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

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

3. 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 Partnership Task Force on Health and Family Welfare

4. 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

5. 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

6. Task Force on Health and Family Welfare Final Report Contents 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

7. Task Force on Health and Family Welfare Final Report Contents 9.Population Stabilisation 10.Focus on Special groups 11.Health Promotion and Advocacy for Health 12.Human Resources Development for Health 13.Research in Health 14.Health Systems Management 15.Health Financing 16.Rational Drug Management

8. Task Force on Health and Family Welfare Final Report Contents 17.Law and Ethics 18.Indian Systems of Medicine and Homoeopathy 19.Panchayat Raj and Empowerment of People 20.Strengthening of Partnership 21.Multisectorality and Intersectoral Co-ordination 22.The Karnataka State Integrated Health Policy 2001 23.Vision 2020 24.Implementation of the Report 25.Major Recommendations and Expected Outcome

9. 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 Task Force on Health and Family Welfare Final Report

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

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

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

13. Reforms in Health Financing User Fee Vs Token Fee Establishment of Hospital Committees Granting Autonomy to Hospitals & Health Institutions Health Insurance: 1.KT– UNDP Community Health Insurance 2.Yashaswini Scheme 3.Arogya Raksha Project

14. 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

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

16.  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

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

18. Lady Medical OfficerMedical Officer Staff Nurse Pharmacist Lab TechSr. HA (Female) Sr. HA (Male) SDCDriver*Aya JHA (F) JHA (F) JHA (M) JHA (F) JHA (F) JHA (M) JHA (F) JHA(M) JHA (F) TBA VHW AWW * Driver for PHCs which have vehicles Lady Medical OfficerMedical Officer Staff Nurse Pharmacist Lab TechSr. HA (Female) Sr. HA (Male) SDCDriver*Aya JHA (F) JHA (F) JHA (M) JHA (F) JHA (F) JHA (M) JHA (F) JHA(M) JHA (F) TBA VHW AWW * Driver for PHCs which have vehicles Lady Medical OfficerMedical Officer Staff Nurse Pharmacist Lab TechSr. HA (Female) Sr. HA (Male) SDCDriver*Aya JHA (F) JHA (F) JHA (M) JHA (F) JHA (F) JHA (M) JHA (F) JHA(M) JHA (F) TBA VHW AWW * Driver for PHCs which have vehicles Lady Medical Officer Medical Officer Staff Nurse Pharmacist Lab TechSr. HA (Female) Sr. HA (Male) SDCDriver*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 DEPARTMENT OF HEALTH & FAMILY WELFARE – ORGANISATIONAL STRUCTURE: PROPOSED DISTRICT LEAVEL, PRIMARY HEALTH CENTRE

19. 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) FDCDriver CHART NO. 4 DEPARTMENT OF HEALTH & FAMILY WELFARE – ORGANISATIONAL STRUCTURE: PROPOSED DISTRICT LEVEL TALUK HEALTH OFFICE

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

21. DIRECTOR PUBLIC HEALTH Add. Director AIDS (KSPC) Project Director RCH & PHC Add. Director Health Promotion AD (CMD) State Survey Off Chief Acc. 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. 9 DEPARTMENT OF HEALTH & FAMILY WELFARE – ORGANISATIONAL STRUCTURE: PROPOSED STATE LEVEL

22. 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) Addl Director Medical Addl Director NCDCAO CHART NO. 10 DEPARTMENT OF HEALTH & FAMILY WELFARE – ORGANISATIONAL STRUCTURE: PROPOSED STATE LEVEL

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

24. DIRECTOR ISM&H Directorate level JD Med Edu JD ISM&H Admin Officer Accounts Officer Ast Drug Controll Principals Col & Hosp DD Ayurveda DD Unani DD Homoeo DD Nat & Yog 3 Drug- Inspectors Physician Gr I District Hospital Dt. ISM&H Officer Phy Gr II Hosp & Disp DD Pharmacy Div DDs ? Aided Col & Hos CHART NO. 12 DEPARTMENT OF HEALTH & FAMILY WELFARE – ORGANISATIONAL STRUCTURE : PROPOSED DIRECTORATE OF ISM&H

25. 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. 13 DEPARTMENT OF HEALTH & FAMILY WELFARE – ORGANISATIONAL STRUCTURE : PROPOSED STATE INSTITUTE OF HEALTH & FAMILY WELFARE (AUTONOMOUS)

26. DRUGS CONTROLLER ADDITIONAL DRUGS CONTROLLER Enforcement Division Drugs Testing LaboratoryPharmacy 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. College of Pharmacy Board of Examining Authority Dy. Drugs Controller - 8 Asst. Drugs Controller -19 Drugs Inspector -56 Principal & Chairman - 1 Member Secretary - 1 Professor - 6 Asst. Professor - 8 Lectures (Pharmacy Lect) -17 (Non Pharmacy) - 5 CHART NO. 14 DEPARTMENT OF HEALTH & FAMILY WELFARE – ORGANISATIONAL STRUCTURE DRUG CONTROL DEPARTMENT

27. 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 CHART NO. 15 DEPARTMENT OF HEALTH & FAMILY WELFARE – ORGANISATIONAL STRUCTURE: PROPOSED 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)

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

29. 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. Task Force on Health and Family Welfare Final Report

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

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

32. 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

33. The Epidemic of Corruption in Health Services 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

34. 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

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

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

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

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

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

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