EKAVI GoK PHC Adoption working with Padmashree Dr. H. Sudarshan
EKAVI GOK PHC Adoption Program Committee. EKAVI is working with Padmasri Dr. H. Sudarshan in this regard. EKAVI is promoting this concept to Kannadigas all around the world.
Innovations in Primary Health Care by Padmashree Dr. H. Sudarshan
Healthcare Delivery-Limited reach of healthcare infrastructure- Adopt market-based models as a scaling-up strategy.
The main issue being addressed is primary health care. Only up to 20 % of rural people have access to quality health care that is available 24 hours, accessible and affordable. The sheer size and extent of the Government health care infrastructure make it the most effective delivery mechanism for primary health care. Moreover, partnering with the Government and taking over the complete management of non-performing and remote primary health centres in tribal areas is the basis for this model. The main beneficiaries are rural people. The goal is to provide quality primary health care – curative, preventie, promotive and rehabilitative aspects along with innovations in primary care. Karuna Trust runs 28 PHCs in almost all districts of Karnataka and 9 PHCs in 9 districts of Arunachal Pradesh. All the PHCs in Arunachal are extremely remote and many of them get cut off during various months of the year.
One apparently small difference that has caused a significant increase in utilization of services is 24 hour PHC and availability of all staff at the Headquarters. This is important because, invariably, doctors in many PHCs attend more like visiting doctors rather than team leaders.
The innovations implemented through our PHCs are:
1) Community Health Insurance: A unique, community-based health insurance policy with compensation for wage loss and immediate claim settlement with a low premium rate of Rs. 20/person/annum and no-disease exclusion. This is being implemented in all the PHCs in .
2) Mainstreaming of HIV/AIDS in primary care and provision of PHC-VCTCs
3) PHCs are now operating as Village Resource Centres in collaboration with ISRO with Telemedicine, Tele-agriculture and farmer advisories, Wasteland & Watershed mapping and management with additional support for capacity-building and monitoring of PHCs
4) Mainstreaming of Traditional Medicine in Primary care with herbal gardens at PHC and sub-centre level, popularization of single herbal remedies for routine illnesses.
5) Integration of mental health care in PHCs
6) Improved community participation with health committees t village and PHC level
7) Health Management Information Systems in all PHCs in collaboration with IIM, Bangalore
8) Provision and management of essential drugs, implementation of standard treatment guidelines and drugs and therapeutics committee in all PHCs
9) PHC waste management systems
10) Effective management, leadership and team building
11) Emergency obstetric care
12) Early detection and prevention of disability.
The model focusses on partnering with the Government. Karuna Trust enters into an MoU with the Government after obtaining clearences from the local leaders and the Zilla Panchayat. The Government staff are withdrawn and we recruit all the staff as per the service guidelines of the Government. The Government pays 75% of the running cost and the rest is to be mobilized by the NGO. Karnataka is one of the first states to begin this scheme for involving NGOs and private medical colleges in running primary health centres. Karuna Trust was the first NGO to be handed over a PHC when in 1996 the Gumballi PHC in CHamarajanagar district was handed over to us after 10 years of work in that area on Leprosy, Tuberculosis and Epilepsy.
The team inis headed by a Project Director who is a senior doctor with over 20 years public health experience as a District Health Officer. He is assisted by another medical doctor who is in charge of capacity-building and program implementation. The Arunachal Pradesh team is coordinated by a team of 3 managers headed by a doctor with 2 offices and support staff.
The crux of this initiative is partnership. The strengths of both the GOvernment and NGO sector is called in to achieve a shared objective. Networking with local NGOs in various PHC areas is key to the initiative. In, Karuna Trust is closely associated with the which has been working in that state for many years.
The Government of Karnataka pays 75% of the running cost while the remaining 25% is to be the NGOs contribution. This is just the running cost. The cost for innovations, capacity-building and monitoring/supervision is also borne by the. In Arunachal Pradesh, the Government pays 90% of the running cost.
Other sources of funding include funding agencies for particular projects, local MPs/MLAs and other philanthropists who are intrested in the betterment of their local PHCs.
We have shown that the PHCs may be run much more effectively and can be model practicing centres for delivering primary health care and innovations to the rural people, at a cost the community and the Government can afford.
3,50,000 people served.
Acceptance of good NGOs in running primary health centres has increased both among the local leaders and the Government. Increased community participation in health care through participation in PHC and village level health committees Improved performence indicators like decreased maternal and infant mortality rates Improved health seeking behaviour Decreased taboo for mental illnesses
Karuna Trust now has 10 years of experience. Also from 1 PHC in one district of one state, the model is now in place in over 35 PHCs in over 30 districts of 2 states. The model has thus demonstrated replicability, sustainability and scalability. The model may be tried in any developing country.
