HEALTH AND NUTRITION VISION 2025

Transcription

1 HEALTH AND NUTRITION VISION Document presented by Karuna Trust, December, 2017

2 Table of Contents I. List of Tables... 3 II. List of Figures... 5 III. List of Abbreviations Executive Summary Overview of Health and Nutrition Sector in Karnataka Current Health Status Current Nutritional Status Institutional Framework Benchmarking Karnataka s Health and Nutrition Sector Global Benchmarks in Health and Nutrition Strategic Analysis of Health and Nutrition in Karnataka Progress of Ongoing Schemes and Proposed Interventions Good Practices and Emerging Trends in Health and Nutrition Insights from Stakeholder Consultations Vision 2025 for Health and Nutrition in Karnataka Vision Statement Key Goals and Targets for Implementation Roadmap Role of Stakeholders and Partnerships Methodology Conclusion

3 Table I. List of Tables Page Number 1 Trend and Comparison of HDI ranking of state vs other states 14 2 List of health facilities with NABH accreditation 17 3 Status of hospitals under NQAS 18 4 Total number of public health facilities, Karnataka 19 5 List of Vacancies at Government Health Facilities, Karnataka 20 6 Distribution of PHCs (Urban vs Rural), Total number of public health services under secondary and tertiary care 21 8 Total number of Registered Blood banks in the state 22 9 Trend of Malaria cases in Karnataka Trend of Filaria cases in Karnataka Trend of Dengue incidence Trend of Chikungunya incidence Statewise comparison on progress of RNTCP Achievements under RNTCP Trend of food and waterborne diseases, Karnataka Status of AntiRetroviral Therapy Centre and Service Physical Target and Achievements for Eradication of Leprosy from to Trend of dog bites across the state Details of Oral health manpower, Karnataka Comparison of Family planning methods, Karnataka Medical education institutions and enrolments for the years Medical Education Institution by Managements for the year Proportion of people living within 20 km and 40 km (as well as outside 40 km) from a dental college in Karnataka. 24 Expenditure on Health and Education as percentage of GSDP Financial Achievements: Health & FW Department (Rupees in Lakhs) List of hospitals under AYUSH The Registered Medical Practitioners of various systems

4 28 RBSK School health programme Progress report for the period of Progress of Supplementary Nutrition programme under ICDS Nutritional Availability for Children up to Three Years, Karnataka vs India Comparison of Nutritional Status of Children Under Five Years in Karnataka ANC Visits, Advice and Breastfeeding Practices Amongst Currently Married Women (15-49 Years) 33 Comparison of nutritional status indicators, state and national level Comparison of Health and Nutritional Indicators (Global) Beneficiaries of Health Schemes initiated by the state as on

5 Figure II. List of Figures Page Number 1 District wise disparities in health status, Karnataka 11 2 Regional Backwardness based on the aggregate development index, Karnataka District wise comparison of Mothers who had at least 4 antenatal care visits, Karnataka Districtwise comparison of children fully immunized between months, Karnataka Comparison of Mothers who had at least 4 antenatal care visits Karnataka vs Other states vs India Comparison of children fully immunized between months- Karnataka vs Other states vs India 7 Comparison of PHC distribution districtwise, Karnataka 14 8 Districtwise comparison of Sex Ratio, Karnataka, Districtwise comparison of Sex Ratio, Karnataka, Comparison of sex ratio, Karnataka vs Other states vs India Distribution of 24x7 PHCs - Districtwise, Karnataka Districtwise distribution of Blood Banks across Karnataka Comparison of NCD prevalence between Male and Female Trends in Diabetes prevalence in Karnataka Distribution of First Referral Units - Districtwise, Karnataka Maternal Mortality Rate Trend, Karnataka Trend of Neonatal Mortality Rate, Karnataka (Urban vs Rural) Trend of Infant Mortality Rate, Karnataka (Urban vs Rural) Nutritional Status of Children Under Five Years in Karnataka Prevalence of Anaemia in Karnataka Trend and comparison of IMR, Urban vs Rural Trend and comparison of IMR, state and national level Trend and comparison of MMR, state and national level Trend and comparison of NMR, state and national level Trend and comparison of U-5MR, state and national level Trend and comparison of TFR, state and national level

6 III. List of Abbreviations ANC Ante Natal Care MDG Millennium Development Goal ANM Auxillary Nurse Midwife or Junior Health Assistant (Female) MMR Maternal Mortality Rate ART Anti Retro Therapy MSM Men who have Sex with Men AYUSH Ayurveda Unani Siddha Homeopathy MSHS BBMP Bruhat Bengaluru Mahanagara Palike NABH BPL Below Poverty Line NACO Mukhyamantrigala Santhwana Harish Yojane National Accreditation Board for Hospitals National AIDS Control Organisation CHC Community Health Centre NCD Non Communicable Diseases CSR Corporate Social Responsibility NFHS National Family Health Survey DALY Disability Adjusted Life Years NFCP National Filaria Control Programme DHFWS Directorate of Health & Family Welfare Services NHRSC National Health Systems Resource Centre ehc ehealth Centre NHS National Health Service EMRs electronic medical records NIMHANS National Institute of Mental Health & Neurosciences FRU First Referral Unit NMR Neonatal Mortality Rate FSW Female Sex Workers NRHM National Rural Health Mission GSDP Gross State Domestic Product NQAS National Quality Assurance Standard HCF Health Care Facility OOPE Out Of Pocket Expenditure HDI Human Development Index PDS Public Distribution System HIV/AIDS Human Immunodeficiency Virus/Acquired Immuno Deficiency Syndrome PHC Primary Health Centre HMIS Health Management Information System PHU Primary Health Unit HRMS Human Resource Management System PPP Public Private Partnership ICMR Indian Council of Medical Research RAB Rajiv Arogya Bhagya ICDS Integrated Child Development Services RBSK Rastriya Bal Swastya Karyakrama IDU Injecting Drug Users RCH Reproductive and Child Health IFA Iron and Folic Acid RGUHS Rajiv Gandhi University of Health Sciences IHHL Individual Household Latrines R&D Research and Development 6

7 IMR Infant Mortality Rate RNTCP Revised National Tuberculosis Control Programme IPHS Indian Public Health Standards SAST Suvarna Arogya Suraksha Trust IRCS Indian Red Cross Society SC Scheduled Caste ISY Indra Suraksha Yojana SDG Sustainable Development Goal IT Information Technology SEZ Special Economic Zones JSS Jyothi Sanjeevini Scheme ST Scheduled Tribe KFHP Kaiser Foundation Health Plan TB Tuberculosis KFH Kaiser Foundation Hospitals TFR Total Fertility Rate KHSDRP Karnataka Health System Development and Reform Project U5MR Under 5 Mortality Rate KJA Karnataka Jnana Aayoga UHC Universal Health Care KPI Key Performance Indicators UIP Universal Immunisation Programme KPME Karnataka Private Medical Establishments UPHC Urban Primary Health Centre KSAPS Karnataka State Aids Prevention Society UMS Urban Malaria Scheme MCH Maternal & Child Health 7

8 1. Executive Summary This document has been made as a part of the Karnataka Vision 2025 document for health and nutrition sector. The goal behind this document is to provide a way forward for the health and nutrition sector in the state. This document addresses the current health and nutritional status in the state, followed by a analysis of what are the strengths, weaknesses and opportunities available for the respective sector. The document also provides insight into where Karnataka stands in comparison to neighbouring states and also, nationally. Recommendations from sectoral workshops and district level workshops, have also been presented in this document. Lastly, broad strategic interventions have been provided to lead us to a better future as a state. The current health status has been divided into twenty two broad topics under which the progress and current situation has been addressed; while for nutritional status specific indicators have been considered and situation analysis has been presented. Over the years, Karnataka has made certain achievements in the field of health and nutrition such as becoming polio free, decline in Infant Mortality Rate and Maternal Mortality Rate, reduction in Anemia cases etc. There has also been good progress in bringing out many state level such as introduction of health schemes such as Madilu, Prasooti Araike etc. These schemes were introduced at a state level to address the concern of reaching out to pregnant mothers and maternal deaths. The Madilu kit scheme focuses on post natal care for mothers who have delivered in public health facility while Prasooti Araike scheme is to provide financial assistance for pregnant women belonging to to lower socio-economic groups. Karnataka has also managed to have it s own State Health Integrated Policy and also, recently a Palliative Care Policy. The state has also introduced a State Nutrition Mission to address the nutritional concerns. Though there has been progress, there is also a need to improve and strengthen existing services and also aim for overall good health and nutritional status of the people of the state. Karnataka in comparison to the neighbouring states continues to lag behind in achieving health outcomes like Maternal Mortality Rate, where Karnataka is at 144 per 100,000 live births which continues to be the highest across southern states. At the same time, the state continues to struggle in reaching vulnerable populations and implementing integration of health services for elderly health, mental health etc. The current major challenge that Karnataka faces is the low expenditure towards health which has been affecting the overall health service delivery, while the nutritional challenges of Karnataka are manifold. The prevalence of anaemia is precariously high with married women (44%), pregnant women (45%) and children (60%) shouldering the greatest burden. One in three children less than three years of age is underweight or stunted. The state has made use of the presence of the mix of health service providers by collaborating and introducing Suvarna Arogya Suraksha Trust (SAST) to address the lag in secondary and tertiary services. This has helped address the concern of high Out of Pocket Expenditure (OOPE) that the citizens have faced. To help improve the public health services, the government has initiated quality assessment and accreditation of it s facilities. While at a governance level, introduction of a Human Resource Management System (HRMS) has been a step forward to address the concerns of human resource management. From a technology and innovation aspect, the state has been a frontrunner in introducing a functional Health Management Information System (HMIS) which again needs to be utilised in a much more concise manner. The state has also advanced in mainstreaming AYUSH into its health system but needs to improve the implementation of the same. Karnataka has been a pioneer in ICDS programme by collaborating with animal husbandry department to provide fresh milk for children. The recently 8

9 promulgated National Food Security Act of 2013 aims to address the problem of malnutrition through the medium of the Public Distribution System (PDS). The state has plenty of opportunities to grow towards improving the health and nutritional status of its people, like for example, increasing the budget for health; strengthening intersectoral collaborations; implementing successful health models such a Kaiser, National Health Services within the state the strengthen partnerships and achieve the goal of Universal Health Care. The newly published State Integrated Health Policy, 2017, in amalgamation with this document can help the state achieve its vision of universal healthcare that is equitable, accessible and affordable. Overall, this document gives a broad overview and insight as to the way forward for the state in the field of health and nutrition and the need for concentrated focus on inter-sectoral convergence. 9

10 2. Overview of Health and Nutrition Sector in Karnataka Being the eighth largest state, geographically, Karnataka has become home to 6.11 crore people (2011 Census) from 5.2 crore people in In the past decade, Karnataka has seen notable progress in terms of improved health status under the National Health Mission guidance. Since the first draft of the Karnataka State Integrated Health Policy, 2004, there have been a number of notable changes seen, along with which, there have been emerging windows of opportunities and challenges Current Health Status The State government has managed to achieve certain Millennium Development Goals through specific measures such as establishment of Health Task Force, State Health Policy initiatives etc. Few of the significant changes seen in state s health status are: Karnataka is Polio free since 2007, India has been declared Polio free since 2014 Life expectancy at birth has increased from 55 years in the 1970s to 67.1 years in 2015 Infant Mortality Rate reduced from 47 in 2007 to 24 per 1000 live births in 2016 Maternal Mortality Ratio reduced from 178 in 2007 to 133 per 100,000 live births in Equity The principle of equity in health is rooted in the recognition of health as a human right. There has to be access to and utilisation of services according to the needs. Inequities in access to health care may be due to supply and demand factors: geographical (regional) distribution, availability of health care personnel, range and quality of primary care facilities, levels of training, timing and organisation of services; distance to the first contact of care, availability and affordability of communication and transport Regional disparities Disparity in the distribution and level of functionality of government health facilities across the state districtwise is seen. 10

11 Figure 1. District wise disparities in health status, Karnataka Figure 2. Regional Backwardness based on the aggregate development index, Karnataka (Source: Task Force Report on Health & Family Welfare, 2001) In the figure above, based a number of comprehensive indicators, the disparities are seen in the health status across the state. It is observed that the northern districts have a relatively poor health status when compared to the southern districts. (Source: Nanjundappa Committee Report, 2002) In the above Figure 2., we observe that in the past there was regional backwardness in the state across 39 Talukas as per the Nanjundappa Committee Report. There seems to be not much change with regards to the same.

12 Figure 3. District wise comparison of Mothers who had at least 4 antenatal care visits, Karnataka (Source: NFHS-4, ) In Fig.3., shows mother s who have completed 4 ANCs visits, districts such as Bangalore, Koppal and Chikmangalur perform poorly in comparison to Chikballapur and Davangere districts. Figure 4. Districtwise comparison of children fully immunized between months, Karnataka (Source: NFHS-4, ) In Fig 4., a comparison, district wise is seen based on children who are immunized between months, where Chikmangalur, Shivamogga and Gadag perform poorly as compared to Kolar and Dakshina Kannada districts.

13 Table 1. Trend and Comparison of HDI ranking of state vs other states States * Value Rank Value Rank Value Rank Value Rank Value Rank Maharashtra Karnataka Kerala Tamil Nadu All India (Source: Economic Survey Of Karnataka ) In the above Table 1., it is observed that over the years, Karnataka s Human Development Index (HDI) ranking has fluctuated and in 2011, had dipped from a rank of 6 to 10. In 2012, the latest data, Karnataka is back at 8th rank with a value of Figure 7. Comparison of PHC distribution districtwise, Karnataka Average PHC Population, districtwise, Karnataka (Source: Karnataka Health Profile ) Most of the northern districts have a high PHC population (average) compared to southern districts. There are PHCs with a very a high population like Bijapur district has population of 21,77,331 under which Kannur PHC which covers population of 70,000 while there is another PHC Kakaniki which covers 13,300 population. 13

14 Figure 5. Comparison of Mothers who had at least 4 antenatal care visits Karnataka vs Other states vs India (Source: NFHS-4, ) In Fig. 5., when Karnataka is compared to neighbouring states, Tamil Nadu and Kerala, it comes in third; while at a national level, Karnataka performs better. Figure 6. Comparison of children fully immunized between months- Karnataka vs Other states vs India (Source: NFHS-4, ) In Fig. 6., Karnataka performs better when compared to Maharashtra and matches the national level coverage rate for immunization. 14

15 Gender Disparities: There are significant differences between the health indices for men and women in the different districts across the state. Here we are looking at sex ratio, birth rate and death rate across the state. In the Task Force Report of 2001, it was observed that the northern districts saw a major difference in sex ratio as compared to the southern. Currently the state has seen progress but the disparity continues to be present in the northern districts. Figure 8. Districtwise comparison of sex ratio, Karnataka, 2001 (Source: Task Force on Health & Family Welfare, 2001) In Figure 9., when analysed districtwise, it is seen that Bangalore, Haveri and Chitradurga have a poor sex ratio in comparison to Udupi and Kodagu districts. When we compare the sex ratio from 2001 to now, we notice that Belgaum continues to have a lower sex ratio while Mandya has drastically improved. 15

16 Figure 9. Districtwise comparison of Sex Ratio, Karnataka, (Source: NFHS-4, ) Figure 10. Comparison of sex ratio, Karnataka vs Other states vs India (Source: NFHS 41) In Fig.10., when we look at the sex ratio of the total population, Karnataka performs better with 973 females per 1000 males than the national average but lower than the neighbouring states, Tamil Nadu and Kerala. 16

17 Quality Under NRHM quality of health delivery was an important aspect and one of the goal of NRHM was to provide quality care, so NRHM developed the IPHS standards for the various categories of health facilities. In Karnataka quality assurance program in healthcare was started under NRHM as a pilot project in Tumkur district. A State and district quality cell especially with focus on RCH was set up, but this programme did not function smoothly due to number of operational reasons. Subsequently the NABH model was adopted by the State for Quality Improvement. This graded accreditation program provides accreditation to Hospitals based on their resources with - entry level, progressive level and full accreditation. NABH accreditation also ensures sustainability to a great extent as the concept of surveillance, re-accreditation and surprise assessments are built into the system. Initially 4 Government hospitals were selected that is Bijapur and Tumkur district hospitals apart from Jayanagar general hospital and KC general hospital in Bangalore. These 4 hospitals underwent the entire process of NABH. The gap analysis as per IPHS and NABH was also conducted on the remaining district hospitals. Of the about 4,000 hospitals across Karnataka, only 123 have National Accreditation Board for Hospitals and Healthcare Providers (NABH) recognition. And Only 4 of the 123 NABH-recognized hospitals are government institutions. Only one PHC has got NABH which is due for renewal now.(nabh official website) Table 2. List of health facilities with NABH accreditation NABH accreditation as per facilities Number of Hospitals Number of Government hospitals NABH accreditation 4 Number of Private hospitals with NABH accreditation 104 Number of Dental Hospitals accredited 1 Number of AYUSH Hospitals with NABH accreditation 5 Number of Blood Banks with NABH accreditation 6 No of Allopathic Clinics with NABH accreditation 3 Total number of hospitals with NABH accreditation 123 (Source: NABH official website as on September 2017) Presently, National Quality Assurance Standards have been developed through the NHRSC keeping in the specific requirements for public health facilities as well global best practices. NQAS are currently available for District Hospitals, CHCs, PHCs and Urban PHCs. The government has launched Quality Certification program for public health facilities and Kayakalp Award Scheme with aim of recognizing the good performing facilities as well improving credibility of public hospitals in community. Certification is provided against National Quality Assurance Standards (NQAS) on meeting 17

