Public health being revamped
Dr.H.Sudarshan discusses the state of Karnataka's public health services
in this interview exclusive to India Together.
Dr.Hanumappa Sudarshan is currently the Chairman of the Karnataka Health Task
Force and a Vigilance Director at the Karnataka LokAyukta, the state's main
corruption fighting body. He is best known for his work with the Soliga tribals
of the B R Hills near Mysore, and is also a winner of the Right Livelihood
Award. The Health Task Force is currently overseeing the implementation of the wide-ranging recommendations it made to the state govt in 2001. India Together
caught up with Dr.Sudarshan at Bangalore in April 2002. This interview was also
telecast as a Radio India Together program on June 10 and 11, at
Bangalore's Gyanvani 107.6 FM Radio.
In 2001, that is last year, you called for a moratorium on starting new medical colleges in the Karnataka? Doesn't the state actually need more doctors?
If you look at the health needs, there are two issues. One is commercialisation of medical education. You want to open a college and make a business, which is one way. The second way to look at it is that these medical colleges also have accountability to the people of Karnataka. This is the model, which Israel has. In Israel each district has a medical college and that college takes the responsibility for the health affairs of that district. So we are saying, we should have our business, but we should also have some accountability for the health of the people. We have suggested three primary health centers to be run by the private medical colleges. Secondly what we're saying is that mushrooming of the medical colleges is not good. The quality standards have to be maintained. Some of the medical colleges do not have enough infrastructure - the hospital, number of beds, and most important, the faculty. We can't have a situation where we increase the number of available medical colleges overnight, but there are no faculty. Some colleges cheat during inspection where they hire faculty from neighboring colleges and show them on their nameplates. We have a shortage of faculty for running the medical colleges. So if we can provide good quality medical education, with good infrastructure, and good faculty, we have no problem. We can produce good quality doctors. But what is happening is that the quality of doctors we are producing - some of the colleges are really good, but -some are really bad, they need to be closed down. So we're saying, let us have good quality of medical education. It should be need based, and the colleges must have some accountability to the people of Karnataka.
In terms of equitable access for women to primary health care, where is Karnataka headed?
In the report of the task force, we talk specifically about gender sensitive primary health care. Desegregated data is available on whether women have access to the health system or are we discriminating. If they are not coming, how can this be changed? Also women's health needs to be looked in a broader perspective - a woman is a human being and this is not just in the reproductive sense. From birth to death, how can the health system respond to the total health needs of the woman, this has also been suggested. Women also have problems of TB, Malaria, and other needs, so we need to take care of that. How to make women-friendly PHCs, hospitals, etc are the questions we have looked into. Collecting gender desegregated data at various levels, including for violence against women - we are insisting that this should be regarded now, wherever possible. Another major issue is female feticide and infanticide. With the law against female feticide now in place, ultrasound machines are closely monitored.
Are you and the Health Task Force happy with the allocations in Karnataka State Budget for 2002?
Our view of budget, with our understanding - first point is that we need to have optimum utilization of the existing budgets. What we have found is that even the existing budgets are not being properly utilized - in terms of optimal utilization of resources. There is a lot of wastage. Unused moneys are being returned, in fact. This type of thing is going on. So just increasing the state health budget at this stage without empowering the whole health system to better manage resources, will be catastrophic. So what we are saying is, empower the service staff, make optimal utilization of the existing budget, and then gradually increase to what is needed, as the capacity is built to handle more money. Just increasing the budget will not make the system better. But having said that, definitely the present budget allocation for health is low, it is about 5% of the total outlay, which is very less. We do want the budget to be increased, and we have recommended that for the next fiscal plan.
One the one hand the Health Task Force has recommended for increased state financing of health services. And on the other hand we hear of the pressures being exerted by the Multilateral Financial institutions (World Bank, IMF) on governments of developing countries to reduce public expenditure through the so-called structural adjustment programs…
No in fact, in Karnataka, we have looked at it and we have no pressures to reduce the budgets for health. Even in the World Bank assisted types of planning processes which happened for the mid-term fiscal plan [the five year plan], the budget has been increased, actually. There is no cut for the health budget, and we have also made clear in the task force recommendations that human resources allocations must not be cut. There are cuts in workforce in other departments but for the Health services, we have clearly said that no cuts, because we need those human resources.
The Task Force has laid an almost extra-ordinary emphasis on Human Resource Development for the Health Bureaucracy in Karnataka. What is the government doing about these recommendations?
Regarding recruitment - filling up of the vacancies - we had recommended this in our interim report itself and I am happy to say that government has taken this seriously and filled up vacancies of doctors, nurses and para-medical staff. Within the next few months we will have all the existing posts filled up, except male health workers. We are debating about whether these posts should be filled up or not. Whatever vacancies exist in the essential staff areas, will definitely get filled up shortly.