Scaling Up stage.
Plan to expand to a few more states. The main focus in the next three years is also on consolidating the work in
Greater encouragement and inculcating a sense of shared achievement in the Government
The initiative was the brainchild of Padmashree Dr. H Sudarshan who began Karuna Trust in 1986 in response to the huge prevalence of leprosy which was as high as 21.4/10000 population. With sustained community based efforts, leprosy was eliminated and the Trust moved on to address felt needs like Tuberculosis, mental illnesses and Epilepsy. 1996 was the landmark in the history of this initiative when the Gumballi PHC in Yelandur Taluk of Chamarajnagar district of Karnataka, one of the most backward districts was handed over to Karuna Trust. Since then, the sucess of this model has resulted in 9 PHCs in and 28 PHCs in now under total management with Karuna Trust. Dr. Sudarshan’s work with the Soliga tribals and in running the rural development work at Karuna Trust ahs been well recognized and he was awarded the Right Livelihood Award in 1996 and the Padmashree in 2000.
|Public-Private Partnerships|Innovations|Tribal R C H Programme|Traditional Medicine|Promotion of Low cost Generic Drugs|Community Health Insurance|Mental Health|Telemedicine|
| Primary Health Care through Public-Private Partnerships (ppp)
| Integrated Educated Project Yelandur , T.Narsipur and Kolar
|Livelihoods & Community Development|
|Livelihoods & Community Development
Sri. H.N. Somasundaram
Sri. P. Viswanath
Hon . Secretary
Phone (R) : 91-80-26563214
Email :firstname.lastname@example.org Karuna Trust – Head Quarters
Ph: 08226-244025, 08226-244018
Public health being revamped
Dr.H.Sudarshan discusses the state of Karnataka’s public health services in this interview exclusive to India Together.
Dr.Hanumappa Sudarshan is currently the Chairman of the Karnataka Health Task Force and a Vigilance Director at the Karnataka LokAyukta, the state’s main corruption fighting body. He is best known for his work with the Soliga tribals of the B R Hills near Mysore, and is also a winner of the Right Livelihood Award. The Health Task Force is currently overseeing the implementation of the wide-ranging recommendations it made to the state govt in 2001. India Together caught up with Dr.Sudarshan at Bangalore in April 2002. This interview was also telecast as a Radio India Together program on June 10 and 11, at Bangalore’s Gyanvani 107.6 FM Radio.
In 2001, that is last year, you called for a moratorium on starting new medical colleges in the Karnataka? Doesn’t the state actually need more doctors?If you look at the health needs, there are two issues. One is commercialisation of medical education. You want to open a college and make a business, which is one way. The second way to look at it is that these medical colleges also have accountability to the people of Karnataka. This is the model, which Israel has. In Israel each district has a medical college and that college takes the responsibility for the health affairs of that district. So we are saying, we should have our business, but we should also have some accountability for the health of the people. We have suggested three primary health centers to be run by the private medical colleges. Secondly what we’re saying is that mushrooming of the medical colleges is not good. The quality standards have to be maintained. Some of the medical colleges do not have enough infrastructure – the hospital, number of beds, and most important, the faculty. We can’t have a situation where we increase the number of available medical colleges overnight, but there are no faculty. Some colleges cheat during inspection where they hire faculty from neighboring colleges and show them on their nameplates. We have a shortage of faculty for running the medical colleges. So if we can provide good quality medical education, with good infrastructure, and good faculty, we have no problem. We can produce good quality doctors. But what is happening is that the quality of doctors we are producing – some of the colleges are really good, but -some are really bad, they need to be closed down. So we’re saying, let us have good quality of medical education. It should be need based, and the colleges must have some accountability to the people of Karnataka.
In terms of equitable access for women to primary health care, where is Karnataka headed?
In the report of the task force, we talk specifically about gender sensitive primary health care. Desegregated data is available on whether women have access to the health system or are we discriminating. If they are not coming, how can this be changed? Also women’s health needs to be looked in a broader perspective – a woman is a human being and this is not just in the reproductive sense. From birth to death, how can the health system respond to the total health needs of the woman, this has also been suggested. Women also have problems of TB, Malaria, and other needs, so we need to take care of that. How to make women-friendly PHCs, hospitals, etc are the questions we have looked into. Collecting gender desegregated data at various levels, including for violence against women – we are insisting that this should be regarded now, wherever possible. Another major issue is female feticide and infanticide. With the law against female feticide now in place, ultrasound machines are closely monitored.
Are you and the Health Task Force happy with the allocations in Karnataka State Budget for 2002?