18 pre-determined criteria. Certified facilities are also provided financial incentives as recognition of their good work. Type of Facility District Hospital Taluk Hospital / Community Health Centre Primary Health Centre Total 20 Internal Assessment Table 3. Status of health facilities under NQAS Peer Assessment External Assessment Awards Will be condu cted in Nove mber Primary Health Care Will be declare d in Decem ber (Source: Department of State Quality Assurance Committee, 2016) Primary health care is essential health care, universally accessible and acceptable with community participation and includes promotion of health, prevention of diseases and rehabilitation and management of common illnesses at affordable costs. Primary Health Care is "the key to attaining an acceptable level of health care for all by the year 2000, as part of overall development and in the spirit of social justice" - The Declaration of Alma Ata Rural Primary Health Care Infrastructure: Primary Health Care is channeled in the rural areas mainly through the activities around the Primary health Centres (2353 centres as on ), the sub-centres (8871 as on ) and Community Health Centres (206 as on ), which are the first referral units. In the past, the state converted 583 Primary Health Units (PHUs) to PHCs but did cover the shortage of staff issues raised at that point of time. The number of 24x7 PHCs in the state are 1031 in number. 18

19 Table 4. Total number of public health facilities, Karnataka Sl No Health Facility Existing Infrastructure as on Dec Sub Centre Primary Health Centre Primary Health Centre (24x7) Urban Primary Health Centre Community Health Community 206 (Source: Karnataka State Health Profile, ) Figure 11. Distribution of 24x7 PHCs - Districtwise, Karnataka (Source Karnataka State Health Profile, ) In Fig 11., it is observed that the highest number of 24x7 PHCs are present in Gadag and Belgaum district, while the least are in Udupi and Kodagu district. Vacancies: In the past, there have been a large number of vacancies which have over time been brought down. In Table 5., we see that the vacancy for male health worker at a sub center level is 42%, this raises concerns as the male health worker plays a major supportive role for the Female Health Worker (ANM). In Table 5., it is observed that there is an urgent need to fulfill vacancies at a CHC level where there is a high percentage. 19

20 Urban Primary Health care As per 2011 census, lakh people reside in urban areas, and the urban slum population is lakhs in Karnataka state. About 31.57% of population live in urban areas of the state. NUHM will cover all the District headquarters and other cities/towns with a population of 50,000 and above. One urban primary health centre (UPHC) is functional for every 50,000 population under NUHM. 361 such centers across the state have been functional till date. 263 existing Urban Family Welfare Centre, Urban RCH Centre, Urban Health Centre, Urban Health Post, etc., have be upgraded and strengthened as UPHC. The Urban PHCs are expected to cover a population of 50,000 while in Table 6., it is observed that currently the 361 UPHCs are covering a population of 65,000. Table 5. List of Vacancies at Government Health Facilities, Karnataka Sl No Staff vacancies in Government Health Facilities Staff Facilities Sanctioned Number of Positions vacant % Vacant Position 1 Female Health worker at Sub-Center (ANM) Male Health worker at Sub-Center Female Health Assistant (Lady Health Visitor) at PHC Male Health assistant at PHCs Medical Officers at PHCs Pharmacists at PHCs & CHCs Laboratory technicians at PHCs & CHCs Nursing Staff at PHCs & CHCs Radiographers at CHCs General Duty Medical Officers (GDMOs) - Allopathic at CHCs 11 Total Specialists [Surgeons, OB&GY, Physicians & Paediatricians] Paediatricians at CHCs Obstetricians and Gynaecologists at CHCs Surgeons at CHCs (Source: Rural Health Statistics, 2016 ; *As on 31st March, 2016) 20

21 Table 6. Distribution of PHCs (Urban vs Rural), 2016 Numbe r of PHCs** Urban Rural Combined Population * Total Populatio n covered per PHC Numbe r of PHCs** Population * Total Populatio n covered per PHC Numbe r of PHCs** Population * ,625,962 65,446 2,353 37,469,335 15,924 2,714 37,534,781 (Source: *Census 2011, **Rural Health Statistics, ) Total Populatio n covered per PHC 61,095, Secondary & Tertiary Health Care Primary Health Care is the most essential health care but it requires the support of Secondary and Tertiary Health Care. Referral to higher levels of care is necessary when primary health care is unable to manage patients with difficult health problems. Realising this, Karnataka State has embarked on various projects to improve secondary and tertiary care. Super speciatliy facilites in the government sector were hitherto cncentrated in Bengaluru. In recent years, a conscious effort has been made by the State ot establish such facilites in various districts. Brancehs of Sri Jayadeva Institute of cardiology have been established in Kalaburagi and Mysuru. A branch of Kidwai cancer institute was establisehed in kalaburgi;super speciality hospitals have been constructed in Bellary and Hubbali under PMSSY and are ready to be commissioned in the next 6 months. Super-speciality hopitals have been sanctioned and tender called for construction in Kalaburagi, Belgavi and Mysuru. Strengtheninig the existing hospitals /newly establisehd hospitals would need significant resources Secondary & Tertiary Health Care Infrastructure: Currently in the state, there are 21 district hospitals and 146 Taluk hospitals. Refer to Table 7. Vacancies: In Table 5., we observe that there is nearly 40% vacant positions for specialists. Table 7. Total number of public health services under secondary and tertiary care Hospitals No. of institutions No. of Beds District Hospital Other Hospitals under HFW Teaching and autonomous Hospitals Taluk Hospitals (Source: Karnataka Health Profile, ) Taluk Hospitals: These are hospitals in Taluk headquarters with sanctioned bed strength of minimum 100 beds. It acts as referral hospital for the rural population. Taluk Hospitals are provided with 10 Specialists and one Dental Surgeon supported by 71 paramedical & other staff. There are 146 Taluk Hospitals in the State. 21

22 Emergency Services Arogya Kavacha 108: Arogya Kavacha 108 Emergency service was started in the state of Karnataka on November 1, 2008, by the Karnataka Health and Family Welfare Department under a Private Public Partnership.The Ambulances are stationed strategically in all Districts and taluks across Karnataka so they can reach the incident location within the shortest possible time anywhere in the state. At present there is one ambulance for every populations with a total of 711 Ambulances throughout the state. The current status is to plan and integrate all the ambulance services accordingly to address the concern of less ambulances. The state has also introduced other services such as Janani Suraksha Vahini (a free referral transport for pregnant women and sick neonates/infants); Nagu Magu ( free drop back facility for post natal mothers and newborns) and Bike ambulance (as a First Response Unit for Road Traffic Accidents Diagnostic Services The diagnostic services for health care include clinical pathology, biochemistry, histopathology, microbiology (including bacteriology, virology and mycology), serology, imaging (X ray, ultrasonography, echocardiography, CAT scan, MRI scan, PET Scan), electronic diagnostics (electrocardiography, electroencephalography, nerve conduction etc.), endoscopies, nuclear medicine and molecular medicine. It is important to define the appropriate tests for the different levels of primary and referral health care institutions. Data about the same was unavailable Blood Bank and transfusion State Blood Council was established in Karnataka during 1996 to provide adequate & safe blood and blood products at reasonable rates. At present, there are 199 registered blood banks in Karnataka of which 66 are supported by NACO. Out of 199 Blood Banks, 40 are in Government Sector, 19 are in Voluntary/Charitable sector, 32 are stand alone, 9 IRCS Blood banks and 99 are Private Hospital based Blood Banks. Table 8. Total number of Registered Blood banks in the state Type of institution Total Number Independent 32 IRCS Blood banks 9 Private Sector 99 Voluntary/Charitable Trust 19 Government Sector 40 Total Registered 199 (Source: Directorate of Health and Family Welfare Services, Annual Report, ) 22

23 Figure 12. Districtwise distribution of blood banks across Karnataka (Source: Karnataka Health Profile ) In Fig 12., it is observed that the distribution of blood banks across the state, the highest number are in Bangalore, followed by Dakshina Kannada, while the least are present in Bidar, Yadgir, Haveri districts Biosafety There is constant danger to patients and staff in the hospital, unless precautions are taken. These may be from radiation during diagnostic procedures (X-rays and nuclear medicine) or from infections. Radiotherapy is used in specialized institutions. Health care workers, patients and public are at the risk of exposure to radiations from both diagnostic and therapeutic procedures using radiation, but radiotherapy is available only in specialised institutions Public Health The Department of Health and Family Welfare Services implements various National and State Health programmes of Public Health importance to provide comprehensive Health Care Services to the people of the State through various Health and Medical Institutions. Karnataka is the first state in the country to implement the same. 23

24 Waste management and pollution control Karnataka has identified 26,788 Health Care Facilities (HCF) as on March The waste is being disposed by common/captive facility with respect to solid waste and by captive facility with respect to liquid waste. Karnataka State Pollution Control Board is the prescribed authority in the state for implementation BMW Rules. All government health facilities from large public hospitals to small village health centers segregate their biomedical waste completely. All liquid biomedical waste at these facilities is disposed of through proper disinfection units. All public hospitals have stopped the burning of biomedical waste on their premises. Instead, private sector agencies now collect their waste and take it to common treatment facilities where it is incinerated at high temperatures. All public hospitals have become mercury-free Communicable diseases The Communicable diseases wing plays a vital role not only in controlling the water borne communicable diseases in the state by regular monitoring, issuing appropriate guidelines to the District Health Authorities but also investigating epidemic /outbreaks in the state Vector borne disease National Vector Borne Disease Control Programme is a programme for prevention and control of vector borne diseases namely Malaria, Filaria, Japanese Encephalitis, Dengue and Chikungunya. Malaria: During 2016, 76% decline in Malaria is achieved compared to 2006 as per National goal. In Table 9., it is observed that the number of Malaria cases have increased while the treatment for the same has reduced. - Urban Malaria Scheme (UMS): The scheme is being implemented in 8 cities/towns of Bangalore, Bellary, Belgaum, Chikmagalur, Hospet, Raichur, Hassan and Tumkur through local bodies. Year B/S Collected & Examined Table 9. Trend of Malaria cases in Karnataka Malaria Cases Pf Cases Radical Treatment Deaths due to Malaria ,05,708 14,794 1,329 14, ,31,843 12,445 1,588 12, ,23,219 19,652 1,701 10, ,95, (Source: Directorate of Health and Family Welfare Services, Annual Report ) Filaria Control Programme (NFCP): The goal of the programme is elimination of lymphatic Filariasis by the year Filaria Control activities are being implemented in Filaria endemic districts of Kalburgi, Bagalkot, Bidar, Yadgir, Raichur, Dakshina Kannada, Udupi & Uttara Kannada. In Table 10., the number of Micro Filaria cases detected as well prevalence rate have reduced over the years. Table 10. Trend of Filaria cases in Karnataka 24

25 Year B/S Collected & Examined No. of Micro Filaria cases detected No. of disease cases No. of cases given treatment MicroFilaria rate % (Source: Directorate of Health and Family Welfare Services, Annual Report ) Dengue Fever: The incidence of Dengue fever in Karnataka has seen an increase over the years. The number of deaths due to Dengue have also increased. (Table 11) Table 11. Trend of Dengue incidence Year Positives Deaths March (Source: Directorate of Health and Family Welfare Services, Annual Report ) Chikungunya: In Table 12, it is observed that the number of confirmed cases has increased over the years, thus suggesting an increase in the incidence of Chikungunya across the state. Table 12. Trend of Chikungunya incidence Year Suspected cases No. of Blood Samples collected No. of cases Confirmed March (Source: Directorate of Health and Family Welfare Services, Annual Report ) Tuberculosis Revised National Tuberculosis control programme was a World Bank assisted and sponsored programme which was implemented in the State in a phased manner from All 30 districts and BBMP covering a population of lakhs under RNTCP from July 2004 onwards. In Table 13. It is observed that Karnataka has registered the highest number of patients for treatment, while the percentage of retreatment of cured is lesser than Kerala. In Table 14, Karnataka has managed to achieve most of the targets while falling short in detection of new sputum cases. 25

26 - Total 191 TB Units are created One TB unit for every 2 lakh population. 566 contractual staff in various cadres recruited under RNTCP in Karnataka. Programmatic Management of drug resistant TB cases:- The entire Karnataka is covered with PMDT programme. There are 3 diagnostic facilities at STDC/IRL, Bangalore (functional) and KIMS Hubli (functional) and RIMS, Raichur (functional), There are 6 in patient facility (DR-TB Centers) at KIMS Hubli, RGICD Bangalore, DH-Gulbarga, PKTB Mysore, VIMS Bellary and DR TB Center at DH- Mangalore. Table 13. Statewise comparison on progress of RNTCP State Population covered by RNTCP Smear positive patients diagnosed Total patients registered for treatment 2015 New smear positive cured % (2014) Smear positive retreatment registered % 2014 Smear Positive retreatment cured % 2014 Karnataka 64,400,000 54,547 80, , Tamil Nadu 76,500,000 41,696 59, , Kerala 33,900,000 14,147 22, , (Source: Directorate of Health and Family Welfare Services, Annual Report ) Table 14. Achievements under RNTCP Achievements Indicator Target Achievement Sputum examination Total TB cases detected New sputum positive case detected Sputum conversion 90% 89.50% Cure rate 85% 84% (Source: Directorate of Health and Family Welfare Services, Annual Report ) Vaccine Preventable diseases: Presently, the state has been polio free since Mission Indra dhanush Programme Phase III has been successfully implemented. While Karnataka, has managed to achieve above 75 percent in most vaccine administration, it lags behind in complete immunization at a mere 36.9 percent. 26

27 Food and water borne diseases: Diseases/ Program me Gastroenter itis In Table 15., it is seen that the number of cases for Gastroenteritis and Cholera has reduced over the years. Even Typhoid seems to have a significant reduction in its incidence. Attack s Table 15. Trend of food and waterborne diseases, Karnataka Deat hs Attack s Deat hs Attack s Deat hs Attacks Deat hs Attack s Cholera Typhoid (Source: Directorate of Health and Family Welfare Services, Annual Report ) HIV AIDS (KSAPS): Death s As per HIV Sentinel Surveillance in India, HIV prevalence in ANC clients was 0.26% whereas Karnataka stands in 8th Position in HIV prevalence. The prevalence among antenatal clinic (ANC) attendees as per HSS was 0.36%. HIV prevalence among the ANC attendees indicates decline in adult HIV prevalence in the state from 1.5% in 2004 to 0.36% in HIV prevalence level ( ) among Female Sex Workers (FSW), Men who have Sex with Men (MSM), Injecting Drug Users (IDU) and Transgender is 0.25%, 0.3%, 0.11 % and 0.5% respectively. HIV prevalence among migrants has been reported to be 0.05% and among truckers has been found to be 0.04%. During , 63 ART + 1 FI ART centers and 111 Link ART centers and 85 Link Plus ART centers have been functioning. Table 16. Status of AntiRetroviral Therapy Centre and Service Indicator Adult Male Status report on ART Adult Female TS/TG Child Male Child Female Total Pre ART Registration Ever Started on ART Alive on ART Reported Death (Source: Directorate of Health and Family Welfare Services, Annual Report ) Leprosy- National Leprosy Eradication Programme It is one of the oldest and the most successful National Health Programme. The prevalence rate of leprosy dropped from 40/10000 population in the year 1986 to 0.40/10000 population in At present 10 districts have prevalence rate 0.50 to 1 (BBMP, Chamarajanagar, Gadag, Uttara Kannada, Yadgir, Bengaluru (Urban), Kalburagi, Koppal, Raichur, Bidar) and in Bellary district prevalence rate is >1 (i.e 1.13/10000 population). Karnataka is considered as a low endemic state up to end of 31/03/2017. Table 17. Physical Target and Achievements for Eradication of Leprosy from to

28 New case detected Cases cured Prevalence Rate Deformity Rate Year Achieved Achieved (Source: Directorate of Health and Family Welfare Services, Annual Report ) Rabies Over the years, Karnataka has seen a rise in the number of dog bites. In Table 18., the number of deaths due to dog bites have increased as well as the number of attacks reported. Table 18. Trend of dog bites across the state Health concer n Dog Bites Attack s Death s Attack s Death s Attack s Death s Attack s Death s (Source: Directorate of Health and Family Welfare Services, Annual Report ) Attack s Death s Integrated Disease Surveillance Programme: IDSP Portal entry happens from the Taluk level on a weekly basis. BBMP has been made as reporting unit under the Bangalore urban district and has started reporting to ensure Urban Health Surveillance Outbreak reports are entered into the IDSP portal on a weekly basis along with the S, P, L reports by the Districts. Eight Government Medical Colleges are identified as Referral labs for laboratory confirmation of epidemic prone outbreaks. 3-4 adjacent districts are attached to each Referral lab for providing laboratory diagnosis. BMCRI-Bangalore, MMCRI-Mysore, BRIMS-Bidar, VIMS-Bellary, SIMS-Shimoga, BIMS-Belgaum, HIMS-Hassan and KIMS- Hubli are the identified Referral labs. Two lakhs, annual grant is allocated to each referral Labs for procurement of required consumables. Eleven District Public Health Laboratories (DPHL) have initiated functioning in district hospitals of Chamarajanagar, Bijapur, Gulbarga, Yadgir, Chitradurga, Koppal, Davangere, Udupi, Bagalkot, Gadag and Haveri for routine hospital based surveillance of communicable disease. Presently these labs are performing culture for all clinical samples and serology (Dengue and Chikungunya). All District Surveillance Unit labs except Bangalore Urban, Bangalore Rural Chikkaballapur & Ramanagara are carrying out bacteriology examination of water and prepares H2S media and Malaria stain and distributes to the peripheral health centres. 28

29 Non Communicable Diseases The Karnataka Health System Development and Reform Project (KHSDRP) has implemented a prevention and control project for the non communicable diseases (NCDs) in the state (National Program For Prevention And Control Of Cancer, Diabetes, Cardiovascular Diseases And Stroke). The program includes cervical cancer, hypertension and diabetes. This project began in the month of July The National Program for Prevention & Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke program is being implemented in a phased manner across the state. Districts Covered : Kolar, Shimoga : Udupi, Tumkur, Chikmagalur : Bagalkot, Bijapur, Belgaum, Gulbarga & Dharwad : Bangalore Urban, Mysore, Hassan, Raichur. District hospitals are supported for prevention, early detection and management of Cancer, Diabetes, Cardiovascular Diseases and Stroke. District hospitals NCD clinic, Cardiac care unit and CHC NCD clinic are functional in Shimoga, Tumkur, Chikmagalur, Kolar and Udupi. According to a report by ICMR and PHFI, the burden of disease for hypertension in the state is between 3500 to 3999 per 100,000 DALYs while for diabetes it is 2700 to 3099 per 100,000 DALYs. While the proportion of total disease burden for non communicable diseases is 62 percent. (Fig 13). Figure 13. Comparison of NCD prevalence between Male and Female (ICMR- PHFI report, 2017) 29