We also have the 250 hospitals run by the Karnataka Health Systems Development Project. Bed strength has been increased, so we need additional staff. So that is also being done - additional specialist posts, and para-medical staff, for the upgraded hospitals. This is regarding new recruitment.
We also had contract doctor appointments. We have said they have to be regularized.
Now those appointments will be moved back to a regular system of appointments. Most important is training, and empowering the doctors - in terms of induction courses for medical officers who have just joined and ongoing regular training for the doctors and para-medical staff. For this we have a State Institute of Health and Family Welfare, this has to be upgraded and it has to be built into a unique institution which takes care of all the training needs of the human resources.
Talking of recruitment, how is the recruitment of doctors and other staff going along for rural Karnataka?
The problem is the chronic shortage of human resources in the so-called backward areas or the northern districts. Nobody wants to go there. They want to be around in the southern districts. So we have recommended recruitments into the district cadre. For the first six years doctors will be at the PHCs, and another 7 years at the Taluka hospital. They can get out of the districts into the state cadre. So for 13 years they have to be in Bijapur or Gulbarga or Raichur, wherever they are recruited.
You draw a distinction between the preference for the market economy of curative medicine in the govt health services and what you call sound public health. In fact you are concerned that the preference for this curative side of the service should not undermine the public health responsibilities of the government.
We are sitting right now behind the public health institute which is in shambles now. We need to really create a premier public health institute. We have the post of additional director for communicable diseases, which needs to be strengthened. A good disease surveillance system at various levels including very strong district disease surveillance units is needed. This together, and amendments to various health related laws has to be taken up. The government has just started thinking and trying implement our recommendations in this area.
Last year, that is 2001, there was a bill to regulate private health care services in the state assembly. Where are we on this regulation?
The earlier Nursing Home Act was more of a license type of Raj. The Task force was not happy with that. We have given a separate private institutions regulation bill. Before that we had recommended a comprehensive bill for both public and private together. So that quality control standards can be the same for both. But government did not accept combining the two. They wanted a separate private inst regulation bill. The older bill has since been withdrawn. In the new bill, the Government will only have a registration role to play. There will be committees at district levels which make their own quality standards and see that the institutions maintain those standards. Hopefully this will be implemented very soon.
Why did the Karnataka government not prefer a common regulation from both government-run as well privately run health care institutions?
Their argument is that that government cannot do this - a legal type of argument was thrown up at us. This does not convince us and it would have been better if the same law regulated the two. But because of the legal problems, so we had to accept that there will be two different bills. But at the same time, within the government, quality standards are being developed - ISO standards. We are insisting on standards - it's just that public health will have its own and private health will have its own.
The PouraKarmika problem in Bangalore seems to be a vexing issue. The task of cleaning cities comes with significant occupational, and primarily health hazards. On the one hand we hear that PKs employed by the BMP will soon get medical insurance. But at the same the time, more than 50% percent of Bangalore's Wards are cleaned by contracted PKs and they are not even paid minimum wages, let alone considerations for health Benefits. Do you see the recommendations of the health task force have an impact on the benefits offered to the contracted PKs?
We have not spoken specifically about the PKs but we have spoken about the employees of the health department itself - insuring them, immunizing them for hepatitis B, which had not been done - has been recommended. We have also recommended incentives for doctors staying in PHCs and those who do administrative jobs, the general staff. For Hospital maintenance contracts, non-clinical contracts - we are looking at the norms. As you rightly said, when we take out labor contracts, minimum wages are not even being made to most of these employees in most of the hospitals. So we need to do something, that when we contract out labor, the contractors pay minimum wages. Probably this calls for a dialog with the labor department and see that these contractors are enlisted and some enforcement is done for basic minimum wages and other facilities to the employees.
Charging fees at government hospitals seems to be very problematic. Let's take Punjab. As you know, because the yellow card system that was supposed to exempt the poor from the fees has for all practical purposes not been implemented.
As a result, poor people in Punjab are today forced to both a bribe and a fee they cannot afford.
Karnataka is also implementing a user fee system in the Karnataka health systems development hospitals; we are not charging for primary health care. But for secondary care and tertiary care, user fees are being charged. This is where I feel that below poverty line people (BPL) should be totally exempted from the user fee. How to identify the BPL people? If we insist on ration cards, some of the poorer people may not even have a ration card. And yellow cards are some times not even distributed either. So our own recommendation is to err on the other side. If the BPL is 35% give free services to 50% of the people. So for the other 50% user fee can be charged. But user fees again are very nominal and they are only about 1% of the total cost of the health care provided in the hospitals. Just a token fee. But this is very useful. The positive side of the user fee is that if we can have the BPL delineator guaranteed, the hospitals can have some discretionary funds available at the hospitals. This has brought about some miracles in the management of those hospitals. They have some money to buy whatever little needs they have - repairs to be done, emergency medicines to be bought, which is really good. They have some resources now. Earlier even when a 15Amps plug had to be bought there was huge process. Now they get it purchase in one day. So this has brought in some good aspects. User fee - I would say it is not user fee, what we are collecting in Karnataka. It is a token type of participation of the users.