Our view of budget, with our understanding – first point is that we need to have optimum utilization of the existing budgets. What we have found is that even the existing budgets are not being properly utilized – in terms of optimal utilization of resources. There is a lot of wastage. Unused moneys are being returned, in fact. This type of thing is going on. So just increasing the state health budget at this stage without empowering the whole health system to better manage resources, will be catastrophic. So what we are saying is, empower the service staff, make optimal utilization of the existing budget, and then gradually increase to what is needed, as the capacity is built to handle more money. Just increasing the budget will not make the system better. But having said that, definitely the present budget allocation for health is low, it is about 5% of the total outlay, which is very less. We do want the budget to be increased, and we have recommended that for the next fiscal plan.
One the one hand the Health Task Force has recommended for increased state financing of health services. And on the other hand we hear of the pressures being exerted by the Multilateral Financial institutions (World Bank, IMF) on governments of developing countries to reduce public expenditure through the so-called structural adjustment programs…
No in fact, in Karnataka, we have looked at it and we have no pressures to reduce the budgets for health. Even in the World Bank assisted types of planning processes which happened for the mid-term fiscal plan [the five year plan], the budget has been increased, actually. There is no cut for the health budget, and we have also made clear in the task force recommendations that human resources allocations must not be cut. There are cuts in workforce in other departments but for the Health services, we have clearly said that no cuts, because we need those human resources.
The Task Force has laid an almost extra-ordinary emphasis on Human Resource Development for the Health Bureaucracy in Karnataka. What is the government doing about these recommendations?
Regarding recruitment – filling up of the vacancies – we had recommended this in our interim report itself and I am happy to say that government has taken this seriously and filled up vacancies of doctors, nurses and para-medical staff. Within the next few months we will have all the existing posts filled up, except male health workers. We are debating about whether these posts should be filled up or not. Whatever vacancies exist in the essential staff areas, will definitely get filled up shortly. We also have the 250 hospitals run by the Karnataka Health Systems Development Project. Bed strength has been increased, so we need additional staff. So that is also being done – additional specialist posts, and para-medical staff, for the upgraded hospitals. This is regarding new recruitment. We also had contract doctor appointments. We have said they have to be regularized. Now those appointments will be moved back to a regular system of appointments. Most important is training, and empowering the doctors – in terms of induction courses for medical officers who have just joined and ongoing regular training for the doctors and para-medical staff. For this we have a State Institute of Health and Family Welfare, this has to be upgraded and it has to be built into a unique institution which takes care of all the training needs of the human resources.
Talking of recruitment, how is the recruitment of doctors and other staff going along for rural Karnataka?
The problem is the chronic shortage of human resources in the so-called backward areas or the northern districts. Nobody wants to go there. They want to be around in the southern districts. So we have recommended recruitments into the district cadre. For the first six years doctors will be at the PHCs, and another 7 years at the Taluka hospital. They can get out of the districts into the state cadre. So for 13 years they have to be in Bijapur or Gulbarga or Raichur, wherever they are recruited. You draw a distinction between the preference for the market economy of curative medicine in the govt health services and what you call sound public health. In fact you are concerned that the preference for this curative side of the service should not undermine the public health responsibilities of the government. We are sitting right now behind the public health institute which is in shambles now. We need to really create a premier public health institute. We have the post of additional director for communicable diseases, which needs to be strengthened. A good disease surveillance system at various levels including very strong district disease surveillance units is needed. This together, and amendments to various health related laws has to be taken up. The government has just started thinking and trying implement our recommendations in this area.
Last year, that is 2001, there was a bill to regulate private health care services in the state assembly. Where are we on this regulation?
The earlier Nursing Home Act was more of a license type of Raj. The Task force was not happy with that. We have given a separate private institutions regulation bill. Before that we had recommended a comprehensive bill for both public and private together. So that quality control standards can be the same for both. But government did not accept combining the two. They wanted a separate private inst regulation bill. The older bill has since been withdrawn. In the new bill, the Government will only have a registration role to play. There will be committees at district levels which make their own quality standards and see that the institutions maintain those standards. Hopefully this will be implemented very soon.
Why did the Karnataka government not prefer a common regulation from both government-run as well privately run health care institutions?
Their argument is that that government cannot do this – a legal type of argument was thrown up at us. This does not convince us and it would have been better if the same law regulated the two. But because of the legal problems, so we had to accept that there will be two different bills. But at the same time, within the government, quality standards are being developed – ISO standards. We are insisting on standards – it’s just that public health will have its own and private health will have its own.
The PouraKarmika problem in Bangalore seems to be a vexing issue. The task of cleaning cities comes with significant occupational, and primarily health hazards. On the one hand we hear that PKs employed by the BMP will soon get medical insurance. But at the same the time, more than 50% percent of Bangalore’s Wards are cleaned by contracted PKs and they are not even paid minimum wages, let alone considerations for health Benefits. Do you see the recommendations of the health task force have an impact on the benefits offered to the contracted PKs?