30 Figure 14. Trends in Diabetes prevalence in Karnataka Oral Health (Source: Policy Brief: How to enhance care for Diabetes and Hypertension through primary health system in Karnataka) Oral Health constitutes a major component of the health care system and is receives low priority in health planning and financing. Oral diseases are perceived as not life threatening or severely debilitating and a lack of awareness among the public and policy makers and the impact, severity of oral diseases make it less prioritised. Oral health status of Karnataka: The oral health picture in Karnataka state is not updated regularly. The last report was released back in Oral health manpower: There are 37,528 dentists registered with the Karnataka State Dental Council of which 338 dentists served in the government agencies. (Central Bureau of Health Intelligence 2017) Within the Karnataka state public health system, 245 Dental Health Officer posts were sanctioned and 183 were filled. 62 positions remained vacant. (National Health Systems Resource Centre,2013). Dentists form 21 percent of all health workers in Karnataka. The dentist density for 1 lakh population is 3.8. in Karnataka. The national density of dentists was extremely low at 2.4 per lakh population, which was made even worse by the severe maldistribution of dentists across districts. Of 593 districts in the country, 58 districts had no dentists at all; 88 districts had no dentists with more than secondary schooling; and 175 districts had no dentists with a medical qualification. Health worker density and income: more dentists per capita - correlation coefficient (Anand and Fan, 2016) 30

31 Table 19. Details of Oral health manpower Indicator India Karnataka Total number of dentists (1.2%) 2001 (8.24) Density= dentists/1 lakh population Dentists in rural areas 20.8 NA Female dentists % with more than secondary schooling 62.1 NA % with a medical qualification Urban dentists NA % of all urban health workers 1.6 NA Density per lakh urban population 6.8 NA Rural Dentists 5088 NA % of all rural health workers 0.6 NA Density per lakh rural population 0.7 NA Urban rural disparities Male dentists NA % of male dentists of all male health workers 1.5 NA Female Dentists NA % of female dentists all female health workers 0.7 NA Male female dentist ratio 3.2:1 NA Graduate Degree (51.2) NA Post graduate degree 2143 (8.8) NA with technical or non-technical diploma 531 (2.2) NA With secondary schooling or less 9239 (37.9) NA (Source: National Health Resource Centre, 2013) In summary, the extremely low availability of dentists in the country left 30 percent of districts in the nation (175/593) completely unserved with a medically qualified dental practitioner. In Karnataka, these districts are Bidar, Koppala, Chamrajnagar and Gadag Occupational Health The Regional Occupational Health Centre (Southern) Bengaluru was instituted in Since inception has been engaged in occupational health research addressing issues of the Southern states - Andhra Pradesh, Karnataka, Tamil Nadu, Kerala and the Union Territory of Pondicherry. There is not much existing data to comment about the current situation for the same. 31

32 Blindness Control The National Programme for Control of Blindness was started in 1976 as a Centrally Sponsored Scheme to counter the problems of Blindness due to various factors and also to reduce the prevalence of Blindness to 0.3 percent by The present prevalence rate of blindness to 0.3 percent by The present prevalence rate of blindness is 1% as per National Survey Eye Banks registered under Human Organs Transplantation Act and 14 eye donation centres are affiliated to eye banks are functioning in Karnataka including 7 Government Eye Banks at Bangalore, Mysore, Belgaum, Hubli, Bellary, Mandya and Hassan. As per the policy of Govt.of India under NPCB eye bank infrastructure is also improved to increase cornea collection and Keratoplasty. Accordingly, 9 Eye Banks have been strengthened under NPCB so far. Majority of the cataract surgeries are being done by NGOs Disaster Management Karnataka State has the distinction of being first in the country to establish a Drought Monitoring Cell (DMC) in 1988 as an institutional mechanism affiliated to Department of Science and Technology, Govt. of Karnataka. Subsequently in 2007, the DMC was renamed as Karnataka State Natural Disaster Monitoring Centre (KSNDMC) and the activities were broadened to also include monitoring of other natural disasters Mental Health The mental care resources in the state consist of NIMHANS, Bangalore, Institute of Mental Health in Dharwad, departments of psychiatry in the medical colleges, private psychiatric hospitals/nursing homes in major cities like Bangalore, Mysore, Hubli, Davanagere and services provided by voluntary organisations. Karnataka is fortunate to have a number of organisations like the Medico Pastoral Association, Richmond Fellowship, Family Fellowship, Cadabams which provide short and long term care and rehabilitation services. There is a need to integrate Mental health into Primary Health care services where the reach is more. During the year District Mental Health Programme is approved in all the 30 districts and BBMP in Karnataka. Counselling services are made available in 34 colleges, 32 workplaces and 15 urban slums. Manasadhara Centers: Community Mental Health Programme, funded by the state one for each District. Day Care Centre / Rehabilitation centre for the recovered mentally ill persons. These centres are functional in 15 districts. Manochaitanya: (Super Tuesday clinic) Programme is a new initiative of Karnataka. Under this programme, on selected Tuesdays Psychiatrist from DMHP/DH/Medical college/private provides specialist Services to the mentally ill at the Taluk level hospitals. Currently these are functional in 139 Taluks of the State Women and Child Health The overall health and developmental status of women in Karnataka has improved over the past several decades. But, the improvement does not compare favourably with that of States like Kerala, Tamil Nadu etc. There is considerable disparity between Rural & Urban Karnataka, between males & females and regional disparities with the districts, due to poor health and other developmental indicators. In Karnataka, institutional delivery improved from 65 percent in DLHS-3 to 89 percent in DLHS

33 Introduction of Facility Based New Born care New Born Care Corner (NBCC): 1070 NBCC are functioning at all delivery points, as on Newborn care corners are established in labour rooms & Operation Theatres in all the 24X7 PHCs, CHCs, Taluk Hospitals and District hospitals. New Born Stabilization Units (NBSU): 166 NBSU are functioning as on NBSUs have been established in all First Referral Units (FRUs) and Taluk Hospitals. Special Newborn Care Unit (SNCU): 37 SNCUs are functioning as on 2016 at all district hospitals and some high performing Taluk hospitals. SNCU Online Monitoring Software: All 37 SNCUs are now integrated with the SNCU Online Monitoring Software at their units. Janani Shishu Suraksha Karyakrama (JSSK): Janani Shishu Suraksha Karyakrama (JSSK) was introduced in early 2012 to reduce the out of pocket expenditure of the parents towards the treatment of sick newborn. This facility is being utilized for neonates and infants admitted to SNCU s and district hospitals. This is a 100 percent Government of India funded Programme, through National Health Mission. The main aim of this programme is to ensure, totally zero out of expenditure to Pregnant Women to avail free delivery services in Government Hospitals. In this Programme five free services are provided in all Government hospitals across the State. The services which are provided free of cost to all pregnant women are; free drugs and consumables, free diagnostics, free blood, free diet and free transport services from home to health institutions and back home. For all Government Hospitals; for providing free delivery services, for each case. Janani Suraksha Yojane (JSY): This is 100 percent Government of India funded Programme, through National Health Mission. The main objective of this scheme is to motivate all BPL, SC and ST Pregnant Women to deliver in Health Institutions, to reduce maternal and infant deaths. In this programme, pregnant women of BPL, SC & ST who deliver in health institutions in rural areas are provided Rs 700 cash incentives, in urban areas; Rs 600 and if they deliver through C- Section in private institutions are provided Rs If the said category Pregnant Women deliver at their homes, they are also provided Rs 500 cash incentives to meet their post-delivery wage loss. In Fig 15., it is observed that the highest number of First Referral Units are present In Belgaum and Mysore districts while the least are present in Bangalore and Yadgir districts. Figure 15. Distribution of First Referral Units - Districtwise, Karnataka 33

34 (Source: Karnataka State Health Profile, ) In Figure 16, There has been a significant dip in MMR over the years. The current MMR in the state is 144 for every 100,000 live births. Figure 16. Maternal Mortality Rate Trend, Karnataka (Source: Census of India, ) In Figure 17, it is observed that the neonatal mortality rate has not seen much of decrease across the state. When the urban versus rural setting is compared, it is noticed that the mortality rates continue to be high in a rural setting (27 per 1000 live births; urban is 12 per 1000 live births) but sees a slow decline. Figure 17. Trend of Neonatal Mortality Rate, Karnataka (Urban vs Rural) 34

35 (Source: SRS Statistical Report 2011,2012,2013 ) Figure 18.Trend of Infant Mortality Rate, Karnataka (Urban vs Rural) (Source: SRS Statistical Report, 2013 and NFHS-4) In Figure 18., it is observed that the Infant Mortality Rate has seen a slow decline across the state with the current rate being 24 per 1000 live births. When the urban versus rural setting is compared, it is noticed that the mortality rate continues to be high in rural setting with a rate of 27 per 1000 live births while urban is 19 per 1000 live births. 35

36 Population Stabilisation Stabilising of population is an essential requirement for promoting sustainable development with equitable distribution but this has to be within the context of enhancing outreach of primary education, enhancing essential amenities such as sanitation, drinking water, health care, employment and empowerment of women. In Table 24., nearly 51 percent used modern contraceptive methods in comparison to 62.5 percent that did in (NFHS-3). According to NFHS-4, nearly 48 percent of the urban population are using some form of family planning method while it is 55 percent in a rural setting. Unmet need for family planning among currently married women is 10.4 percent, which has not seen much change in comparison to the year Table 20: Comparison of Family planning methods, Karnataka Family Planning Methods NFHS-3 ( ) NFHS-4 ( ) Any method Total Unmet Need Modern method Focus on Special groups (Source: NFHS-4) While Karnataka has managed to address the health concerns of the major population groups, the vulnerable communities continue to be at loss in terms of access to good quality services Tribal Health Currently, there are 50 Scheduled Tribes (ST) in Karnataka notified according to the Constitution (Scheduled Tribes) Order (Amendment) Act The sex ratio for Scheduled Tribes in Karnataka is 990 females per 1000 males which is higher than the all-india average of 964 for STs as well as the State overall average of 973 females per 1000 male population. The literacy rate among the tribal population in Karnataka is 51 percent in urban and 65.7 percent in rural areas, while the overall figure of the State is 60.4 percent in rural areas and 76.2 percent in urban areas. The literacy rate among male population was found to be significantly higher at 57.5 percent than the female counterparts where it is 42.5 percent. Despite efforts from the Government and non-government organizations to take primary health care to these marginalized people, there has been a very limited number of studies reported on the health status of the tribal communities of the state Elderly Health Karnataka is one of the few states to implement the National Programme for the Healthcare of Elderly. Senior Citizen under RSBY Scheme: There is need for providing social security to Senior citizens as they cannot work and earn due to age. Government of Karnataka has come up with a plan to provide health security to the senior citizens within the ambit of RSBY as a top up scheme for families holding RSBY card. 36

37 Health Promotion and Advocacy The Health Education and Training Section of this Directorate is organized below programmes mainly responsible for: 1. Arranging exhibitions Health & FW programmes at Mysore Dasara Exhibition, 2. Celebration of world Health Day programme on 7th of April every year at state Level and peripheral levels. 3. Nomination of Members for Arogya Raksha Samiti s. 4. Deputation of Medical and Non medical staffs for Haj Yathra every year. 5. Conduct state level National programme for DHO s / DS review meeting. All DHOs to arrange the monthly progress review meeting. 6. Deputation of In-service MBBS/Ayush Doctors and Staff Nurse for 12 months PGDPHM course Human Resource Development Medical Education and Research: Providing access to affordable education to meritorious students has been the objective of the State. There has been an increase in the number of seats available in government sector for under-graduate and post-graduate medical courses through opening of new medical colleges as well as increase in intake. While the intake in MBBS in government as well as private colleges was 8265(Government: 2750) in , that in PG medical was only 3316 seats (Government: 643). there is a strong case for further increase of seats in post-graduate medical courses in general and in government medical colleges in particular to provide a) an opportunity for MBBS graduates to specialize in their chosen subject; b) To enhance availability of specialists. 248 Nursing Colleges recognized by Indian Nursing Council turn out Nurses (B.Sc. Graduates) every year. The department has also been providing secondary and tertiary care under medical college hospitals. The entire capacity for tertiary care is in the hospitals administered by the Medical Education Department (MED). A major part of the secondary care capacity is also with that department as 19 out of 42 district or major secondary care hospitals are attached to the government medical colleges and are administered by that department. Vision 2025 for the Health sector can be realized when HFWD and MED work in tandem and have improved coordination. The Karnataka Compulsory Service by Candidates Completed Medical Courses Act stipulates one year compulsory service either after MBBS or post-graduation or super-specialty for candidates who have completed such courses from KarnatakaIt could be post bachelor s, masters or specialty course. Currently the department is trying to vacate the stay order on the same. The department has also introduced tertiary level services and has been trying to improve the infrastructure of it s facilities accordingly. Superspeciality services have been introduced in Hubballi and Bellary. Along with Trauma care centre in place in Bengaluru, new centres are being itroduced in Mysuru and Kalaburgi. Table 21: Medical education institutions and enrolments for the years Sl No. Type of Institution Numbers Enrolments 1 Medical college 55 8,125 2 Ayurvedic Colleges 66 4,170 3 Homoeopathic College

38 4 Unani College Naturopathy and Yoga Science Dental colleges 39 2,770 7 Pharmacy Colleges Nursing Colleges ,840 (Source: Economic Survey of Karnataka, ) Table 22. Medical Education Institution by Managements for the year Sl No. Type of Institution Government Aided Unaided 1 Allopathy College Super Specialty Institutions 8 3 Ayurveda Homoeopathy Unani Naturopathy and Yoga Dental Pharmacy College (B. Pharm) 1 53 (Source: Economic Survey of Karnataka, ) Dental Education: Karnataka has 46 dental colleges, the highest in India and produces 3260 dentists every year. These 46 colleges make up 16% of the colleges in India serving about 5% of India s population (5,02,10,000). The number (and proportion) of people in Karnataka living within 20 km and 40 km (as well as outside 40 km) from a dental college is tabulated in Table 23. (Sandhu, Kruger and Tennant 2014) Table 23: Proportion of people living within 20 km and 40 km (as well as outside 40 km) from a dental college in Karnataka. Distance Population Percent Within 20km Within 40 km Outside 40 km The above table shows that 40% of people of Karnataka are living 40 kms away from a dental college (tertiary care centre) and affects the accessibility to oral health care. More than 80% of dentists serve 30% of the population based in urban areas. The people in the rural areas have no access to oral health care. The out of pocket spending especially from middle class and poor people is a matter of concern as dental treatment in private sector is expensive. (Task force on Health and Family Welfare 2001) Compulsory Rural Service: As per World Health Organisation, the ratio of doctors to people should be 1:1000. But, it is 1:1,700 in the state. The Karnataka Compulsory Service by Candidates 38

39 . Completed Medical Courses Act, has made rural service mandatory for all students who have completed MBBS and postgraduate medical from Karnataka with the amendment. 3,300 MBBS graduates and 2,000 post graduates are expected to work in rural areas Training (SIFHW): The State Institute of Health and Family Welfare is an apex training institute of the Health and Family Welfare Department which was established in SIHFW is headed by Director and is assisted by Joint Director, 10 deputy directors and an administrative wing. It has a network of 4 HFWTCs, 19 DTCs, 28 ANM TCs and 4 LHV TCs in the various districts to meet the training needs Health System Management/ Governance: The structure and management practices of the health system have to be such that they serve the purposes and meet the objectives of the system. The efficiency of the health services is dependent on two factors. The first would be the management of the services as an administrative structure, while the second would be the quality and adequacy of external but related aspects. Administration: Karnataka Government has started implementation of HRMS in March, 2005, which is unique in the entire country. Today HRMS is rolled out in the entire state. HRMS is generating salary bills of more than five lakh employees and also maintaining employee service history. Human Resource Management Systems (HRMS): or Human Resource Information systems (HRIS) or HR Technology shape an intersection between human resource management (HRM) and information technology. It merges HRM as a discipline and in particular its basic HR activities and processes with information technology. Transfer Policy: The state government introduced the Transfer Policy under the Regulation of Transfer of Medical Officers and Other Staff) Act, 2011 (Karnataka Act 2 of 2011) was published in Notification No: HFW 89 HSH 2011 dated: in part IV-A, No: 506 of the Karnataka Extraordinary Gazette dated: Those who have completed 10 years of service in one particular position get transferred by the department accordingly. The last circular was released by the department in Vigilance Cell and Lokayuktha: In order to improve the public health care system in the State of Karnataka, the then Chief Minister set up a Task Force on Health and Family Welfare in December The Task Force was required to make recommendations regarding improvements necessary in the management and administration of the department and to monitor the impact of the recommendations. One of the major concerns of the Task Force report (published in 2001) was the issue of corruption in the health sector. Corruption was found at various levels of the system and in all aspects and sectors of health care. The Task Force recommended the setting up of an institutional mechanism in the Directorate of Health. A Vigilance Cell was established in the Department of Health in 2002 to investigate minor complaints on Class II, III and IV group of health staff received by the department directly and also cases referred to it by the Lokayuktha (literally people s representative - see comments box for more information). Health Management Information System: HMIS (Health Management Information System) is an initiative undertaken under the National Rural Health Mission (NRHM) launched by Government of 39

