboratory Dist. 2 DEPARTMENT OF HEALTH & FAMILY WELFARE – ORGANISATIONAL STRUCTURE: PROPOSED DISTRICT LEVEL Medical DMO (DS) PG in Clinical + Hos Adm Dist.qualification PGs can also enter .CHART NO. Maint Unit Dist. HMIS Unit Public Health DHO PG in Public Health State cadre (KHS) PG qual.

HA (Male) SDC Driver* Aya JHA (F) TBA JHA (M) JHA (F) JHA (F) JHA (M) JHA (F) JHA (F) JHA(M) JHA (F) VHW AWW * Driver for PHCs which have vehicles . PRIMARY HEALTH CENTRE Lady Medical Officer Medical Officer Staff Nurse Pharmacist Lab Tech Sr. HA (Female) Sr. 3 DEPARTMENT OF HEALTH & FAMILY WELFARE – ORGANISATIONAL STRUCTURE: PROPOSED DISTRICT LEAVEL.CHART NO.

4 DEPARTMENT OF HEALTH & FAMILY WELFARE – ORGANISATIONAL STRUCTURE: PROPOSED DISTRICT LEVEL TALUK HEALTH OFFICE Taluk Health Officer DPH 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.

PO IEC . HMIS Unit AMOs Blindness PO Nutri HP. Maint Unit Civil works Vehicle maintenance Equipment maint Opth-PO Onco-PO FW . Medical Store LEP+STD/HIV Dt. 7 DEPARTMENT OF HEALTH & FAMILY WELFARE – ORGANISATIONAL STRUCTURE: PROPOSED STRUCTURE AT DISTRICT HEALTH OFFICES – DHO & DMO DHO District Hospital District Laboratory DMO Prog Co-ordinator DSO RCH-PO Entm Vector -PO TB .CHART NO.PO Dt.PO Statis Microbiologist Pathologist Biochemist Mental-PO CVS-PO Dt.

CHART NO. 9 DEPARTMENT OF HEALTH & FAMILY WELFARE – ORGANISATIONAL STRUCTURE: PROPOSED STATE LEVEL DIRECTOR PUBLIC HEALTH Add. Director Health Promotion AD (CMD) State Survey Off Chief Acc. Director AIDS (KSPC) Project Director RCH & PHC Add. Officer 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 .

CHART NO. 10 DEPARTMENT OF HEALTH & FAMILY WELFARE – ORGANISATIONAL STRUCTURE: PROPOSED STATE LEVEL DIRECTOR MEDICAL Addl Director Medical Addl Director NCD CAO JD Medical JD GMS JD-Hosp North JD-Hosp South JD-TrauEme Med JD Ophthal (MINTO) JD-CVS & Diabet JD-Dent Health JD-MH (NIMHANS) JD-Onco (KIDWAI) .

11 DEPARTMENT OF HEALTH & FAMILY WELFARE – ORGANISATIONAL STRUCTURE: PROPOSED STATE LEVEL DIRECTOR Ext.CHART NO. Staff as in KHSDP . Aided Projects DIRECTOR Procurement & Maint AD (SPC) Planning & Monitor Secretary PWD Joint Director Planning Joint Director HMIS Joint Director Procurement JD-Bio-Medical Equip Maintenance Superintendent Eng Civil DD-Law & Ethics (Forensic Medicine) Civil Engineering.

ISM&H Officer Phy Gr II Hosp & Disp .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 DrugInspectors DD Pharmacy Div DDs ? Physician Gr I District Hospital Dt.

CHART NO. 13 DEPARTMENT OF HEALTH & FAMILY WELFARE – ORGANISATIONAL STRUCTURE : PROPOSED STATE INSTITUTE OF HEALTH & FAMILY WELFARE (AUTONOMOUS) PRINCIPAL SECRETARY Governing Board Director Selection Post SIHFW (Autonomous) Commissioner / DGHS Directorate Joint Director Training Joint Director Research (Social Scientist) Specialists Communication Health Mgt RCH/NCD Deputy Director Course Content Deputy Director Training Principals RHFWTC/DTC ANM Training Centres .

CHART NO. 14 DEPARTMENT OF HEALTH & FAMILY WELFARE – ORGANISATIONAL STRUCTURE DRUG CONTROL DEPARTMENT 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) -1 Superintendent (Lab) -1 Other Technical -7 Officers Junior Chemists -30 Govt. Drugs Controller -19 Drugs Inspector -56 Principal & Chairman -1 Member Secretary -1 Professor -6 Asst. Drugs Controller .8 Asst. Professor -8 Lectures (Pharmacy Lect) -17 (Non Pharmacy) -5 . College of Pharmacy Board of Examining Authority Dy.

15 DEPARTMENT OF HEALTH & FAMILY WELFARE – ORGANISATIONAL STRUCTURE: PROPOSED DEPARTMENT OF MEDICAL EDUCATION SECRETARY MEDICAL EDUCATION Director Medical Education Autonomous Teaching Hospitals/Institutions DEAN BMC DEAN MMC AD Med Edu DEAN GDC *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 DD (ME) DD (DE) * Regional Institute Ophthalmology (RIO) could be made into an Autonomous Institution .CHART NO.

Karnataka . PRINCIPAL SECRETARY Drug Controller Commissioner / DGHS SIHFW Director (ME) Pop & Health Research Dir. 8 DEPARTMENT OF HEALTH & FAMILY WELFARE – ORGANISATIONAL STRUCTURE: PROPOSED STATE LEVEL Autonom Hosp. ISM&H Autonomous Teaching Hospital / Institute Commission on Health Secretary (ME) CAO Finance CVO Vigilance Director Public Health Director Medical Director EAP Director Procurement / Maintenance NGO Cell Joint Director Special Groups Additional Director Planning Additional Director N.CHART NO.

Task Force on Health and Family Welfare Final Report Rational Drug Management • Optimization of Drug procurement – quantification. Govt. procedures Establishment of Standard Treatment Guidelines. Medical Stores/District Stores – reorganisation Drugs Control Department –Strengthening for effective supervision. • • • . Essential Drug List and State Formulary.

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

The Epidemic of Corruption in Health Services Corruption in Hospitals a. Corruption in service delivery by the following: • Ayaas/ward boys • Nurses • Contract workers • Technicians •Administrative Staff • Pharmacist • Doctors • Specialists .

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 .

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 .The Epidemic of Corruption in Health Services Corruption in Hospitals b.

mamools • Manufacturing License: Inspection of units for fresh & renewal .Epidemic of Corruption in Health Services Drugs Control Department • Lokayukta ride on Drugs control Department – wide spread corruption .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 .

• Trading of blood by Unlicensed Blood Banks & chemists. HIV infected blood sold .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.

.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.

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

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

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 .