We have not spoken specifically about the PKs but we have spoken about the employees of the health department itself – insuring them, immunizing them for hepatitis B, which had not been done – has been recommended. We have also recommended incentives for doctors staying in PHCs and those who do administrative jobs, the general staff. For Hospital maintenance contracts, non-clinical contracts – we are looking at the norms. As you rightly said, when we take out labor contracts, minimum wages are not even being made to most of these employees in most of the hospitals. So we need to do something, that when we contract out labor, the contractors pay minimum wages. Probably this calls for a dialog with the labor department and see that these contractors are enlisted and some enforcement is done for basic minimum wages and other facilities to the employees.
Charging fees at government hospitals seems to be very problematic. Let’s take Punjab. As you know, because the yellow card system that was supposed to exempt the poor from the fees has for all practical purposes not been implemented. As a result, poor people in Punjab are today forced to both a bribe and a fee they cannot afford.
Karnataka is also implementing a user fee system in the Karnataka health systems development hospitals; we are not charging for primary health care. But for secondary care and tertiary care, user fees are being charged. This is where I feel that below poverty line people (BPL) should be totally exempted from the user fee. How to identify the BPL people? If we insist on ration cards, some of the poorer people may not even have a ration card. And yellow cards are some times not even distributed either. So our own recommendation is to err on the other side. If the BPL is 35% give free services to 50% of the people. So for the other 50% user fee can be charged. But user fees again are very nominal and they are only about 1% of the total cost of the health care provided in the hospitals. Just a token fee. But this is very useful. The positive side of the user fee is that if we can have the BPL delineator guaranteed, the hospitals can have some discretionary funds available at the hospitals. This has brought about some miracles in the management of those hospitals. They have some money to buy whatever little needs they have – repairs to be done, emergency medicines to be bought, which is really good. They have some resources now. Earlier even when a 15Amps plug had to be bought there was huge process. Now they get it purchase in one day. So this has brought in some good aspects. User fee – I would say it is not user fee, what we are collecting in Karnataka. It is a token type of participation of the users. I am also the vigilance director for Lokayukta for Health Education and Social welfare. When the LokAyukta chief justice took over, I had given him report wherein I had identified corruption as one of the major issues. Next day he called me and asked me to join him. We have gone around the hospitals and seen how the BPL people are suffering – the corrupt system and how they are given prescriptions. We are mainly looking at these issues in a public type of enquiry and making the doctors and hospitals accountable so that the below poverty line people are taken care of. That is our main agenda which I am pushing through at the LokAyukta.
Isn’t the fact the Karnataka Lokayukta is suo motu visiting government hospitals to check corruption an indication that the complaints driven process is not really taking off?
Corruption is at various levels. In medical education, starting from joining the medical college – you can buy a seat, you can buy the examiner, the corrupt examination system, you can get question papers. This is much better now with the Rajiv Gandhi University, they are trying bring in some reforms, but still, in the viva-voce and practicals, many people have paid and it is still continuing, we are not sure we have plugged that. This time, the Lokayukta has been very pro-active in the post-graduate examinations, for example we knew which hotels that corrupt elements will be staying in and we tried to prevent those types of corruption. So this is about medical education. When students pass out, we found that the students have to pay a bribe to register at the Karnataka Medical council. So we took it up with the council that have rectified it. Similarly in the recruitment process. The Karnataka Public Service commission for example, and other agencies. There were problems. Now it is merit-based recruitment. We have streamlined the system and we have also looked into transfers. Transfers and promotions. These are the areas. Then again there is corruption in the purchase of equipment and medicines. All these we are trying to plug. It’s a very difficult task, but awareness is being created. When we go to hospitals, the LokAyukta not only looks at the below-poverty-line people, how they are taken of, but cleanliness is also looked at. The mortuary for example, from the birth to death, there is/was corruption in hospitals. If a child in born, we have to pay to the nurse and the other staff. There are different prices for babies. 200 Rs for male babies, 150 Rs for female babies, you might have heard of it. And then death. When people came for post-mortem, staff would squeeze money from them. So LokAyukta visits the mortuaries, and directs to make sure that everything is given free, even the cloth to be tied around the body should be free, no money should be charged. These types of reforms from the birth to death, we are trying to bring in. Reforming the entire system is a long process, but we have initiated several measures.
Do you agree that the Karnataka LokAyukta’s work will be strengthened if the public started actually filing formal corruption complaints as opposed to complaining cynically about corruption?