40 India. Accurate, relevant and up-to-date information is essential for the health service providers at all levels so that they can initiate action on the gaps in the system, based on evidence and information. Hence Government of India directed all the states to capture data as per the HMIS formats on a web-based system (HMIS) from all facilities. Karnataka is the first state in the country to capture facility wise data from Sub Centre level since August The data captured will be validated at each level and minimizes the error. Lot of information pertaining to RCH activities are captured under HMIS Mother and Child Tracking System (MCTS): A web based Pregnant Women and Child Tracking System (MCTS) introduced aiming to provide pre-natal & post natal care at the door steps of rural poor. So far lakhs pregnant women and lakhs children have been registered under the system. This programme is greatly appreciated by the Government of India which has asked other States to consult Health Financing Though the public health services in India play a vital role, their contribution to total health services in the country is low. Public spending on health was an unusually low 0.22 per cent of the GDP in (MoHFW, Government of India, 2005). As per the latest World Bank data, India spends 3.8 percent of GDP on education and 1.4 percent of GDP on health which is below the world average of 4.4 percent and 6 percent, respectively. Karnataka spends 3 percent of its overall state expenditure towards health. Although, the total expenditure on health has increased over the years, the proportion of health expenditure to the GSDP has decreased from 1.46 ( ) to 1.0 ( ) while the percentage of total State expenditure spent on health has remained stagnant. It is estimated that about 70 percent of per capita expenditure on health was incurred by households, while public sources covered only 23.2 percent of this expenditure. Table 24. Expenditure on Health and Education as percentage of GSDP Sl. No. States Health % to GSDP (Actual) (RE) % Difference 1 Maharashtra Karnataka Kerala Tamil Nadu (Source: Niti Aayog Report- Social Sector Expenditure of States Pre & Post Fourteenth Finance Commission ( & ) Food and Drug Control Food licensing in rural areas is currently done by Medical Officers, while there has been quite a few vacancies for food inspectors. Essential Drug List (EDL) & Standard Treatment Guidelines (STG) updates: Karnataka State has prepared EDL and STG as per the recommendation of Task Force. The same needs to be 40

41 updated. Department of Drug Controller, Karnataka: The State Drugs Control Department is existing since 1956 as an Independent body under the control of the Ministry of Health and Family Welfare. It is headed by the State Drugs Controller. The main objective of the Department is to implement the Drugs and Cosmetics Act, 1940 and Rules there under and to ensure the quality of the Drugs and Cosmetics manufactured and marketed in the state in the interest of the public health. By exercising strict control and vigilance on the drugs marketed in the State, the Department eradicates the menace of Spurious and substandard drugs, ensures safety of drugs and their availability on the controlled prices to the public. The Department has three wings: The Enforcement Wing: Enforcement wing consists of one Additional Drugs Controller assisted by 13 Deputy Drugs Controller, (3 DDC s Vacant) Deputy Drugs Controller are assisted by 60 Assistant Drugs Controllers (2 ADCs vacant) under Assistant Drugs Controllers 112 Drugs Inspectors are provided. (83 Drugs Inspectors posts are remained vacant as on ). Drugs Testing Laboratory: Drugs Testing Laboratory division is headed by Principal Scientific officer and is assisted by 3 Chief Scientific Officer s of 3 laboratories. 19 scientific officers are working as government analysts. Out of 113 junior scientific officers 33 posts remained vacant as on The Pharmacy Education: Administrative control and supervision of Pharmacy Education vests with Drugs Controller. Prosecutions Instituted: The prosecutions instituted under Drugs and Cosmetics Act, 1940 and Rules 1945, Drugs (Price Control) Order, 2013 (An order issued under Essential commodities Act 1955) and Drugs and Magic Remedies (Objectionable advertisement) Act 1954 and Rules. During the year (1 st April 2016 to 31 st March 2017), a total of 688 cases were found while the prosecution is pending for 645 under the D&C Act; 39 under the DPCO and 4 under the DMR. Drugs and Logistics Society: With an intention to select, procure, store and distribute various categories of drugs in time to all the Health Institutions in a more scientific approach, thereby to ensure availability of right drug at the right time in the right proportion in the hospitals, Karnataka State Drugs Logistics & Warehousing Society (KSDLWS) was established with the assistance of European Commission to the tune of Rs crores in the year Indent processing: The KDLWS received the District indents and consolidate the state level requirement of drugs. 53 Final list of Drugs & its quantities were approved by Need Assessment Committee and the tender were floated. KSDLWS has decided to get the online indents from all health institutions from the year Physical Achievement: Along with the existing 14 district warehouses, 13 new warehouses have been made operational during the year Drugs are procured as per the requirements of the health institutions and are being supplied through 27 district drug warehouses. Procurement of Equipments: KSDLWS has carried out the procurement of equipments, furniture s and ICT components for the year The total amount for the year is Crs Table 25. Financial Achievements: Health & FW Department (Rupees in Lakhs) 41

42 Sl. No Budget Targeted for the year Budget released for the year Budget Utilised up to * Percentage % % Remarks (NP) Purchase of Drugs & Chemicals (P) Equipment & Furniture s. (Source: Directorate of Health and Family Welfare Services, Annual Report, ) *Principal Secretary stated that about INR 340 Cr is being spent towards the same which includes the NHM funds for drugs Indian Systems of Medicine (AYUSH) The Hospitals and Dispensaries which comes under ZP Sector are being monitored by the concerned District s District AYUSH Officers. Government Central Pharmacy Bangalore supplies 60% of Medicine (Ayurveda and Unani) to Govt. AYUSH Hospitals and Dispensaries & 40 % of Medicine procured & supplied from Karnataka State Drug Logistics & Warehousing Society, Bangalore and Indian Medicines Pharmaceutical Corporation Limited, (Central Government Enterprise). 100% of Homoeopathic medicines procured and supplied from Central & State Government Enterprises. The Details of Hospitals with bed strength and dispensaries functioning in this State as on In the state, there are four Ayurveda medical colleges with attached hospitals. Table 26. List of hospitals under AYUSH System Government Hospital No. of dispensaries No. of Hospital No. of Beds Ayurveda Unani Homoeopathy Nature Cure Yoga Total (Source: Directorate of Health and Family Welfare Services, Annual Report ) Table 27. The Registered Medical Practitioners of various systems Name of System No of practitioners Ayurveda

43 Unani 2010 Integrated systems 2433 Naturopathy and Yoga 817 Siddha 06 Homoeopathy Total (Source: Directorate of Health and Family Welfare Services, Annual Report ) Panchayat Raj and Empowerment of People Karnataka is a pioneer in decentralised democratic system. At the District level, District Health and Family Welfare Officer is the head of Public Health Services. Implementation and monitoring of various National & State Health Programmes in all below 100 beds health care service institutions which are under Zilla Panchayat Sector are done by the District Health and Family Welfare Officer. All the PHCs and CHCs and below 100 bedded hospitals come under the Zilla Panchayat. The Panchayat Raj curently manages the PHC under them. Empowerment of people: Village Health Sanitation Nutrition Committee (VHSNC): One of the key elements of the National Rural Health Mission is the Village Health, Sanitation and Nutrition committee (VHSNC). The committee has been formed to take collective actions on issues related to health and its social determinants at the village level. They are particularly envisaged as being central to local level community action under NRHM, which would develop to support the process of Decentralised Health Planning. Thus the committee is envisaged to take leadership in providing a platform for improving health awareness and access of community for health services, address specific local needs and serve as a mechanism for community based planning and monitoring. There are three components for VHSNC: Community Planning, Community Action and Community monitoring. We have done one round of training about Community Planning, Community Action while community monitoring is pending. Arogya Raksha Samitis: 2353 Arogya Kalyan Samitis have been registered in Karnataka as of 31st March, Strengthening Partnerships: The role of private sector especially the Not-for-profit private sector in Karnataka has played a major role. Various schemes of the health department have been implemented through this partnership, like the Blindness control, TB control programme, Leprosy control, HIV programme etc. Revised Arogya Bandhu Scheme: Karnataka is a pioneer of innovative schemes in many spheres including health. One such innovative scheme is Arogya Bandhu a Public - Private - Partnership (PPP) launched in July Here the private means the NGOs. The Arogya Bandhu scheme was brought to halt in between and this produced immense challenge in implementing the management of PHCs. The Revised Arogya bandhu Scheme of the Dept of Health & Family Welfare, which covered a total of 56 Primary Health Centres in the State is being managed by various organizations under public private partnership. Out of these 56 PHCs, 21 are managed by 11 medical colleges and 35 by 10 NGOs. SAST: This Trust was introduced by the state government for secondary and tertiary care, under the Public Private Partnership model. 43

44 Multisectorality and Intersectoral Collaboration Intersectoral Action for Health calls for positive mutually supporting relationship between health sector and other sectors to achieve health outcomes, which are more efficient, effective, equitable and sustainable than could be achieved by the health sector alone. Whether within the Government or outside it, decisions affecting health should be taken collaboratively. School health: School Health Programme has subsumed under Rashtriya Bal Swasthya Karyakram (RBSK). This programme commenced from the year of , under this programme 0 to 18 years children are screened for 38 health conditions broadly classified under 4 D s. Rashtriya Bal Swasthya Karyakram (RBSK) is implemented in the State in all rural and urban areas children studying in 1st to 12th standard in Government, Government Aided and Residential Schools and in Anganwadi Centers. This programme is being implemented in coordination with Department of Health and Family Welfare, Women and Child Development, Public Instruction, PU Board and Social Welfare. During , out of an annual target of , students enrolled in Anganwadies centers, Government and Government Aided schools were screened and 7503 students (April-16 to Mar-17) have undergone for different surgeries. Table 28. RBSK School Programme Progress report for the period of Beneficiaries Annual Target Achievement % Health Screening of 0-18 years children (Anganwadi and school) 1,52,07,929 1,18,16, % (Source: Directorate of Health and Family Welfare Services, Annual Report ) Rural Development: The drinking water infrastructure of the State comprises 2,24,608 bore wells fitted with hand pumps, piped water supply schemes and mini water supply schemes. Among the of rural habitations covered under the various schemes, about 8198 (13.61%) of habitations receive above 55 lpcd of water, (82.82%) receive less than 55 lpcd. The cause of worry is that 2146 (3.56%) are still water quality-affected habitations in the rural areas. Sanitation: Karnataka has been the forerunner in putting forth concerted efforts to implement Nirmal Bharat Abhiyan in the Rural parts of the State. In , 7.08 lakh Individual Household Latrines (IHHL) were covered. During the current year, up to December 2016, 4.62 lakh IHHL have been covered against a target of 4.29 lakh for Integrated Child Development Services (ICDS): This programme is implemented with the Coordination of Women and Child Development Department. There are 204 ICDS projects, AW Centers including Mini Anganwadi Centers are functioning in the State. Pregnant women, Lactating mothers and 0-6 years Children are beneficiaries of this programme. Mathrupushtivardhini Scheme: This programme will be implemented in 39 most backward Talukas of Karnataka covering pregnant and lactating mothers. This micro nutrient granules will be given from 2nd trimester for 6 months during pregnancy and it will be continued for 4 months during lactation totally for 10 months. 44

45 Table 29. Progress of Supplementary Nutrition programme under ICDS Year Expenditure (in lakh) No. of Beneficiaries , ,472, , ,479, , ,524, * 71, ,479,425 (Source: Directorate of Health and Family Welfare Services, Annual Report ) State Health Policy State Health Policy, 2004: The first state health policy was recommended by TSF health and family welfare in The same was placed before the assembly and accepted as the first integrated state health policy. Karnataka Integrated Public Health Policy, 2017: In order to ensure that the latest technological and policy developments are within the policy focus of the State, a new updated State Integrated Public Health Policy had been initiated through the Karnataka Jnana Aayoga (KJA) based on a request by the Government. To help the state move towards achieving the Sustainable Development Goals, the new revised state health policy has been approved. Karnataka Palliative Care Policy, 2016: Karnataka became the third state after Maharashtra and Kerala to have a policy for palliative care. The policy ensures all terminally ill patients and the geriatric population get mandatory all-round care and will be implemented in six districts across the state Health Assurance (SAST) SAST, an independent Trust, was formed as a special purpose vehicle in 2009 under the Department of Health & Family Welfare Department, GoK, to steer the implementation of Health Assurance Schemes of GoK on a project mode. Initially, the mandate was to oversee implementation of a cashless treatment to BPL card holding families for tertiary ailments in any of the empanelled Public Private Super Specialty Hospitals in Karnataka by strategically purchasing the services offered by these hospitals. With this intention, the Scheme Vajpayee Arogyashree was rolled out in to protect the needy BPL families from the financial hardship for treatment of catastrophic tertiary ailments. The Vajpayee Arogyashree scheme was evaluated by the World Bank which found that there was 64% reduction in out of pocket expenditure for the beneficiary and mortality was reduced by 68% among BPL families % households more likely to use tertiary care for covered conditions under VAS Rajiv Arogya Bhagya for APL (RAB): For the benefit of APL families,this scheme commenced implementation from on a co-payment basis. The cost sharing pattern for general ward is on 70:30 basis. Jyothi Sanjeevini Scheme (JSS): This health assurance scheme is specifically for the benefit of all State Government Employees and their dependants without any cap on the financial limit 45

46 and the treatment is totally cashless. Rastriya Bal Swastya Karyakrama (RBSK): Initially, the scheme was covering 36 procedures under 2 specialties only. Due to dire need, the scope was enlarged to cover 7 tertiary specialties with 538 procedures and 345 secondary procedures. Mukhyamantrigala Santhwana Harish Yojane (MSHS): the State Government launched the Good Samaritan scheme on March 8 th 2016 Mukyamantrigala Santhwana Harish Scheme (MSHS) for cashless treatment within the Golden Hour of 48 hours for victims of road accidents within the state of Karnataka irrespective of the nationality or domicile of the victim. Any accident spot nearby hospital having trauma / emergency care facility can treat the victim. Senior Citizen Scheme (Tertiary) under RSBY: Due to increasing BPL beneficiaries accessing treatment under VAS and due to fund constraint, Principal Secretary, HFW, GoK, directed that tertiary treatment for Senior Citizen s could be met out of the fund available under RSBY. Indra Suraksha Yojana (ISY): Free medical coverage to dependant families of Farmer s who committed suicide. Till date 1148 cards have been issued. Recently, SAST has received 4 beneficiaries Preauths for approval. Cochlear Implants: Cochlear Implant Scheme of National Health Mission, Health and Family Welfare Department, Karnataka will be implemented through the Rashtriya Bal Swasthya Karyakram (RBSK) and Suvarna Arogya Suraksha Trust (SAST) Health Technology & Innovations Telemedicine : At present 21 District & 5 Taluk hospitals Telemedicine facilities provided. They will get opinion from 11 specialist centers. e- governance provided KSWAN connectivity for all the above centers. In under NHM PIP approved to extend Telemedicine facility for all Taluk & 206 Community health centers. Tele-Radiology : Teleradiology started during : Established in District Hospital Chikkaballapura, Hassan, wenlock hospital Mangalore, General Hospital Lingasur. They will send the CT & X-ray Images to get opinion from the radiologist at BMC & RI, Bangalore. District Hospital Raichur, Kalburgi & Chitradurga work under progress. CSR project: Samsung Tab IRIS, the first commercial tablet which is UIDAI approved for Aadhar verification would enable the state to build their database in a digital format through ANMs. These TABs are preloaded with PHC Management Information System. ehealth Centre (ehc): is an initiative where IT will be used to enable local healthcare services and telemedicine, while collecting data pertaining to patients health and related issues. elaj clinics are technology-enabled, smart clinics equipped with multi-parameter monitoring device developed by Packet BIO, the technology partner of Biocon Foundation, which enables multiple diagnostic tests and generation of electronic medical records (EMRs) of patients. E-Hospital project which covers District Hospital/Taluka Hospitals and allows health care providers to collect, store, retrieve, and transfer information electronically which can minimize handwriting or other communication errors by having physicians or other providers enter data into a computer system. 46

47 E-Arogya, an Android Tablet based software application for digitalising the work process of ANMs. It helps to collect field level data directly on TABs and send to central server for quick reports, analytics and dashboard. This Tablet based application will be used for enhanced Tele-Medicine and video based health program awareness Health Industry India including Karnataka especially Bengaluru and other states is expected to rank amongst the top 3 healthcare markets in terms of incremental growth by In 2015, Indian healthcare sector became the 5th largest employer Growth of private hospitals in Karnataka India including Karnataka esp Bengaluru and other states is expected to rank amongst the top 3 healthcare markets in terms of incremental growth by 2025.In 2015, Indian healthcare sector became the 5th largest employer. There is ample opportunity for development of the healthcare industry including Karnataka. The total number of private sector hospitals as per KPME is 25,542 which is rising steadily. The low cost of medical services has resulted in a rise in the state s medical tourism, attracting patients from across the world. The health insurance has aided the rise in healthcare spending, a trend likely to intensify in the coming decade which is happening in Karnataka along with the economic prosperity which is driving the improvement in affordability for generic drugs in the market. Private players in the healthcare industry in Karnataka are making their supply chains efficient and leveraging economies of scope to reduce cost. Large investments by private sector players are likely to contribute significantly to the development of Karnataka s hospital industry and the sector is poised to grow to US$ 250 billion by Increase in number of hospitals in Tier-II and Tier-III cities has fuelled the growth of private sector in Karnataka Pharmaceutical companies Karnataka contributes 8 percent to the country s revenue in the pharmaceutical sector. The state has exclusive pharma SEZ s in Hassan and Yadgir. Karnataka ranks 5th in pharmaceutical Exports, contributing 12 percent to country s exports. Karnataka pharmaceutical policy 2012 aims to develop infrastructure, foster R&D and attract mega projects in the sector. Initiatives like venture capital fund of INR 50 crore with 26 percent contribution from Government, formation of Karnataka Pharmaceutical development council and The vision group and promotional activities have been introduced in the Policy. Karnataka Pharma industry is home to 221 formulation units and 74 bulk drug units. State s Pharmaceutical industry generated Rs 8,000 crore in revenue contributing 8% of the country s total revenues, ranking 10th in the number of Pharmaceutical manufacturing. Exports 40 percent of its pharma produce Health Equipment Manufacturers Karnataka has ranked on top with highest share of over 25 per cent in the total output worth about Rs 5,300 crore of medical and dental instruments and supplies sector generated across India, according to a recent ASSOCHAM study.of the total number of 26 factories in medical and dental instruments and supplies segment in Karnataka, 25 such factories were under operation as of Karnataka had sixth highest share of just over eight per cent in terms of direct employment generated by medical and dental instrument factories operating throughout the country. 47