I am also the vigilance director for Lokayukta for Health Education and Social welfare. When the LokAyukta chief justice took over, I had given him report wherein I had identified corruption as one of the major issues. Next day he called me and asked me to join him. We have gone around the hospitals and seen how the BPL people are suffering - the corrupt system and how they are given prescriptions. We are mainly looking at these issues in a public type of enquiry and making the doctors and hospitals accountable so that the below poverty line people are taken care of. That is our main agenda which I am pushing through at the LokAyukta.
Isn't the fact the Karnataka Lokayukta is suo motu visiting government hospitals to check corruption an indication that the complaints driven process is not really taking off?
Corruption is at various levels. In medical education, starting from joining the medical college - you can buy a seat, you can buy the examiner, the corrupt examination system, you can get question papers. This is much better now with the Rajiv Gandhi University, they are trying bring in some reforms, but still, in the viva-voce and practicals, many people have paid and it is still continuing, we are not sure we have plugged that. This time, the Lokayukta has been very pro-active in the post-graduate examinations, for example we knew which hotels that corrupt elements will be staying in and we tried to prevent those types of corruption. So this is about medical education.
When students pass out, we found that the students have to pay a bribe to register at the Karnataka Medical council. So we took it up with the council that have rectified it. Similarly in the recruitment process. The Karnataka Public Service commission for example, and other agencies. There were problems. Now it is merit-based recruitment. We have streamlined the system and we have also looked into transfers. Transfers and promotions. These are the areas. Then again there is corruption in the purchase of equipment and medicines. All these we are trying to plug. It's a very difficult task, but awareness is being created.
When we go to hospitals, the LokAyukta not only looks at the below-poverty-line people, how they are taken of, but cleanliness is also looked at. The mortuary for example, from the birth to death, there is/was corruption in hospitals. If a child in born, we have to pay to the nurse and the other staff. There are different prices for babies. 200 Rs for male babies, 150 Rs for female babies, you might have heard of it. And then death. When people came for post-mortem, staff would squeeze money from them. So LokAyukta visits the mortuaries, and directs to make sure that everything is given free, even the cloth to be tied around the body should be free, no money should be charged. These types of reforms from the birth to death, we are trying to bring in. Reforming the entire system is a long process, but we have initiated several measures.
Do you agree that the Karnataka LokAyukta's work will be strengthened if the public started actually filing formal corruption complaints as opposed to complaining cynically about corruption?
That is very important. Actually, if we can strengthen the hospital committees itself, including PHC committees, which we have suggested from the task force - like the Madhya Pradesh example where the samitis which are pro-active and are mobilizing resources - this will be very useful. But community participation in all this - their awareness to complain to the LokAyukta was not there. We have covered 15 districts by the middle of April. By end of April, we will have covered all the 27 districts. Awareness is being created and now they know they can redress the grievances with the LokAyukta. We take action immediately and respond to their grievances.
The Task Force was convened in Dec 1999. The submission of Interim recommendations in 2000 and the final recommendations in 2001. What is your feeling about the process and as Chairperson of the Task Force, are you happy?
First of all, we had a very committed team. The members of the task force have really given time, it is a love of labor. Some of the members have been working honorary, full time. Producing this kind of report has been a very good experience. We had very good bureaucrats who co-operated with us, we had good secretaries who helped us, and most important was the chief minister himself. He also listened whenever we made presentations and he has acted too, which has been very encouraging. But at the same time, given the pace at which the govt is implementing - the health department - some of us feel frustrated, coming from NGO background. Things could move much faster. But that is how it is, we have to accept certain limitations within the govt. We sometimes take a pro-active role in pushing things, but still there are a lots of limitations in the existing system. And I feel the Karnataka Health system is running at about 25-30% efficiency. If we can implement part of the recommendations also, it will increase the efficiency to 50% and that will have a tremendous impact. But how to change mindsets? The whole concept of making this happen and community participation, these are challenges. Probably over the next ten years, if we invest on this, especially community participation and empowering people for their own health, things will definitely improve.
Dr. H.Sudarshan, Chairman,
Task Force on Health & Family Welfare,
PHI Building Annex, 2nd Floor
Phone & Fax: 2271021
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