That is very important. Actually, if we can strengthen the hospital committees itself, including PHC committees, which we have suggested from the task force – like the Madhya Pradesh example where the samitis which are pro-active and are mobilizing resources – this will be very useful. But community participation in all this – their awareness to complain to the LokAyukta was not there. We have covered 15 districts by the middle of April. By end of April, we will have covered all the 27 districts. Awareness is being created and now they know they can redress the grievances with the LokAyukta. We take action immediately and respond to their grievances.
The Task Force was convened in Dec 1999. The submission of Interim recommendations in 2000 and the final recommendations in 2001. What is your feeling about the process and as Chairperson of the Task Force, are you happy?
First of all, we had a very committed team. The members of the task force have really given time, it is a love of labor. Some of the members have been working honorary, full time. Producing this kind of report has been a very good experience. We had very good bureaucrats who co-operated with us, we had good secretaries who helped us, and most important was the chief minister himself. He also listened whenever we made presentations and he has acted too, which has been very encouraging. But at the same time, given the pace at which the govt is implementing – the health department – some of us feel frustrated, coming from NGO background. Things could move much faster. But that is how it is, we have to accept certain limitations within the govt. We sometimes take a pro-active role in pushing things, but still there are a lots of limitations in the existing system. And I feel the Karnataka Health system is running at about 25-30% efficiency. If we can implement part of the recommendations also, it will increase the efficiency to 50% and that will have a tremendous impact. But how to change mindsets? The whole concept of making this happen and community participation, these are challenges. Probably over the next ten years, if we invest on this, especially community participation and empowering people for their own health, things will definitely improve. (Concluded)
SPECIAL FEATURE: HEALTH CARE IN KARNATAKA
Envisaging a healthy growth
|The state-run health care system in Karnataka is striving hard to overcome problems such as regional disparities and regain its former standards. At the same time, health services in the private sector, especially the multi-speciality hospitals, have earned a reputation for themselves.|
THE Princely State of Mysore was a pioneer in basic health care. In 1806, it was perhaps the first State in the country to take up a vaccination drive against small pox. The State administration set up a government hospital in Bangalore in 1846, the first public health unit in Mandya in 1929 and the world’s first two birth control clinics in 1930. But after Independence, the State of Karnataka, which churns out around 1,800 doctors every year, has been striving to keep up with those standards, especially in the rural areas.
BY SPECIAL ARRANGEMENT
The Vanivilas hospital, one of the oldest hospitals run by the Karnataka government.
Karnataka, like any other State, is full of regional, even sub-regional disparities in the matter of development. The health infrastructure in certain regions, most notably the State’s capital, Bangalore, and to a lesser extent the coastal towns of Mangalore and Manipal, has developed well but other areas, especially the rural areas where 60 per cent of the population lives and the northern districts, have not received sufficient attention from the government and the private sector.
Overall, the State has a crude birth rate of 22 (for every 1,000 of the population), a crude death rate of 7.2, an infant mortality rate of 55 per 1,000 live births, a maternal mortality rate of 195 per one lakh live births and a total fertility rate (the number of children born to a woman during her reproductive years) of 2.2.
The State’s Health and Family Welfare Services has 8,143 sub-centres (that is, one for 5,000 people), 581 Primary Health Units (PHUs), 1,679 Primary Health Centres (PHCs), 19 mobile units, 7,304 maternity annexes, 17 urban PHCs and 110 Community Health Centres. While the doctor-population ratio is 1:10,260, the bed to population ratio is 1:1,220. In a novel scheme to improve services, the government has allowed 14 PHCs to be managed by medical colleges and trusts. At these PHCs, 75 per cent of the staff salary is paid by the government and 25 per cent by the private entrepreneur.
There are 87 Urban Family Welfare Centres, 124 Urban Health Centres and 24 district-level and 149 taluk-level hospitals. There are 51 other hospitals, including super-speciality hospitals, which treat illnesses like cancer, heart ailments and tuberculosis. As part of the World Bank-funded Karnataka Health Systems Project, the State government has over the past seven years strengthened and upgraded at a cost of Rs.624 crores the infrastructure in 204 of its taluk and district hospitals. As a consequence, six government hospitals have won ISO-9002 certification. Under the project, user charges are levied in taluk and district hospitals, non-clinical services in some hospitals have been privatised and 44 primary trauma care centres established to provide emergency services to accident victims.
Treatment is free for those below the poverty line (BPL) for almost all services in the State government hospitals. For specialised treatments such as cardiac surgeries, BPL families can get up to Rs.50,000 from the Chief Minister’s Relief Fund. The government has also been sanctioning Rs.50,000 twice a year to each of the district hospitals, which can use the fund to buy from the private sector medical services that are not available with them.