48 2.2. Current Nutritional Status An overview of the nutritional status in the state of Karnataka is being created through the purview of multiple reports that provide factual data vis-a-vis the national and state scenarios. The entire data is being represented in a life-cycle approach across the population, spanning different age groups as shown below. Karnataka has a number of schemes and programmes like ICDS, Akshara Dasoha, Bala Sanjeevini, Ksheera Bhagya, Matrupurna Yojane, Jananni Suraksha Yojana, Tayi Bhagya, Madilu, WIFS, Suvarna Arogya Kavacha, Karnataka Comprehensive Nutrition Programme, Homes for Senior Citizens etc. run by different departments, each with its own objectives but within the overarching goal of improving the health and nutritional wellbeing of various categories of population i.e. women, children, adolescents girls, malnourished, pregnant and lactating women etc Birth and Early Childhood Nutritional Availability In terms of nutritional availability, there is a major rise in the percentage of children under three years who are exclusively breastfed within one hour of birth, both at the national level and the state level. With respect to children aged 0-5 months who are exclusively breastfed, the percentage is higher at the state level in comparison to the national level (K. NFHS ). A similar trend is observed with respect to children aged 6-9 months receiving solid or semi-solid food and breastmilk (K. NFHS ). Table 30. Nutritional Availability for Children up to Three Years, Karnataka vs India Indicators Maharashtra Karnataka Kerala Tamil Nadu India Children under 3 years who are exclusively breastfed within one hour of birth Children aged 0-5 months who are exclusively breastfed Children aged 6-9 months receiving solid or semi-solid food and breast milk NFH S % 51.8 % 45.5 % (Source: NFHS-3, NFHS-4) NFH S % 56.6 % 43.3 % NFH S % 58.0 % 69.7 % NFH S % 54.2 % 46.0 % NFH S % 56.2 % 93.6 % NFH S % 53.3 % 63.1 % NFHS -3 NFHS- 4 NFHS -3 NFH S % 54.7% 23.4% 41.6 % 33.3% 48.3% 46.3% 54.0 % 77.9% 67.5% 55.8% 42.7 % 48

49 Nutritional Status of Children: Further, the NFHS data shows a steady decline at the national level in the percentage of children under three years who are stunted. A similar trend is observed with underweight children under the same category. This observation holds up well when viewed across the latest rounds of NFHS (K. NFHS ). However, if the latest data is comparatively analysed with the previous survey (NFHS-3), a significant reduction in the above values cannot be inferred. A major disturbing fact is that the percentage of children under three years who are wasted has been gradually increasing, highlighting the gravity of acute malnutrition that plagues the nation (K. NFHS ). Table 31. Comparison of Nutritional Status of Children Under Five Years in Karnataka Karnataka NFHS-3 ( ) NFHS-4 ( ) Stunted (height-for-age) Wasted (weight-for-height) Underweight (weight-for-age) Severely Wasted (weight-for-height) NA 10.5 (Source: NFHS-4, NFHS-3) Figure 19. Nutritional Status of Children Under Five Years in Karnataka 49

50 (Source: NFHS-4, Karnataka) Reproductive Age Group and Adults: Ante-Natal Care (ANC): The indicators with respect to ANC services amongst currently married women aged years have not been very encouraging with respect to data that has emerged at both the national and state levels. Though the performance of Karnataka is comparatively better than the average national performance on these counts, it leaves a lot to be desired. Sl. No. Table 32. ANC Visits, Advice and Breastfeeding Practices Amongst Currently Married Women (15-49 Years) Indicators Karnataka India 1 ANC of currently married women (aged years) (a) Government health facility 49.20% 54.40% (b) Private health facility 44.80% 36.40% (c) Community-based services 4.50% 9.50% 2 Advice received on breastfeeding during ANC visit 89% 59.60% 3 Advice received on nutrition during ANC visit 70% 56.60% 4 3 or more ANC visits by currently married women 70.20% 51.00% 5 Consumption of 100 plus IFA tablets /syrup 45% 30.00% 6 Initiation of breastfeeding (a) Within 1 hour of birth 56.50% 41.50% (b)children under age 6 months exclusively breastfed (c)children age 6-8 months receiving solid or semi-solid food and breastmilk (Source: NFHS-4, Karnataka) 54.20% 54.90% 46.80% 42.10% Anaemia: The prevalence of anaemia declined over the years at the national level as shown in the figure 1.1 below (K. NFHS ; NFHS ). The percentage of pregnant women aged years who are anaemic has reduced. The percentage of children aged 6-59 months who are anaemic has reduced from 70 to 60% (K. NFHS ; NFHS ). In Karnataka, the prevalence of anemia across different age groups appears to be declined from NFHS-3 to NFHS- 4 survey. The gaps between the current values and previous reported data are declining as shown in the table below. Figure 20. Prevalence of Anaemia in Karnataka 50

51 (Source: NFHS-4, Karnataka) 2.3. Institutional Framework The proposed organogram for the document has been presented in Annexure-I Laws and Acts relating to Health: Legislation in health helps in implementing the health policy of the government and in protecting the society. There are a large number of Acts, Rules and Regulations, Central and State, affecting health care and health care providers. There are laws that have direct effect on health care, but there are many more which indirectly affect the health of the people. (For detailed list of acts under health, refer Annexure-II) The Karnataka Medical Council: was established by an Act of the legislature (Act no. 34 of 1961). The Council provides registration to doctors qualified in Modern Medicine. The Council is empowered to enforce the code of medical ethics. It can conduct enquiries regarding professional conduct, negligence, moral turpitude, false certification and infamous act. It can award punishment to the erring doctor, byway of warning, suspension or removal of the name from the register. While registration under the appropriate council (Medical, Dental, Nursing, Pharmacy) is mandatory for the practice of the profession, the law has now mandated renewal of registration compulsory among all councils. with evidence of having effectively participated 51

52 in continuing education in the appropriate discipline. The other state level councils are dental, nursing, pharmacy, AYUSH. Karnataka Private Healthcare Establishment Bill Karnataka had the Karnataka Private Nursing Homes (Regulation) ordinance, 1976 and the Rules --there under. But, this was never implemented as they tried to bring in a control mechanism for the pricing of services. The Karnataka Private Medical Establishment Act, 2007 and Karnataka Private Medical Establishments Rules, 2009 are in force. This legislative aims to regulate, control and monitor Private Medical Establishments in Karnataka for providing quality care according to medical ethics by prescribing service quality. The act requires private hospitals to display their service rates openly so that the citizens have the benefit of choice. The emergency care was made mandatory. No. of Registered Medical establishments registered under KPME ACT is as per the DHS annual report Amendment to KPME Act, The government of Karnataka, is planning to bring amendments to the KPME Act, 2007 by again trying to bring in a price control mechanism, penalty clauses and grievance redressal mechanism etc. Private sector hospitals are objecting to the amendments proposed. The subject is still under discussion between all the stakeholders. The Karnataka Good Samaritan and Medical Professional (Protection and Regulation during Emergency situations) Bill, 2016, has been enacted to protect people who try and help victims of accidents and also seeking to incentivize bystanders to help accident victims. Public Health Act: The draft of the Karnataka Promotion of Public Health and Prevention of Diseases Bill has been prepared by officials of the Karnataka Health System Development and Reform Project (KHSDRP) in coordination with Karnataka Institute for Law and Parliamentary Reform and is under discussion with all the stakeholders and not yet finalised Benchmarking Karnataka s Health and Nutrition Sector Karnataka has seen a slow and steady improvement in terms of the main health indicators, such as IMR, MMR but they have plateaued over time. Here, we are comparing Karnataka with the neighbouring states, Tamil Nadu and Kerala and with Maharashtra, as certain models have been implemented there as well as nationally compared the state s progress. To benchmark and see where Karnataka stands in terms of health and nutritional indicators below we have provided a comparison of the same Health Infant Mortality Rate: According to Figure. 21, it is seen that in comparison to neighbouring states, Tamil Nadu and Kerala, Karnataka still lags behind in terms of addressing the concern of IMR. While when compared to Maharashtra and at a national level, Karnataka is performing better and needs to continue strengthening its health service delivery. Over the years, Karnataka has seen a decline in IMR, similar to other states and nationally. Figure 21. Trend and comparison of IMR, Urban vs Rural 52

53 (Source: SRS Statistical Report 2011,2012,2013, 2014, 2015, 2016 ) Figure 22. Trend and comparison of IMR, state and national level 53

54 (Source: SRS Statistical Report 2011,2012,2013, 2014, 2015, 2016 ) Maternal Mortality Ratio: In Fig 23., Karnataka is the highest at 144 per 100,000 live births in comparison to Tamil Nadu, Kerala and Maharashtra while it is lower than the national level of 167 per 100,000 live births. When the trend is seen over the years, Karnataka has seen a steady decline as well as plateau period with a sudden dip but continuation of the plateau with no decline in the MMR. Figure 23. Trend and comparison of MMR, state and national level (Source: Census of India, ) Neonatal Mortality Rate: In the below figure, Karnataka has seen a very low decline at 22 per 1000 live births in comparison to the neighbouring states while it is lower than the national level at 28 per 1000 live births. Over the years, it is seen that the NMR continues to remain stagnant, while nationally there has been a significant decline. 54

55 Figure 24. Trend and comparison of NMR, state and national level (Source: SRS Statistical Report 2011,2012, 2013 ) Under-5 Mortality Rate: In the below figure it is observed that in comparison to the neighbouring states, Karnataka has a higher U5MR of 25 per 1000 live births while is lower than the national U5MR of 29 per 1000 live births. It is also seen that Karnataka has been a significant decline in U5MR from the year 2011 to Figure 25. Trend and comparison of U-5MR, state and national level (Source: NFHS-4 ) Total Fertility Rate: In the below figure, it is noticed that Karnataka has a low TFR of 1.9 in comparison to its neighbouring states, while is better than the national TFR of 2.2. Trendwise, it is observed that over the years, Karnataka is seeing a plateau period. 55

56 Figure 26. Trend and comparison of TFR, state and national level (Source: NFHS-4; NFHS-3 ) Nutrition In Table 35., When we look at indicators such as stunting, nearly 36% of the children are stunted and 35% are underweight. In adults, it is observed that nearly 24% of women are overweight/ obese while 56

57 it is 22% in men. Anemia continues to be a major concern with 45% of pregnant women age years are anemic. Table 33. Comparison of nutritional status indicators, state and national level Sl. No. Indicator Statistics 1 Stunting Karnataka India (a) Children who are stunted 36 % 38.90% (b) Children who are wasted 26.90% 21.90% (c) Children who are underweight 35.30% 35.70% 2 Physical malnutrition status of men and women (a) Women whose BMI is below normal 20.70% 22.90% (b) Men whose BMI is below normal 16..5% 20.20% (c) Men who are overweight/obese 22.10% 18.10% (d) Women who are overweight/obese 23.30% 20.70% 3 Anaemia Pregnant women age years who are anaemic (Source: NFHS-4) 45% 50.30% 2.5. Global Benchmarks in Health and Nutrition In this section we present the status of Karnataka in comparison to global standards which have shifted from the Millennium Development Goals (MDGs) to Sustainable Development Goals (SDGs). As per the SDG s, health and nutrition come under Goal 2: Zero Hunger Goal 3: Good Health and Well Being 57

58 Under these specific goals, below Karnataka has been compared with neighbouring countries such as Bhutan, Bangladesh, Thailand and Sri Lanka to see where we stand Health The SDG-3 can be used as a benchmark for the three health indicators addressed, Maternal Mortality Ratio, Under-Five Mortality Rate and Neonatal Mortality Rate. Universal Health Coverage is an explicit target under SDG-3 and can act as the anchor to guide and inform SDG goals in health. Currently, Karnataka stands at 133 per 100,000 live births while it is better performing than our national level, when compared to Bhutan, Sri Lanka, we have a long way to go ahead (the SDG-3 states to reduce it to 70 per 100,000 live births). The Under-Five Mortality Rate in Karnataka is currently at 32 per 1,000 live births while Sri Lanka is at 9.6 per 1,000 live births which is a major difference and has already achieved the SDG target (25 per 1,000 live births). The Millennium Development Goal (MDG) for Under 5 Mortality Rate has already been achieved in Karnataka in the past. The Neonatal Mortality Rate currently in the state is 22 per 1,000 live births, where the other countries are also along the similar range, with Sri Lanka standing out and already achieving the SDG-3 target of 12 per 1,000 live births. From district discussions and state level workshops, feedback was given to have the vision of reaching a goal of reducing the Maternal Mortality Ratio by 50 percent Nutrition When nutritional indicators under the SDG-2 targets, it is observed that Karnataka still needs to improve in addressing stunting in under five children when compared with Thailand and Sri Lanka. While when wasting in under five children is observed, it is noticed that Karnataka is the highest in comparison to other countries. This shows the dire need to address the nutritional concerns faced within the state and the need to reduce the number of children under five who are wasted. Table 34: Comparison of Health and Nutritional Indicators (Global) Indicators Karnataka India Bhutan Thailand Bangladesh Sri Lanka Maternal Mortality Ratio (per 100,000 live births) SDG 2030* per 100,000 live births 58

59 Under-5 Mortality Rate(per 1000 live births) Infant Mortality Rate (per 1000 live births) Neonatal Mortality Rate (per 1000 live births) Stunting Among Children under 5 years(%) Wasting Among Children under 5 years(%) per 1,000 live births per 1,000 live birth 36% 38% 34% 10% 36% 15% 40% reduction in the number of children under-5 who are stunted 27% 21% 6% 21% 14% 5% 40% reduction in the number of children under-5 who are wasted (Source: NFHS 4; EPI Fact sheets 2016, Global Nutrition Report- 2017) 59

60 3. Strategic Analysis of Health and Nutrition in Karnataka In this section, we focus on what are the strengths, opportunities, gaps and strategic interventions in the health and nutrition sector. Based on the current health and nutritional status trend, the strengths, opportunities, gaps and strategic interventions have been presented in the table below. Sl No. 1 Equity 2 Quality Topic Strengths Gaps - - There is huge gap with respect to North and South Karnatka, districtwise and backward Talukas as per Nanjundappa Commitee - Unequal distribution of health facilities between North and South Karnataka districts is seen in terms of regional, pattern of utilisation of health services (public and private), provision of government primary health care facilities etc. - No data is available on the actual inequities, based on gender, age, region and disabilities. - Taluk level disparities have also been identified in all divisions of the State - The department has initiated the process of accreditation across the public health facilities - The major gap seen is that very few government institutions have received accreditation for quality. - Of the about 4,000 hospitals across Karnataka, only 119 have National Accreditation Board for Hospitals and Healthcare Opportunities and Enablers There are lot of people in the backward districts and Taluks, who are demanding for equity. Vairous committees have been formed to bring in equity -To ensure quality assessment and accreditation of all government facilities Strategy Specific planning and budget of the backward districts and taluks. - Full implementation and follow up of quality accreditation of all public health facilities which wil improve the utilisation and perception about public health facilities among people - Need for quality

61 3 4 Primary Health Care Secondary & Tertiary Health Care - Number of PHCs are more than the Govt of India norms -Introduction of Urban Primary Health Centres Providers (NABH) recognition. And Only 4 of the 119 NABH-recognized hospitals are government institutions - The quality of care needs to be strengthened thus increasing the utilisation of public health facitlites - Vacancies is a big concern that needs to be addressed - Current infrastructure is poor and needs to be improved both in Urban and rural settings - Rural PHC: Referral system has been poorly implemented and managed. Teaching hospitals attached to the medical colleges function as referral hospitals too, and provide secondary and tertiary care less complicated cases that could be attended to at lower levels get referred to the teaching hospitals avoidable referrals lead to overburdening of the secondary and tertiary care centres, and unnecessary travel expenses to the patients for health care. - -Major factor affecting the efficiency and quality of care provided by the secondary and tertiary care hospitals in the government sector is the mismatch between requirements and the - Enhancing existing services by working towards filling in vacancies and provision of better infrastructure - Enhancing existing services by working towards filling in vacancies and provision of better infrastructure assessment of all government facilities against IPHS standards - -Effective implementation of NQAC and NABH - Reorganisation of PHCs and their population across the district and the state - Filling up all exisiting vacancies - Strengthening of every unit of the referral system, and putting in place a system of audit of referral cases to provide a continuous feedback loop on quality of referrals is a must. - Make the secondary and tertiary health care institution fully functional, with the required staff (avoiding mismatch) and equipment in good working condition. - The equipments must be 59

62 5 Public Health -Many national programmes and state level schemes have been introduced under NHM -Various departments and supervisory staff have been implemented -Targets under certain programmes have been achieved such as being Polio free state etc - Introduction of health programmes to address health needs of specific age groups (elderly and adolescents) provision of buildings, number of beds, equipments, laboratory and other facilities on the one hand and the actual human and material resources. - Emergency Services: The ambulance service serves a population of 85,000. This needs to be reconsidered. -Absence of public health cadre -Implementation of programmes continue to have a vertical approach - Typhoid continues to be a major concern, yet the typhoid vaccine has been withdrawn have withdrawn the typhoid vaccine -Cholera is still a problem that needs to be addressed - Lack of assessment, supervision, monitoring and evaluation of the programmes - Absence of addressing oral health needs of community and integrating it in services - Create a system that can assess, monitor and evaluate the programmes maintained in good working condition; the downtime must be reduced to the absolute minimum - All diagnostic service laboratories must be strengthened or restructured as shown above and all vacancies should be filled up and equipment and reagents provided in a time bound fashion so that the entire system is fully functional - The specific specialty hospitals should be spread across the district and a multi-specialty hospital should be present in all the districts. - To implement the Public Health Cadre to improve the public health - Relook at the implementation of programmes with an integrated approach - Create a system that can assess, monitor and evaluate the programmes - Oversee and conduct regular intermittent trainings for staff on a regular basis - Recording, reporting and communication systems will need to function with accuracy and speed and lead to decision-making and response at the district level - The private and voluntary sector to be included in the 60

63 6 7 Mental Health & Neurosciences Women and Child Health -Mental care resources in the state consist of NIMHANS, Bangalore, Institute of Mental Health in Dharwad, departments of psychiatry in the medical colleges, private psychiatric hospitals/nursing homes in major cities like Bangalore, Mysore, Hubli, Davanagere and services provided by voluntary organisations. - District Mental Health Programme has been implemented and first of it's kind based on the National Mental Health Policy has been passed - Introduction of psychiatrists at district level - Maternal Mortality Rate has decreased over the years - Infant Mortality Rate has seen a significant decline - Deaddiction centres are few in number - The health needs of women are addressed by the RCH programmes, which are restricted to the reproductive phase. - Health seeking behaviour of women has been affected by gender insensitiveness in society - Neonatal Mortality Rate has not seen any decline - Rural setting, IMR - Proper implementation of current mental health programme at district and PHC level - Strengthen the existing facilities with workforce and infrastructure coverage by the surveillance system - Introduce oral health promotion as an integral part of health promotion at every level of health care and as part of the school health programme. - Overall mental health programme needs to be strengthened and implemented in all districts and health centres. - Deaddiction centres for alcohol, drugs and tobacco - to enhance the mental health skills of all doctors - to develop a wide variety of community based rehabilitation facilities - ensure availabilitiy of essential drugs for management of mental health disorders - Ensure Functional FRUs in all Talukas and CHCs - Streghthen district level SNCU's and add Taluka level SNCU's - Ensure availability of trained staff especially ANMs - To ensure child and maternal care, the Government to create an awareness on prepregnancy, during pregnancy 61

64 8 9 Population Stabilisation Special groups (Tribal Health; Elderly health) - State has achieved the expected goal of 1.9 Total Fertility Rate - Healthcare in tribal areas by NGOs -Introduction of national health programme on elderly health continues to be higher in comparison to urban setting -Backward districts need more focus - Poor implementation of Family planning methods is observed -Sterlisation approach is gender biased with main focus on women - Number IUD users is poor - unmet needs have not been fulfilled - Number of PHCs in tribal areas are very few in number - Need for filling in the vacancies in the PHCs in tribal areas - No disaggregated data available for special groups - Referral services in tribal areas are neglected. -To focus on backward districts where TFR is yet to be achieved -To have specific planning for Tribals, Elderly and Differently abled. and post-pregnancy related topics. *Refer Public Health -Focus on backward districts where TFR is yet to be achieved -The approach to this should be through Community Needs Assessment (CNA) not via expected levels of achievment or a target type of approach - Scope to further reduce the TFR and reach the unmet needs for family planning services - Tribal Health: - Establish Health Wellness centres in Tribal areas - Region specific and tribe specific health plans should be made - Traditional healing systems must be encouraged and documented in tribal areas and there should be integration of Allopathic medicine with the Traditional systems - There should be increased collaboration between the government and the NGOs in tribal areas. The voluntary agencies must be involved in all health and development activities undertaken by the government - Differently abled: Shift from institutional approach to a community based rehabilitaion 62

65 10 11 Health Promotion and Advocacy Human Resource Development (Medical Education) - - Neglected domain - Very less is spent towards the same - State has 55 medical colleges (16 government and 39 private) - Initiation of Compulsory Rural Service - Medical education department needs to reduce shortage of specialists to work in rural areas. - Delay in implementation of compulsory rural service - AYUSH medical education has not come under the department - To provide more expenditure towards this area (Other countries spend 6%) approach; single to multidisability approach - Geriatric care facilities should be provided at secondary and tertiary levels. - Sensitization on special needs of the elderly both public and private institutions - Need to provide more expenditure towards this area (Other countries spend 6%) - Ensure it is headed by Additional Director with communication expertise - Soft skill training of staff - Reinforce importance in VHSNCs and ARS - The Non Governmental organisations must be encouraged in their activities for health promotion including innovative programmes - - Medical education system should provide the specialists needed for the secondary and tertiary care - Certificate courses -> Diploma courses -> Master s courses - The private practice by the teaching faculty should be banned altogether - Provision of more Postgraduate seats for doctors inservice - Ensuring implementation of one year of rural service 63

66 12 Health System Management/ Governance and Leadership - Introduction of Transfer policy - Establishment of KPME Act - The implementation of decentralisation in healthcare management - Establishment of Human Resource Management System (HRMS) - Establishment of State Health System Resource Centre(SHSRC) - Corruption in procurement of drugs and equipment and in hospitals for services has come down but needs more improvement - Department has not been able to procure drugs and equipments from good companies - The government doctors are currently allowed to do private practice after their duty hours. At present, teaching staff (doctors) in medical colleges are being paid AICTE pay scales, and are allowed to do private practice after office hours. Doctors who do not choose to practice could avail nonpracticing allowance, the maximum being Rs per month for a professor. It may not be possible for the State to pay remuneration at market rates to doctors, especially specialists and super-specialists, so as to compensate for notional loss of private practice - Poor patient referral system - Lack of performance appraisal and performance based payment only for - NHM emphasises health system management - AYUSH, Pharmacy, Nursing education could be be brought under the umbrella of Medical Education - Transparency and accountability mechanisms, e-procurement and Ombudsman for preventing corruption - The private practice by the government doctors should be banned altogether and a suitable mechanism to pay them well should be found. - Robust patient referral system has to be built in - Right to Health needs constitutional amendment, has to be introduced at the national level - Sector Regulations: A state level regulator covering private and public Hospitals both may be considered to improve accountability in the entire health sector. Medical colleges and hospitals attached to them and superspecialty hospitals running super-specialty courses come under the regulatory control of NMC, and minimum standards, hence may be exluded from this sector regulations. The role of such regulator may encompass the following 64

67 ASHAs non operation surgeons! - Absence of Right to Health similar to Right to Education - Public health cadre highly recommended in the Task Force Report of Health and Family Welfare, 2001 has not been implemented -The issue of absenteeism of doctors in the health facilities needs to be addressed - Conversion of PHUs to PHC s but vacancies have not been filled in - Absence of a grievance redressal system - Vacancies are seen of existing posts according to the norms and new posts; PHUs converted to PHCs without adding the required additional staff aspects. i. Objective, transparent and unobtrusive regulations and regulatory mechanism for the private hospitals; ii. Common minimum standards and protocol for infrastructure, manpower and treatments for private and public hospitals; and iii. Performance and productivity oversight on public hospitals. - Introducing performance - Biometric presence at the facilities with access to data by all - Set up performance targets where citizen engagement is seen (VHSNC and ARS) -Improving quality of infrastructure, basic services and security for the staff and not just filling in vacancies - Accommodation at facilities should be provided for all staff 13 Health Financing - State initiated health schemes have been implemented - Overall expenditure towards health is extremely low -Adequacy of funding in relation to the present and future needs and to the functions and responsibilities of the Department; - The adequacy of financial delegations; - New National Health Policy, 2017 states that state expenditure on health should be 8%. - Increase the health expenditure towards health to 8% for essential drugs, increasing the salaries of doctors and specialists and non practising allowance to stop private practice and increasing the budget towards health assurance programmes (SAST) 65

68 14 15 Drug and Food Control/ Management Indian Systems of Medicine (AYUSH) - Establishment of Standard Treatment Guidelines; Essential Drug List - Mainstreaming AYUSH into PHC level - Payscale in sync with MBBS graduate - Operational issues relating to reduction of accounting workload at field levels and simplification of procedures - Expenditure on health is very low: Optimum utilisation of existing budget is not being done OOP is increasing due to poor governance (mostly spent on drugs and diagnostic invest on making them freely available) - Due to less budget, state initiated schemes also see a fallback in providing for beneficiaries. -CSR funds not being mobilised - To revise EDL and STG as well as budget allocation towards drugs - Poor implementation and administration - Cross practice - Absenteeism of AYUSH doctors - Inadequate funding - To establish or relocate units of ISM&H with necessary infrastructure at CHCs, Taluka and District hospitals - A comprehensive review of the financial reporting system is necessary so that it becomes part of the HMIS - It should be ensured that release of funds and sanction orders are issued well in time and that the quantum of funds released should be adequate since such releases, in combination with sufficient financial delegations, would ensure maintaining and improving health services - CSR funds could 2% to be used (govt regulation) - Essential Drug List & Standard Treatment Guidelines needs to be revised - Budget allocation towards drugs is INR 340 Cr- in Task Force Report, it was suggested that 10% of budget be used towards drugs which in turn will reduce OOP - Drugs and therapeuatic committee needs to be implemented - Establish or relocate units of ISM&H with necessary infrastructure at CHCs, Taluka and District hospitals - Doctors qualified in a particular system of medicine 66

69 16 Panchayat Raj and empowerment of people - Introduction of VHSNC's and ARS - Decentalisation has helped in reducing absenteesim - Poor implementation, monitoring and supervision of VHSNCs and ARS - Decentalisation has not had its impact, no trust. - Untied fund utlisation is poor - Monitoring component needs to improve as it is not effective, currently - NHM gives importance to communitisation processes should practice only that system; Bring Ayush Education under the administrative domain of Medical Education - Strengthen the implementation of VHSNCs, ARS and community processes - the strengthening of the community partnership in the ownership and management of the programme should be undertaken orienting and involving Panchayatraj institutions actively in the process - The functions, functionaries and resources for such services at PHC, CHS and Taluka hospitals should be placed with the PRI s with full operational control -The involvement of the Panchayat institutions and of the community in providing health services should be encouraged for improvement and enhancement of these services based on real need - Improve community participation and monitoring mechanism - The effectiveness, performance and productivity of public health system delivering primary and most of the 67

70 17 18 Strengthening Partnerships Multisectorality and Intersectoral Collaboration - Introduction of Arogya Bandhu scheme and SAST - Tradtional partnerships initiated under blindness control, TB etc - Integration on service delievery for specific government schemes - A lot of intersectoral programmes have been initiated, such as swachh bharat abhiyan, school - Delay in reimbursement - Abrupty withdrawing the Arogya Bandhu scheme - Most of these General Practitioners are in the private sector; some of them may be employed in certain non-governmental health organizations. - 70% of the population utilise private services; need for more stronger integration of services - Need for better implementation and monitoring of the intersectoral collaborations - NHM gives importance for streghtening partnerships and this needs to be strengthened - There are other determinants that impact health: To work with other deparments to integrate health in secondary care at subdistrict level can not be managed in any credible manner from the state headquarter. The functions, functionaries and resources for such services at PHC, CHS and Taluka hospitals should be placed with the PRIs with full operational control. - We need to focus our attention as to how the services of the General Practitioners can be utilized to the health care needs of our population particularly in rural areas. - The Not for Profit can play a significant role, through appropriate operational and financial partnerships with the government, in delivery of primary and public health services. -To clearly distinguish between NGOs and for profits. More opportunities to be provided to NGOs tand to strengthen the same. - The Arogya Bandhu scheme for NGOs must be strengthened - SAST for partnering with private sector - Work with other deparments to integrate health in their programmes, so cross sectoral approach ( police department, water, 68

71 State Health Policy Health Assurance (SAST) Health Technology & Innovations health programmes (RBSK) etc - Task Force on Health and Family Welfare, Integrated State level policy was introduced; which underwent revision in Introduction of Palliative Care Policy - Formation of SAST -To avoid duplicity and scope for misappropriation, GoK took a conscious decision to bring all Health Schemes under one umbrella of SAST - Initiation of use of technology in health such as HMIS, Tele-medicine - The revised Integrated state health policy was released before the National Health Policy: Would have been useful if it was parallel to the NHP - Many interventions suggested in SHP 2004 yet to be implemented - Limited to only secondary and tertiary care services -Limited budget allocation (500 cr) - Limited use of technology - Poor use, implementation and monitoring - The use of technology is not geared towards management of the service delivery from the perspective of the personnel delivering the services or the patients receiving those services. their programmes, with a cross sectoral approach (police department, water, nutrition etc) - Integrating RBSY, Yeshaswini and Rajiv Arogyashree schemes - Bengaluru is the slicon valley and many entrepreneurs and start ups available nutrition etc) - All developmental programmes must have inputs from the health sector to make use of the opportunity to improve health and prevent problems. - Need to relook at the state health policy and revise it in line with the national health policy - To build on this successful model and replicate/ upscale it to Primary Health Care as well- Universal Health Coverage - increase in budget allocation - To grow and utilise health technology towards better service delivery such as telemedicine, EMR and HMR, drug logistics, e- partograph etc. - The technology should be used with bottom-up management approach 22 Health Industry 23 Nutrition - Growth of number of hospitals, pharma industry and equipment is seen -There are programs to provide food grains per - Not utilised for public healthcare - Ineffective implementation of the ongoing programmes: - Further growth of hospitals of pharma, hospitals and equipment - To stregthen existing programmes and - To increase or improve collaborations with the health industry for appropriate drugs and equipment - State and District Nutrition Missions should be formed in 69

72 month to each member of priority households. -Free meals for pregnant women and new mothers (up to six months after delivery) through the AWCs. -Free meals through local AWCs for children between the ages of six to sixty months. -One mid-day meal, free of charge, on all school working days, for children in the age group of six to fourteen years. -Food security allowance from the state government for persons who do not receive supply of the entitled quantity of food grains or meals. - There are established nutritional rehabilitation centres - Inadequate screening and referral for nutritional support at primary health care level. - In spite of effective identification of severely malnourished children at a younger age, only a fraction of them received treatment at NRCs. (October 2012) - Nearly 50% severe stunting was observed by nutritional surveys in the backward districts of Karnataka, in children aged up to three years and 11 months. - Poor implementation of the food supplementation - The quantity and quality of food supplied to AWCs is below par, contrary to the supplementation objective of the programme. - Poor infrastructure and maintenance at the AWCs. - Bal Vikas Samitis do not have a major say in the functioning of the AWCs. - Rightful beneficiaries are not completely covered under the ICDS programme - Poor implementation of the MDM Programme - Inadequate monitoring by Vigilance Committees and Food Security Committees, which are inactive. introduce a policy on nutrition - National Nutrition Mission has just been launched line with the National Nutrition Mission. - Good intersectoral coordination and budget allocation so that sufficient pulses and food products are available for provision - Adopting the intergenerational, life cycle approach by addressing the nutritional needs of infants, children, adolescent girls and pregnant and nursing mothers - Increase program coverage by demand creation by involvement of the community - Integrate and monitor multisectoral ongoing programmes - In addition to IFA tablets, the State may be take up food fortification (rice, oil and salt) in Mid-Day Meal Programme in schools and in ICDS in Anganwadies. - The fortified oil and salt are available in the market. For rice fortification, fortified rice kernels are available from several suppliers. The Government will have to set up blending units in each district. Such initiative for the Mid-Day Meal Programme in four districts is being taken up already by the Education Department. 70

73 3.1. Progress of Ongoing Schemes and Proposed Interventions There are several schemes introduced by the Government of Karnataka that address the health concerns specifically to maternal and child health and nutrition. There are alos schemes ongoing funded by the Government of India. Here, specifically the ones managed by the state have been presented. Thayi Bhagya: This Programme envisages, totally free Maternal & Child Health Care of all categories of Pregnant Women and Mothers in the State, with the core intention of zero Out of Pocket Expenditure to all women for MCH Services. The goals and objectives of this programme are achieved with main focus on equity, and ensuring quality MCH services which are available, accessible and affordable to all sections of the society. In addition to the said services, BPL, SC and ST category Pregnant Women and Mothers are provided incentives in cash and kind to motivate them to avail MCH Services in Government and Private Hospitals, with the sole intention of reducing Maternal & Infant Morbidity and Mortality. Madilu: This is one of the four components of Samagra Mathru Aarogya Palane (ThayiBhagya) Scheme, it is being implemented since , with 50 % of the budget coming from GoI, through National Health Mission and the remaining 50 % of the budget is being provided by the State Government. In this programme, a kit containing 19 items which are useful to the post-natal women and her infant is being provided to BPL, SC & ST beneficiaries, who deliver in any Government Hospital in the State. This benefit is provided to all deliveries of BPL, SC & ST women in HPD districts and for only two live births in the remaining districts of the State. Prasooti Araike: This is one of the four components of Samagra Mathru Aarogya Palane (Thayi Bhagya) Scheme, out of which, the three components, Viz., Prasoothi Araike, Thayi Bhagya and Thayi Bhagya Plus are 100 % Government of Karnataka funded schemes. Prasoothi Araike scheme is being implemented from with the objective of providing cash benefits to BPL, SC and ST communities Pregnant Women, to enable them to take nutritious diet during pregnancy and post-natal period to reduce maternal and infant morbidity and mortality. This scheme is implemented in all the districts of the State, except Kolar and Dharwad. 28 Beneficiaries of this scheme receive cash incentives of Rs.1000 in two instalments, the 1st instalment is provided to the Pregnant Women during her 4-6 months pregnancy and the 2nd instalment of Rs is provided immediately after delivery, if the beneficiary delivers in any Government Hospital in the State. The 2nd instalment will include the JSY cash component. From , the cash incentives, for the Pregnant Women and Post-natal mothers has been enhanced for SC & ST beneficiaries to Rs each. Extended Thayi Bhagya (Plus): A cash assistance of Rs. 1000/- for a private hospital delivery is paid to rural SC, ST and BPL women for the first 2 live births in all other districts other than 10 High Priority Districts in accredited private hospitals. Danta Bhagya Yojane: Danta Bhagya Yojane was rolled out by the Government of Karnataka in 2015 which is first of its kind in India. The program includes delivery of complete dentures to total edentulous patients who are above 60 years of age and fall in the below poverty line. It is a state government programme with a PPP model. It is currently executed through 43 private dental colleges and 2 district hospitals. In , 1606 dentures were given and in , 3300 dentures were given. In the first quarter of 2017, 1018 dentures are already delivered. There are suggestions to decrease the age from 60 to 45 years, also to include removable partial dentures,