There are around 22,000 practising doctors in the State. Of them, 4,197 are working in the State’s health institutions and about 15,000 in the private sector. The total bed strength in government health institutions is 43,479 while their outpatient departments serve 60,000 patients every day. There are nearly 2,000 hospitals in the private sector, which interestingly have as many beds as the state sector.
According to officials, the shortage of doctors and supervisory staff, financial crunch and an ever-increasing population are some of the major reasons for the state sector’s inability to provide a more effective health delivery system. The shortage of doctors, especially specialists, and funds forced the government to hand over in April 2002 part of the management of the Rajiv Gandhi Super Speciality Hospital in Raichur to Apollo Hospitals. Under an agreement, the Karnataka government pays for the maintenance cost of Rs.3 crores to Rs.4 crores a year.
As a result of the funds crunch only a half of the State’s 8,154 sub-centres have permanent buildings.
Karnataka has slipped from the sixth place to the seventh in the Human Development Index. And on most human development indices, Karnataka is barely above the all-India average.
In a bid to achieve the “Millennium Development Goals”, the Congress-Janata Dal (Secular) coalition government has decided to make primary health care (and primary education) the focus of its development effort. Presenting the new government’s first Budget, Deputy Chief Minister Siddaramaiah announced an increase in the Plan outlay for the health sector from Rs.333 crores to Rs.377 crores, which would be utilised to improve taluk-level hospitals and the medical infrastructure in impoverished northern Karnataka. The enhanced outlay should partly stabilise the State’s falling public health expenditure, which had fallen from 1.02 per cent of the gross state domestic product (GSDP) in 1999 has fallen to 0.7 per cent in 2004. Ideally it should reach 2 per cent of GSDP.
Under the Rs.765-crore World Bank-assisted `Health, Nutrition and Population (HNP) Project’ the government hopes to improve and extend the primary health care system. The focus of the five-year programme “is to increase access to health care for the rural poor and the underprivileged, and to strengthen primary health care with community participation”.
BY SPECIAL ARRANGEMENT
The Bangalore Mahanagar Palike’s referral hospital at Hosahalli in Bangalore.
Says Mohamed Sanaulla, Commissioner, Health and Family Welfare Services: “Our aim is to stabilise and improve facilities. It is a misnomer to say that the services at government hospitals are not good. In fact, our understanding is that, especially in the rural areas, the level of satisfaction among the people is better with the government health service. People are even prepared to pay `unregistered’ (bribe) expenses.”
IN a bid to ensure effective primary, secondary and tertiary health delivery systems in the State, successive Karnataka governments have implemented a number of measures. The HNP Project seeks to improve the services at the 1,679 PHCs. To be implemented in three districts as a pilot project, this will also aim at increasing public-private participation and introducing an insurance scheme for the common people, with the government subsidising the premiums.
The Rs.30-crore World Bank-aided Integrated Disease Surveillance Project, spread over five years, is designed to gather initially information regarding communicable diseases such as malaria, cholera, gastroenteritis and typhoid. Information on non-communicable diseases like cancer and hypertension, and trauma care will be compiled later. An information technology network has already been established at the taluk and district levels. The information thus gathered from the district, State and national levels will be analysed and utilised for more effective diagnosis, management and prevention of communicable diseases.
The State is also giving shape to the Rs.15-crore European Union-funded Drug Logistics and Warehousing Project, under which 14 warehouses will be set up in the districts. The current system of indenting for packages would be replaced by the indenting for drugs. As part of it telemedicine programme, five private speciality hospitals are being connected via satellite to 25 district and four taluk hospitals. The system is functioning in two hospitals. The private hospitals have offered free consultations. The Indian Space Research Organisation (ISRO) has set up the satellite link at a cost of Rs.35 crores.
Karnataka is also hoping to improve the birth rate, infant mortality and maternal mortality parameters in the State when the Government of India’s Reproductive and Child Health-Phase II programme is implemented in 2005. The State government has set up regional diagnostic laboratories in seven districts to conduct sophisticated tests, including CT scans.