74 incentive of 750 rupees per complete denture and 300 per removable denture, to establish dental labs in 10 more districts, dental treatment camps at taluka and sub taluka level with a budget of Rs 10,000 per camp and to increase the delivery of 500 dentures per month. Other suggestions included to add dental caries treatment, pit and fissure sealants and oral cancer screening in the Rashtriya Bala Swasthya Programme and restorative procedures, endodontic treatment, scaling for people with special abilities. (Basapathy 2017) Table 35. Beneficiaries of Health Schemes initiated by the state as on Sl. Programmes * No. 1 Prasuti Araike 485, ,219 45,940 66,587 2 Madilu 323, , , ,365 3 Thayi Bhagya 42,471 37,194 17,871 16,225 4 Janani Suraksha 383, , , ,840 Yojane 5 Extended Thaayi Bhagya 15,081 6,772 1,993 11,739 (Source: Directorate of Health and Family Welfare Services, Annual Report ) 70

75 3.2. Good Practices and Emerging Trends in Health and Nutrition Across the world, there are many new emerging trends that could be modelled in the state as well. Out of the many, the following few have been mentioned as they can be the way forward for Karnataka to be a pioneer in Kaiser Permanente (KP) It is one of the largest health maintenance organizations in USA, accounting for more than 9.6 million members in eight regions of the country. KP model of integrated care is based on stratification of the population and supply of different type of services according to needs. The Kaiser Permanente Medical Care Program comprises three separate yet interdependent entities: Kaiser Foundation Health Plan (KFHP), Kaiser Foundation Hospitals (KFH), and Permanente Medical Groups. In the KP model, the population receives promotion and prevention services with the aim to control exposure to risk factors. The core components to the KP model put emphasis on prevention, self-management support, disease management and case management for members with multiple conditions. A crucial component that has defined the success of the KP integrated care model is that all entities within the KP group are mutually accountable for a patient s outcomes and positive patient experience and provider incentives are linked to quality of care and patient satisfaction. The idea is to implement this successful model of integrated healthcare across the state where overall integration happens of all the services ranging from Sub centre to Tertiary care. This can be an incentive based model which can focus mainly on prevention of diseases which has been proven to be more effective. Some of the achievements of the Kaiser Permanente model are reduction in heart disease mortality rate by 26%; increase in blood pressure control from 37 to 77 percent; The prevalence of adult smoking declined from 12.2 percent to 9.2 percent etc National Health Services (NHS) Model The UK has a government-sponsored universal healthcare system called the National Health Service (NHS). The NHS was launched in It was born out of a long-held ideal that good healthcare should be available to all, regardless of wealth one of the NHS's core principles. It covers everything, including antenatal screening, routine screenings (such as the NHS Health Check), treatments for long-term conditions, transplants, emergency treatment and end-of-life care. Citizens are entitled to healthcare under this system, but have the option to buy private health insurance as well. The NHS Plan promises more power and information for patients, more hospitals and beds, more doctors and nurses, significantly shorter waiting times for appointments, improved healthcare for older patients, and tougher standards for NHS organizations. The NHS consists of a series of publicly funded healthcare systems in the UK. The NHS was rated as the best system in terms of efficiency, effective care, safe care, co-ordinated care, patient-centred care and cost-related problems. It was also ranked second for equity. This model can be implemented within the state specifically for PHC where the public and private health providers are combined under one umbrella. This can be implemented at the district level where the health providers can be paid accordingly. Currently, 80% of the patients go to the private providers so we need to integrate them at our PHC level to help improve accessibility and affordability for the people of the state. 71

76 Thailand Healthcare Model Thailand's healthcare system incorporates the private and public sectors. The government regulates health care through a system of capping, which protects its interests while providing a climate for competition. The private sector operates 50% of hospitals which receive US$ 26/year/patient from the government. The government assumes about 100,000 patients for each private hospital. The government and third party providers are developing a range of insurance plans. Private providers offer insurance plans based on public insurance plans. The private providers voluntarily work within government-regulated insurance caps. Private providers are considering delivering of services to non-paying patients to increase revenue. Thailand scores higher than its neighbors in life expectancy and infant mortality. The private sector treats more publicly funded patients than they did in the past which is improving accessibility. Some private hospitals have streamlined their operations by setting up neighborhood clinics for nonhospital-based day services, mobile clinics, an extramural hospital, and home care services. This is another example of a successful healthcare model which has partly been implemented in the state under SAST. This model can be upscaled across the state as it has been a success in addressing the secondary and tertiary care services fee Universal Health Care: Countries should give a high priority to achieving full population coverage of an affordable package of services, rather than covering selected population groups with more generous packages of services and leaving some people relatively uncovered. UHC can only be achieved through publicly governed, mandatory financing mechanisms (general taxation and social health insurance contributions) that compel wealthier and healthier members of society to subsidize the poor and the vulnerable. Financing systems dominated by private voluntary financing (user fees and private voluntary insurance) will never achieve UHC. The transition towards UHC, in redistributing health benefits and financial burdens, is a highly political process that is likely to face opposition from powerful interest groups. Sustained political commitment from the highest level of government, including the head of state, is therefore essential in implementing successful UHC reforms. 72

77 3.3. Insights from Stakeholder Consultations In this section, we have taken a detailed overview of the feedback and suggestions provided from the district and state level workshops conducted across the state. There have been many overlapping themes across the state such as Universal Health Care, quality accreditation of public health facilities; Improving the reach of ambulances; Reducing MMR and IMR etc. Sl No. Topic State level suggestions District Suggestions Department Suggestions 1 Equity 2 Quality One of the ways forward is receiving accreditation for all our government health facilities. 3 Primary Health Care The need to change and improve the perception of the public health sector Households to be recognized as places of health delivery for promotive, preventive care where home is recognized as part of the 4th tier health system Continuous capacity building: Training of workforce that is continuous with the goal of providing best knowledge and practice - Need to move towards universal health care - Need for quality assessment of all government facilities against IPHS standards - universal health coverage should be made available for every citizen - IMR and MMR need to be reduced and addressed. - By 2025, diseases such as dengue, malaria, chikungunya, brain fever, etc. to be reduced to 1% of the cases reported as on date. - MMR and IMR should be addressed as per the Tamil Nadu model. - Improve and supplement the facilities with good quality equipment - Essential diagnostics for treatment such as dengue - Add Maternity Care centres to supplement govt facilities - Number of fully equipped mobile health units, dialysis centres, geriatric centres should be increased manifold to cater to every citizen by By 2025, there should be at least Year 2025 to have regulated rates for treatment and operations of all healthcare and medical facilities - Rapid Response Teams (RRTs) could be setup at district level for disaster management. Toll free number could be maintained by disaster management department for sharing information on emergency rescue and relief. - Life expectancy to be improved to 76 by Improvement in life expectancy Currently, it is 69 for males and 72 for females. - Immunization to be brought to 90% by Department is benchmarking with Kerala (91%) and Sri Lanka (98%). - Birth Rate to be brought down to 15% by 2025 from the current 18.3%. - Death Rate to be brought down to 5% by 2025 from the current 7%. - IMR to be brought down to 20 by 2025 from the current 28

78 one ambulance within 20km radius and a scheme be formed to provide a universal smart insurance card at a certain subsidized fee and with improved process - accommodation at headquarters should be provided for all the doctors and staffs. - A 24*7 operative, full-fledged super-specialty hospital with specialists and state-of-the-art equipment should be made operational in the district by Establish Tribal Health Research Center and district level equipment maintenance team by The specific specialty hospitals should be spread across the district and a multi-specialty hospital should be present in all the districts. - A comprehensive study to list down most critical 5-10 diseases should be taken along with data collection. State government should conduct a study on conditions of Isolation Hospitals and set up such hospitals in every district and maintain with a model code of operations. - Government should make a provision to provide separate staff to address the healthcare issues of the nomadic, semi-nomadic and tribal people. - Health helpline to be operated and controlled from district level. - Transgenders have to be treated with complete respect and should - MMR to be 75 by 2025 from the current ~ Doctor-Patient ratio: XX by 2025 from the current XX Department to provide data - XX Number of ambulances per lakhs of population? - All PHC and CHC to be fully equipped with basic infra and basic staffs by All CHC would have ICU and operation theatre at block level by 2025? - XX % of people to be covered under various schemes by Department to share the number. - For every 1 lakh population (urban area), there should be 1 full fledge ward air condition clinic by

79 4 Secondary & Tertiary Health Care 5 Public Health 6 Mental Health & Neurosciences 7 Women and Child Health 8 Population Stabilisation 9 Special groups (Tribal Health; Elderly health) 10 Health Promotion and Advocacy 11 Human Resource Development There is a need to look at the doctor-patient ratio Workforce needs to be motivated constantly: Enabling environment should be provided to all health worker to help them perform better Improving quality of infrastructure, basic services and security for the staff and not just filling in vacancies Need to decrease the workload of overburdened health workers The Male Health Worker has be provided with education, employment, houses and government facilities. - Every primary health center should have mental health professionals. - Cancer hospitals need to be built at the district level and end-stage cancer patients need to have palliative care to address patients concerns - Counselling and education about Maternal mortality and child marriages - To ensure child and maternal care, the Government to create an awareness on pre-pregnancy, during pregnancy and postpregnancy related topics. - Increase number of Medical Officers at govt facilities to 3 MO's. - Uptodate Training for staff - Every PHC must have at least 1 female doctor to cater to woman patients. - soft skill training for doctors - The current Doctor to population ratio is 1:25000, it was discussed that by 2025 it is important to increase this to 1:

80 12 Health System Management/ Governance and Leadership become an endangered species, need for training institutes? The issue of Maldistribution needs to be addressed where local recruitment is done ( Selection of the health staff needs to be more local) Need to create a national level human resource cell or human resource directorate VISION: Less than 10% vacancy in all levels of health system Set up performance targets where citizen engagement is seen Grievance redressal needs to be set up Accreditation of all facilities Biometric presence at the facilities with access to data by all Need to create Public State Health accounts Public display of budget monitoring that integrates into a single health account port available in public domain VISION: Share of public expenditure on private sector should come down to 50% from current 70% = 10% expenditure of any HH should be reduced to 2% on healthcare (total - Alternative medical system such as Ayush should be encouraged and established at district levels and dentist should be appointed at government hospitals. - By 2025, the salaries of rural doctors to be on a par with private hospital doctors or more, which could attract more doctors to rural areas. - Need to effectively implement acts and schemes - Bio-metric attendance system could be in place at every PHC. - Setting up District Appointing authority, encourage people from the villages to get trained in medical courses, therefore appointing them to serve in PHCs of their respective villages. health expenditure) 13 Health Financing - Reduce OOP by 50% - Reduce OOP by producing efficient facilities at all levels of care - Introduce "Smart insurance card"to reduce OOP - By 2025, the out of pocket expenditure of pregnant women should come down by 60% - The GDP contribution from healthcare should be Revival of VHSC, nutritional committee funds may be raised to 25K per year The out-of- pocket expenditure ranges from rural to urban areas. It should be brought down by 60% to the current rate for both urban and rural areas. Further the spread/ gap should not differ by maximum of 5 10% 76

81 14 Drug and Food Control/ Management 15 Indian Systems of Medicine (AYUSH) 16 Panchayat Raj and empowerment of people Policy documents need to mention role of AYUSH where there is a clear definition of AYUSH practitioner in the health system and to be recognised as part of the system Health centres should be holistic centres incorporating AYUSH interventions when needed Making AYUSH an evidence based science State should establish a unified health system with AYUSH and FM Directorate where swasthya is the main focus Need to rethink the role of traditional healers in revitalization of Local Health Traditions Vision: Role of AYUSH needs to be given a serious thought at intervention level with a holistic approach for all health conditions increased gradually to 5 per cent from 1.5 per cent, as is currently. - Tamil Nadu model of drugs distribution should be in place by 2025 to avoid unnecessary issues related to drug distribution. - Government medical stores to provide all the essential drugs at affordable rates. Government to make sure generic medicines are supplied to them. Also maintain the quality of drugs. - Alternative medicine efforts, such as AYUSH, should be encouraged by the government statewide, along with establishment of a panchakarma health clinic at taluk level. - Hi-tech Panchakarma hospitals should be established at district level; - A lab technician and x-ray technician should be appointed at the Ayush hospitals. Ayush should have its own infrastructure and be involved under ESI scheme. 77

82 17 Strengthening Partnerships 18 Multisectorality and Intersectoral Collaboration -How can the private sector play a crucial role with the government in ensuring better health delivery services? -Public Private Partnership convergence where the public and private sectors converge in all aspects of health service delivery -Primary health care services have been the main focus of the government, while secondary and tertiary care have been a big concern; -Collaborate with private sector in facilitating the government schemes and providing secondary and tertiary services in hard-to-reach areas across the state -PPP models need to be strengthened and bring in quality standards -Specialist care provision from private sector in order to reduce the Out-Of-Pocket (OOP) expenditure -Assist the government in a sustainable reliable costing policy -Accreditation of the private sector -Leveraging the services of the private sector Vision: o We need to have a trustful and transparent relationship (mistrust) o Regulation in both sectors o Through CSR come out with integrated management information system -24/7 functioning of the hospital, by providing hi-tech equipment, and through provision of decorous infrastructure. One of the method could be by establishing such hospitals is through PPP (Public Private Partnership). - Children of the Girijana area should be educated and utilized for forest maintenance, since the Scheduled 78

83 19 State Health Policy - Incorporate recommendations made in State Health Integrated Policy 20 Health Assurance (SAST) Tribe Forestry Girijana has a good understanding of the forest, their social and economic levels can be improved if they are appointed directly to the Forest Departments job. - The group observed that there was a lack of communication between various departments; for example to address domestic violence or outraging of women s modesty where the police department, health department, social welfare department and other departments need to come together to address this issue in an integrated manner. - At least one police personnel should be appointed in every hospital to manage/ prevent any untoward incident at hospitals. - - Increase presence of biotoilets - All schools should have yoga session in their curriculum - Cleaning up of garbage sites, drains and sewers should be undertaken periodically across the district to prevent mosquito breeding and other related diseases. -Health tips & schemes should be included in school syllabus to make children aware about basic health issues and remedies 79

84 21 Health Technology & Innovations 22 Health Industry - Innovations and appropriate use of technology so that it supports PHC - Creating an enabling environment via appropriate technology - Integration of technology to have a comprehensive approach - Use of technology for shortage of human resources not only in treatment aspect but training as well - Need for a benchmark for efficiency of equipment - Why not use technology as an enabler to identify visible and invisible hotspots of diseases (GPS mapping) - Effective use of data mining in decision making - Use of technology to identify or early diagnosis of diseases - Data analytics: Vertical set of data being used for actionable work - Use of technology for diagnostic tools at grassroot level: At every facility from grassroot level health technology should help with available and affordable diagnostic services - Creating a State Health portal which is dynamic and accurate and available on public domain linked to national health portal related to the health programme that includes multi sectoral data VISION: Every patient who accesses any health delivery service needs to have a record which is accessible to all - The group suggested developing an app where any patient can be tracked and hospitalized at the nearest health center in case of emergency. - Hospitals to be digitalized and should be made E-hospitals and Health Department should have a system of e-documenting all medical treatment by implementing e-hospital software at Primary Health Centers, Community Health Centers, Public Hospitals, and District Hospital. 80

85 4. Vision 2025 for Health and Nutrition in Karnataka 4.1. Vision Statement Achieving Universal Health Care through an equitable, accessible, affordable, quality and well governed health system for the people of Karnataka Mission Statement: 1. Strengthening and reforming public health care system to enhance its credibility, efficiency and effectiveness; 2. Establishing objective, transparent and unobtrusive regulations and regulatory mechanism for the private hospitals; 3. Using technology for sector management from service delivery perspective Key Goals and Targets for 2025 The way forward has been presented here based on Key Performance Indicators (KPIs) mentioned in the National Health Policy, The key goals and targets have been identified based on the trend analysed for each KPI in the current health status. The idea behind selecting these specific goals and targets is to be in line with the National Health Policy, Key Performance Indicators Key Goals/Targets Source

86 1. Healthy status and programme impact a. Life Expectancy and healthy life i. Increase Life Expectancy at birth Baseline State India* - Male Female ii. Reduction of TFR b. Mortality by age and/or cause i. Reduce Under Five Mortality ii. Reduce MMR NA iii. Reduce infant mortality rate NA iv. Reduce neo-natal mortality** v. Reduce still birth rate <10 c. Reduction of disease prevalence/incidence i. Achieve global target for HIV/AIDS - All people living with HIV know their HIV status All people diagnosed with HIV infection receive sustained ART All people receiving ART will have viral suppression ii. Achieve and maintain elimination status of - Leprosy by Eradication - Kala-Azar by Lymphatic Filariasis in endemic pockets by Eradication iii. To achieve and maintain a cure rate of >85% in new sputum positive patients for TB by % NA iv. Reduce incidence of new cases in TB to reach elimination status by 2025 v. To reduce the prevalence of blindness vi. To reduce premature mortality from cardiovascular diseases, cancer, diabetes or chronic respiratory diseases NA 25% 40% 25% 82

87 a. Coverage of health services i. Increase utilization of public health facilities 2. Health Systems performance - Out patient by 50% from current levels 20% 40% 75% - World bank study - Inpatient by 50% from current levels 50% 60% 75% - World bank study ii. Antenatal care coverage to be sustained > 90% - Skilled attendance at birth to be sustained 93.90% 97% 100% > 90% iii. More than 90% of the newborn are fully immunized by one year of age iv. Meet need of family planning above 90% at national and sub national level v. Known hypertensive and diabetic individuals at household level maintain "controlled disease status b. Cross sectoral goals related to health 65% 80% 95% > 90% 89.60% 95% 100% > 90% NA 30% 90% 80% i. Relative reduction in prevalence of current tobacco use - by 15% - by 30% ii. Access to safe water and sanitation (Swachh Bharat Mission) - 75% 100% All a. Health finance 3. Health systems strengthening i. Increase health expenditure by Government as a percentage of SDP ii. Increase State sector health spending 3% 6% 7% - iii. Decrease in proportion of households facing catastrophic (OOP) health expenditure from the current levels b. Health infrastructure and human resource i. Ensure availability of paramedics and doctors as per Indian Public Health Standard (IPHS) norm in high priority districts ii. Increase community health volunteers to population ratio as per IPHS norm, in high priority districts (ASHAs) 72% 50% 20% 25% 1:1,681 1:1,200 1:1,000-1:1,000 1:750 1: Health Assurance SAST i. Secondary and Tertiary Care 70% 90% 100% - 83

88 ii. Primary Health Care 20% 75% 100% - 5. Quality NABH & NQAS website i. Percentage of institutions accredited 1% 20% 50% - 6. Good Governance (Transparency, Accountability) i. Making the staff stay in facility (24x7 PHC, FRU and above) 50% 75% 100% - ii. The private practice by the government doctors should be banned altogether and a suitable mechanism to pay them well should be found. iii. Public Health Cadre 7. Health Technology - - To be implemented To be implemented i. Diagnostics and equipment NA 50% 75% - Rural Health Statistics Department of Health and Family Welfare, Karnataka data ii. ICT (MCH and health) 50% 75% 100% - 8. Equity Nanjundappa Commitee Report, 2002 i. Number of C- catergory Districts with lowest development index ii.number of Talukas with lowest development index (most backward talukas as per Nanjudappa Committee) Nutrition NFHS-4 i. Stunting in Under 5 children 36.2 % 25% 15% - ii. Wasting: Reduce childhood wasting 26% 20% 15% - iii. Anemia: reduction of anemia in women of reproductive age 45% 25% 10% - iv. Reduction of low birth weight cases 7.6 % 4% 2% - v. Increase the rate of exclusive breastfeeding in the first six months 54% 75% 100% - *Source: For India, all have been taken from National Health Policy

89 4.3. Implementation Roadmap Sl No. Topic Strategy Short Term Medium Term Long Term 1 Equity - Specific planning and budget of the backward districts and taluks. 2 Quality -To ensure quality assessment and accreditation of all government facilities 3 Primary Health Care - Enhancing existing services by working towards filling in vacancies and provision of better infrastructure 4 Secondary & Tertiary Health Care - Enhancing existing services by working towards filling in vacancies and provision of better infrastructure 5 Public Health - Create a system that can assess, monitor and evaluate the programmes 6 Mental Health & Neurosciences - Proper implementation of current mental health programme at district and PHC level 7 Women and Child Health - Strengthen the existing facilities with workforce and infrastructure 8 Population Stabilisation -To focus on backward districts where TFR is yet to be achieved 9 Special groups (Tribal Health; Elderly health) -To have specific planning for Tribals, Elderly and Differently abled. 10 Health Promotion and Advocacy - To provide more expenditure towards this area (Other countries spend 6%) 11 Human Resource Development - To decrease the workload of overburdened health workers - To relook at infrastructure for staff 12 Health System Management/ Governance and Leadership - To strengthen existing governance and management 13 Health Financing - To increase the state expenditure on health 14 Drug and Food Control/ Management 15 Indian Systems of Medicine (AYUSH) - To revise EDL and STG as well as budget allocation towards drugs - To establish or relocate units of ISM&H with necessary infrastructure at CHCs, Taluka and District hospitals

90 16 Panchayat Raj and empowerment of people - To strengthen the implementation of VHSNCs, ARS and community processes 17 Strengthening Partnerships - To increase prospects of collborating and involvement of other sectors 18 Multisectorality and Intersectoral Collaboration - To work with other deparments to integrate health in their programmes, with a cross sectoral approach (police department, water, nutrition etc) 19 State Health Policy - To relook at the state health policy in line with the national health policy 20 Health Assurance (SAST) - To build on this successful model and replicate/ upscale it 21 Health Technology & Innovations - To grow and utilise health technology towards better service delivery 22 Health Industry - To increase or improve collaborations with the health industry 23 Nutrition - To stregthen existing programmes and introduce a policy on nutrition 86

91 4.4. Role of Stakeholders and Partnerships There is a promising future for health and nutrition to take forward the role of various stakeholders within the government and outside. While the Government of Karnataka has initiated various programmes and schemes, addressing the needs of the state there have been few aspects that need more strengthening and support Intersectoral Convergence While the government has recognised the need for intersectoral convergence by introducing School Health Programmes, ICDS etc, there are other areas in which there is a need to strengthen the convergence such as: Rural Development sector for safe drinking water and sanitation; the infrastructure of public health facilities managed by the Zilla Panchayat. Education: Promoting education of girls which will in order have an impact in bringing down the MMR in the state; Ensuring the Mid day meal programme is functioning smoothly. Governance: Strengthening the existing governance structure. Finance: Increasing the budget for health during budget allocation will help bring in the much needed changes and improvement in health and nutrition status Public Private Partnership SAST - The initiation of this Trust has helped address the OOP expenditure faced by the low socioeconomic community in order to received secondary and tertiary care. This has been one of the strongest moves by the government which can and should be upscaled across the state and also boost the role of the private institutions in being accountable for provision of health services to all. Arogya Bandhu Scheme - This scheme introduced by the government has helped address the health needs of vulnerable populations placed in inaccessible areas, for example, tribal communities. This model of public private partnership, which brings in collaboration between both the sectors to address the common problem of the people needs to be upscaled and well resourced. Mobilising CSR initiatives: The private sector continues to grow in the state at a fast pace in terms of health service delivery, pharma industries, hospitals etc. There is growing trend where CSR funds are being utilised towards improving health of those belonging to lower socio-economic groups. The government can facilitate and take forward future partnerships for the same.

92 5. Methodology The vision document has been initiated by the Government of Karnataka to build a governance strategy for the next 7 years in 13 sectors under which Karuna Trust was selected as a knowledge partner for health and nutrition sector. A state level workshop was conducted with a diverse panel of health experts from across the state with suggestions about which areas of health need to be the focus for health and nutrition. The overall suggestions and points discussed were consolidated by Karuna Trust and then incorporated as part of the skeletal framework for the vision document. Post the state level workshop, district level workshops were conducted across all 31 districts with inter sectoral discussions with focus given towards district specific health issues. These district level workshops were very productive and a lot of feedback was provided which has been incorporated in the document as well. Health determinants are multidimensional and multi-sectoral. An interaction was undertaken with other sectors, which influence health. They included the education, rural development, social justice & empowerment, IT and governance. Data that has been represented in the document has been collected from various government resources and put in place. For the overall document framework, the Task Force Report, 2001 has been taken as a guide. References have been taken from the following documents: Directorate of Health and Family Welfare Services, Karnataka, Annual Report, Economic Survey of Karnataka, Department of Planning, Programme Monitoring and Statistics, Karnataka Health Profile, Department of Health and Family Welfare, Karnataka Integrated Public Health Policy, 2017 Sample Registration System Bulletins, National Family Health Survey- 3, National Family Health Survey- 4, District Family Health Survey -3, District Family Health Survey- 4, Niti Aayog website ( My Gov.in website ( ) NABH website ( Rural Health Statistics, Key Indicators Of Social Consumption In India Health, National Sample Survey Office, 71 St Round, 2015 Tamysetty, S. & Sudarshan, Nutritional Status Of Karnataka Shiddhalingaswami V H, 2014, Critical Analysis Of Dr. D M Nanjundappa Committee Report And its Implementation WHO EPI Fact Sheets, 2016 Niti Aayog: Social Sector Expenditure of States Pre & Post Fourteenth Finance Commission ( & ) 88

93 This document was collectively prepared by Karuna Trust with the following members on board: Dr H Sudarshan Dr Samantha Lobbo Dr Sathyanarayana Dr Kishoremurthy M Dr Mahesh Kadammanvar Special thanks to Dr Rajeev Basapathy Rudrappa 89

94 6. Conclusion Though the state has seen a lot of improvement in the past and present, there is a lot more to be done to bring in a better quality of healthcare to the people of the state. While the government has been progressive and addressed health concerns by introducing new schemes and programmes there is a need to focus mainly on: 1. Increasing the budget for health to 8% of total expenditure 2. Universal Health Care 3. HR management: Filling up of vacancies of health workers and specialists 4. Quality accreditation of public health facilities 5. Good governance Keeping this in mind, the vision for the state is achievable and can be made a possibility! 90

95 7. Annexures Annexure I: Refer Attachment Annexure - II: List of Acts related to Health 1. Medical Termination of Pregnancy Act, 1971 and Rules Pre-natal Diagnostic Techniques (Regulation and Prevention of Misuse) Act, 1994 and Rules The Transplantation of Human Organs Act, 1994 and Rules, Drugs and Cosmetics Act 1940 and Rules, 1945; The Drugs (Control) Act, 1950; The Drugs (Prices Control) order, Drugs and Magic Remedies (Objectionable Advertisements) Act, The Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act, 1995 and Rules, The Mental Health Act, Epidemic Diseases Act, Consumer Protection Act, 1986 and Rules, Maternity Benefit Act, Dangerous Drugs Act, Narcotic Drugs and Psychotropic Substances Act, Poison Act, The Industrial Disputes Act. 15. The Water (Prevention and Control of Pollution) Act, The Air (Prevention and Control of Pollution) Act, The Environment (Protection) Act, Hazardous Wastes (Management and Handling) Rules, Insecticides Act, Infant Milk Substitutes Act, Prevention of Food Adulteration Act, 1954 and Rules Fatal Accidents Act, Personal Injuries (Emergency Provisions) Act, Personal Injuries (Compensation, Insurance) Act, Medical Degrees Act, Indian Medical Council Act, 1956 and Rules, 1957; Medical Council of India (Regulations on Graduate Medical Education) Indian Medical Council (Amendment) Act, Indian Medicine Central Council Act, Homeopathy Central Council Act, Dentists Act, Nursing Council Act, Pharmacy Act, Cigarettes (Regulation of Production, Supply and Distribution) Act, National Food Security Act, The Mysore, Ayurvedic & Unani Practitioners Registration and Medical Practitioners Miscellaneous Provisions Act, 1961 and Rules The Minimum Wages Act, The Biomedical Waste (Management and Handling) Rules, The Karnataka Prohibition of Smoking in Show Houses and Public Halls Act, 2016

96 Vision 2025 for health and nutrition in Karnataka KARUNA TRUST 1

97

98 1 EXECUTIVE SUMMARY There are multiple determinants, innumerable causal pathways and varied paradigms of the nutrition status of the population. Attainment of optimal nutritional outcomes by many organised societies still remains a major priority. The nutritional status of the population is the index of the commitment of any nation towards the welfare of its citizens. While developed nations are relatively better off at tackling challenges associated with nutrition, it is the lowand middle-income countries that lag behind in indicators with respect to the same. Despite being logical to assume that higher rates of poverty are associated with poorer nutritional status, the association seems more complex than this. The available statistics reveal that malnutrition rates amongst children in some parts of Karnataka are higher. Given Karnataka s ambitions of being a global power, the nutritional status of its masses poses an even greater challenge. Vulnerable populations such as the Scheduled Castes and Tribes, pregnant women and girls bear the maximum brunt of this scourge. The role of nutrition in health has remained a priority and has witnessed affirmative action through the legislative efforts of the Government of Karnataka, such as in the State Integrated Health Policy (2004). Recognising nutrition as a significant determinant of health, it laid down measurable targets in relation to the same with respect to vulnerable populations over a shortterm period. As a sectoral legislation with indirect bearing on nutritional sufficiency of the state, the Karnataka State Agricultural Policy (2006) too is a significant statute with the potential to address major issues with nutritional availability. The nutritional challenges of Karnataka are manifold. The prevalence of anaemia is precariously high with married women, pregnant women and children shouldering the greatest burden. One in three children less than three years of age is underweight or stunted. Nearly one-third of the women in the state have below the average Body Mass Index (BMI). Systemlevel gaps are playing an important role as is visible from the data on coverage of immunization, supplementation during Ante-Natal Care (ANC) care, compliance with ANC visits and breastfeeding practices in the state. Nutritional monitoring reports for the state point out micronutrient deficiencies as well as the prevalence of wasting and underweight in infants and children of the tribal areas. Policies that have a bearing directly or indirectly on the nutritional status of the citizens have been in force in India right from the beginning of the post-independence era. The Prevention of Food and Adulteration Act of 1954 was a pioneering piece of legislation in this regard. It governed the issues concerned with food safety and purity in the nation for a very long period of time. It helped with the creation of the initial framework for food monitoring and safety by enabling the establishment of a Food Standards Committee and Central Food Laboratory at the national level. It has since given way to the Food Safety and Standards Act of 2006 which has widened the ambit of monitoring and enforcement of food safety by compliance with science-based standards through regulations mentioned therein. The recently promulgated National Food Security Act of 2013 aims to address the problem of malnutrition through the medium of the Public Distribution System (PDS). As a statute of commitment, the National Nutrition Policy (1993) laid down the roadmap for institutional and structural changes at programme and departmental levels. However, a concentrated focus on inter-sectoral convergence had been missing from the same. 3

99 1.1 CURRENT NUTRITIONAL STATUS (SITUATIONAL ANALYSIS) An overview of the nutritional status in the state of Karnataka is being created through the purview of multiple reports that provide factual data vis-a-vis the national and state scenarios. The entire data is being represented in a life-cycle approach across the population, spanning different age groups as shown below. Birth and Early Childhood Nutritional Availability: In terms of nutritional availability, there is a major rise in the percentage of children under three years who are exclusively breastfed within one hour of birth, both at the national level and the state level. With respect to children aged 0-5 months who are exclusively breastfed, the percentage is higher at the state level in comparison to the national level. A similar trend is observed with respect to children aged 6-9 months receiving solid or semisolid food and breast milk. Table 1.1. Nutritional Availability for Children up to Three Years (1)(2)(3) Indicators Karnataka India NFHS1 NFHS2 NFHS3 NFHS1 NFHS2 NFHS3 Children under 3 years who are exclusively breastfed within one hour of birth Children aged 0-5 months who are exclusively breastfed Children aged 6-9 months receiving solid or semisolid food and breast milk 5.6% 18.5% 35.6% 9.5% 16% 23.4% NA NA 58.0% NA NA 46.3% NA NA 72.5% NA NA 55.8% Nutritional Status of Children Further, the NFHS data shows a steady decline at the national level in the percentage of children under three years who are stunted. A similar trend is observed with underweight children under the same category. This observation holds up well when viewed across the latest two rounds of NFHS. However, if the latest data is comparatively analysed with the previous survey (NFHS-2), a significant reduction in the above values cannot be inferred. A major disturbing fact is that the percentage of children under three years who are wasted has been gradually increasing, highlighting the gravity of acute malnutrition that plagues the nation. The facts described above have been represented below. 4

100 Table 1.2 Nutritional Status of Children Under Three Years in Karnataka For Karnataka, though statistics show reduction in malnutrition indicators for children below three years across the three survey periods, the challenges on account of the same persist. It is worrisome that more than one-third of children falling in this category are underweight and stunted as represented above. Reproductive Age Group and Adults: Ante-Natal Care (ANC) The indicators with respect to ANC services amongst currently married women aged years have not been very encouraging with respect to data that has emerged at both the national and state levels. Though the performance of Karnataka is comparatively better than the average national performance on these counts, it leaves a lot to be desired. 5

101 Table 1.3. ANC Visits, Advice and Breastfeeding Practices Amongst Currently Married Women (15-49 Years) (6) Sl. No. Indicators Karnatak a India 1. ANC of currently married women (aged years) (a) Government health facility 49.2% 54.4 % (b) Private health facility 54.8% 36.4 % (c) Community-based services 4.5% 9.5% 2. Advice received on breastfeeding during ANC visit NA 59.6 % 3. Advice received on nutrition during ANC visit NA 56.6 % 4. 3 or more ANC visits by currently married women 81.2% 49.7 % 5. Consumption of 100 plus IFA tablets /syrup 64% 46.9 % 6. Initiation of breastfeeding (a) Within 1 hour of birth 46.5% 40.5 % (b) Within 24 hours of birth 73.2% 70.9 % (c) After 24 hours of birth 26.8% 29.1 % Anaemia The prevalence of anaemia too has shown an incremental surge over the years at the national level. The percentage of pregnant women aged years who are anaemic has risen. Similarly, the percentage of ever-married women who are anaemic has also witnessed a rise. The percentage of children aged 6-35 months who are anaemic has risen. In comparison, the percentage of ever-married men aged years who are anaemic is seen to be much lesser. In Karnataka, the prevalence of anemia across different age groups appears to be much higher. The gaps between the current values and previous reported data are significantly 6

102 large as shown in the table below. Figure 1.1 Prevalence of Anaemia Across Groups in Karnataka Status of Physical Malnutrition Amongst Sexes In terms of physical malnutrition, the trends at the national and state levels have shown a decline in the percentage of women whose Body Mass Index (BMI) is below normal, at the same time showing significant numbers for men under the same category. The percentage of women who are overweight or obese is seen to be higher at the state level than the national level. Table 1.4. Physical Parameters of Men and Women with Respect to Nutrition Karnataka India NFHS-2 NFHS-3 NFHS-2 NFHS-3 Women whose BMI is below normal 38.8% 31.4% 36.2% 33.0% Men whose BMI is below normal % % Women who are overweight or obese 13.6% 18.1% 10.6% 14.8% Men who are overweight or obese % % Elderly Population An evaluation report on the status of nutrition in the elderly population in Karnataka using BMI as an indicator found out that the largest percentages of men (56.2%) and women (51.7%) were found to be in the normal BMI classification. With regard to energy deficiency, 8.6% of men and 7.9% of women were found to have a first-degree chronic energy deficiency (CED); 11.4% of men and 6.7% of women were found to have second-degree CED; and 14.3% of men and 14.6% of women were found to have third-degree CED. There were no men or women who were found to be severely obese. Women were found to be more overweight and obese compared to men (8). 7