Volume 21 – Issue 18, Aug. 28 – Sep. 10, 2004
India’s National Magazine
from the publishers of THE HINDU
|Campaign for the Revitalization of Primary Health Centres (2006 onwards)|
|This campaign was undertaken by the Janaarogya Andolana – Karnataka (People’s Health Movement – Karnataka) to address crucial issue of state withdrawal from health services and the situation of Primary Health Centres (PHCs) which were being rendered dysfunctional all across the state. There are about 1600 primary health centres in the state spread across 27 districts.Though India was a signatory to the Alma Ata Declaration of 1978 which declared the progressive mechanism of the state to ensure Health for All by 2000’, in the post-reforms era, the state fund allocation was reduced to a dismal 0.9% of the GDP in India! In a socio-political atmosphere where there is unregulated privatization of medical practice allowed on the one hand, and state is steadily withdrawing from health services, especially the primary health care, on the other, access to Primary Health Care is becoming increasingly difficult for the vulnerable communities and the poor in general. Besides, as the government itself is pushing the agenda for the privatization of primary health centres in the name of public-private partnership, people’s right to health is being increasingly denied. In this context, JAA-K took the initiative of mobilising people towards the issue of revitalizing PHCs. The important milestones in this process were as follows:
a) Dialogue with the State:
April 7th being the People’s Health Day, JAA-K decided to hold a dialogue with the State on the eve of this day, viz. 6th April, 2006. The meeting was held Ashirvad, Bangalore from 2.30 – 4.30. Nearly 100 delegates representing various organisations and various districts presented their findings on the study conducted in sample PHCs. The Deputy Health secretary and Dr. Vijaylaxmi, the chief health officer of BMP attended the sessions. Nearly 100 delegates from various districts attended the dialogue with the state. Dr. Vasundhara chaired the sessions. Presentations were made from the districts of Raichur, Kolar, Kanakpura (Bangalore Rural), Tumkur, Bangalore Urban on the state of Primary Health Care and the conditions of the availability of services at the Primary Health Centres. These presentations were based on the surveys of PHCs done in these districts. The common emerging issues were,
The responses of deputy health secretary and the chief health officer were not adequate and their attitude of putting everything back on people left the people disappointed. Hence the group decided to meet again to choke out the future strategies.
b) State level brainstorming meeting on Right to Primary Health Care
A state level brainstorming meeting of organisations/ networks interested in strengthening primary health care was organised on April 25th 2006 at Vishranti Nilayam, Bangalore. About 25 people from various organisations across 10 districts attended the meeting. The meeting was called to ensure that a truly vibrant people’s movement emerged and that the movement worked towards ensuring access to primary health care.
Dr. Gopal Dabade shared about Jagruthi’s work in Khanapur taluk of Belgaum district. He said that 350 SHG’s had been started in 22 villages. Low sex ratio was one of the problems in the district. Eight months back in the PHC at Beedi village, the doctor sent back a lady who had brought her husband, because she did not have money. She began begging to meet her medical needs. The SHG federation members discussed the issue and SHG members of neighbouring villages decided to protest in front of the PHC. The decision was conveyed to the DHO, who came to the village immediately, transferred the doctor, brought medicine supplies and revamped the PHC. Jagruthi along with the people decided to turn the day of action into a day of awareness, since their demands had been met, and they invited the same DHO to spread awareness. Later, a film on the ‘action at the PHC and the awareness campaign on primary health care’ in Belgaum was screened.
Other Participants from Kolar, Bidar, Raichur shared about their experiences about the situation of PHCs in their respective districts. The common emerging issues were corruption, prescriptions to be bought from outside, lack of cleanliness, lack of staff, etc. She said that people were selling land and livestock to access medical care in private hospitals because of pathetic state of affairs in Government health centres. She said that lack of awareness led to people being exploited.
All the participants expressed the need for more training in health related issues. The need for training materials in Kannada was also expressed. The information about
The participants then shared about their expectations from the meeting, which included the following:
§ Training to NGOs and activists
A brief action plan (with time frame) was discussed which included expanding the group in each district, meeting of large group, trainings (4th – 5th month) and a PHC survey.
c) State level Strategy Planning Meeting on Right to Primary Health Care (RPHC)
A state level Right to Primary Health Care (RPHC) strategy planning meeting was held at Ashirvad, Bangalore on Sunday, June 25, 2006 on the theme “Revitalising PHCs”. The meeting focussed on strategy planning for the revitalisation of Primary Health Centres within the framework of right to health care. About 18 representatives from 8 districts attended the meeting.
The issues that were discussed were,
1. Campaign priority
2. Information required from the Government
a. Structure of health system, staffing pattern and staff responsibilities.
CHC as a resource centre agreed to be the contact for the campaign and also to provide necessary logistical support with information and coordination.
d) Weekly core meetings
Regular weekly core meetings of the core members in the Right to Primary Health Care Campaign (Prasanna, Kshama, Saras, Chander, Naveen and Premdas) took place at CHC mostly on Wednesdays discussing the week by week progress of the programme and the details of the follow up that was required. .
e) Right to Information (RTI) training
A training on the topic ‘Using Right to Information in the Right to Health Care Campaign’ was conducted from 9.30 a.m. to 2.30 p.m. on 25th July 2006 at Christian Medical Association of India (CMAI). It was attended by about 30 people from various organisations. Mr. Cyriac Anand from Sakshi trust conducted the training on the know-how of Right to Information Act.
Issues raised in the RTI training workshop for PHCs were (1) macro data at the state level, health budget and its distribution district-wise, vacant positions of staff, health programmes, procurement of drugs etc. (2) micro data: Staff, functions and responsibilities, facilities such as infrastructure, medical and other services, budget and finances, medicines and availability, equipment, monitoring and inspection, documents
f) State level meeting on Right to Health Care Campaign
A state level meeting on Right to Health Care Campaign was held at CMAI office on Cunningham Road, Bangalore on 25th August, 2006. Various organisations including GMO, Kolar and NJMO Raichur, participated in the same. The main issues of the meeting were report of district meeting, address data base, core group meeting on Wednesdays, budget preparation (for human resource and campaign material), right to information act to be use as a tool for the campaign, background information prepared so far and translated. The meeting ended with the discussion on multiple strategies for the consolidation of the campaign, to form a survey format as a tool for advocacy and to form district level committees for the promotion of the right to primary health care.
g) Revitalising Primary Health Care (RPHC) Planning meeting
The Revitalising Primary Health Care (RPHC) Planning meeting was held at CHC on 4th January 2007 from 10.am to .3.30 pm. The participants included representatives from 5 districts and different networks. The agenda of the meeting was sharing of district processes, planning for state-wide action on February 1, 2007, state level action to address health issues, strategies to be adopted and division of responsibilities for different districts. The participants narrated their experiences regarding health systems in various districts. It was decided that a state level action would be held to raise issues of health care all across Karnataka state. Lathi campaigns; targeting family and welfare department; constant advocacy and approaching elected representatives such as MLAs and MPs were discussed as strategies to be adopted in the future. CHC took responsibility to financially support Chitradurga, Tumkur and Mysore districts. Oblesh was to be the contact person. Premdas was involved in the preparation of a pamphlet ‘Right to Health’ in Kannada which was distributed in all the districts.
h) State-wide Public Action on Revitalising Primary Health Care (RPHC)
On February 1, 2007, action took place across 13 districts in the state where memorandums were submitted to the District Health Officers (DHO) and the Chief Executive Officers (CEO) of Zilla Panchayats regarding the state of health systems in their districts. People in large numbers gathered and held a dialogue with the CEO and DHO of their districts. Press Conferences, rallies and submission of memorandum were the common factors across all these districts. The action was well covered and reported in all major vernacular newspapers and local televisions.
In Chamarajnagar, JAA-K members had a dialogue with the District Health Officer (DHO) for 3 hours and various people presented testimonies in front of the DHO. Kolar too had a series of meetings with the Chief Executive Officer (CEO) of the Zilla Panchayat (ZP) and were evolving series of actions for improvement of services. There was some visible change in some of the PHCs. About 50 women of various SHGs in Gadag District took out a rally and presented memorandums to the district administration. In Koppal district, JAA-K members conducted a press conference before 1st February and had all the newspapers highlighting the plight of the PHCs in their district. JAA-K members in Raichur district had collected data from 50% of the PHCs and had presented the consolidated data to the district authorities. As a follow up of this, the Chief Executive Officer (CEO) of the Zilla Panchayat (ZP) agreed to tackle the infrastructure related issues of the PHCs in this year’s action plan. There were also a series of actions by Jagruti and other JAA-K related organizations in Belgaum District which resulted in some visible changes at the PHC level.
CHC in collaboration with Obalesh of the Human Rights Forum for Dalit Liberation (HRFDL) supported action directly in three districts namely Mysore, Chitradurga, and Tumkur were covered.
In Mysore, over 170 people from 4 taluks – H.D.Kote, Nanjangud, Hunsur and Mysore participated in the action. Over 100 of the participants were women. The issues covered in Mysore related to access to drugs, functioning of the primary health centre and social determinants. Media persons from different Kannada publications like Prajavani, Vijaya Karnataka and K.P. Andolana covered the event.
In Chitradurga, 110 people participated in the action. Of these, 93 participants were women. Organisations who participated included HRFDL, Dalit World, SPIN network, Sadhana Samasthe, and so on. The issues covered in Chitradurga related to availability of health personnel, availability and access to drugs and with regard to functioning of the primary health centre. Media persons from different Kannada publications like Prajavani, Vijaya Karnataka and Praja Pragathi covered the event.
In Tumkur, 118 people participated in the action. Of these, 78 participants were women. Organisations who participated included Matanga Women’s Association, MMO, REDS, Jeevika, DJS and some other development organisations from Tumkur. As the result of the rally and meeting, a health action committee was formed in the district. Media persons from different Kannada publications like Prajavani, Samyukta Karnataka, Vijaya Karnataka and Praja Pragathi covered the event.
|Last Updated ( Tuesday, 29 May 2007 )|
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