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Karnataka has made significant progress in improving the health status of its community
with considerable improvements in life expectancy and a decline in infant mortality,
fertility, malnutrition, illiteracy etc. Despite all these achievements, certain
groups of the population are at the risk of developing malnutrition, disease or
disability because of their different attributes or characteristics such as geographical
isolation, socio- economic status, age group, gender and physical afflictions. The
awareness of these communities regarding their health needs is poor, their health
seeking behaviour is not appropriate and many of them do not have access to quality
health care services. The Karnataka Health System Development Project with the support of World Bank has decided to give special impetus to improve the health care services
for these vulnerable communities. Accordingly, assigned the task to the Indian Institute
of Health Management
Research, Bangalore to carry out a social assessment of vulnerable
communities for assessing their health status, identifying their health care needs,
barriers in availing existing health facilities and their perception on health related
matters.
The social assessment study was carried out among the vulnerable communities i.e.
economically weaker section, scheduled castes, scheduled tribes, women and adolescent
girls in selected districts of Karnataka. Before developing the conceptual framework,
literature review was done and accordingly, the study was designed. The study design
was qualitative and data collection methods included focus group discussions, in-depth
interviews and case studies and various PRA methods to assess the perception of
vulnerable communities towards their health problems and availability and utilization
of health care services. Besides this, two workshops were conducted with various
stakeholders including district level officials from health, women and child department,
education, tribal welfare, NGOs at Mysore and Bagalkot.
Based on the Dr. Nanjundappa's Committee report, four regions i.e Bangalore, Mysore,
Belgaum and Gulburga were taken up for the study. From each of these regions, one
district was selected i.e. Tumkur, Mandya, Bagalkot, Koppal. For representation
of Tribal Settlement Population, districts Mysore and Kodagu were selected and for
NGO consultation, district Chamarajnagar was selected. From each of the selected
districts, two taluks having maximum SC and ST population were selected. Further,
from each taluka, four to five villages were randomly selected for data collection.
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Findings of the Social Assessment Survey
From the study findings it is evident that the health status of the vulnerable communities
is poor and the existing health care delivery system is inadequate to meet their
requirements. Poverty, illiteracy and ignorance, malnutrition, inadequacy of potable
water, lack of personal hygiene, poor sanitation, and inadequate Hospital
coverage and poor quality of Health care services are the major
reasons for unsatisfactory health status of these communities.
The common health problems perceived by the community are malaria, tuberculosis
and respiratory disorders. The problems like snakebites, dog bites and scorpion
bites were also found to be common in rural areas. It was reported that children
mostly suffer from acute respiratory infections (ARI), diarrhea and fever. Many
respondents were aware that their health problems are due to poor availability of
safe drinking water and poor sanitary conditions.
Women in these communities commonly suffer from reproductive tract infections (RTIs)
and backache. The deliveries are mostly conducted at homes. Their status is low
in these societies. They are economically dependent and have poor decision-making
authority. When they fall sick, their spouse and family do not consider it necessary
to get them treated because of gender bias. Also, the women need some companion
to accompany them to the Hospital, which is again a constraint in availing the Health
care services.
Adolescents in these communities have a low level of awareness on sexual and reproductive
health.
As a result, they are vulnerable to unwanted pregnancies and sexually transmitted
infections (STIs). They get married early and have early pregnancies for which there
are a number of social, cultural and economic reasons.
A barrier for the utilization of government facilities was reported to be poor accessibility
due to lack of public transport system, especially during night. The women, children
and emergency cases face problem in accessing these facilities. The tribal settlements
are small and isolated and are difficult to reach by service providers. Many tribes
live in small hamlets.
The community has a stereotypical image about government hospitals i.e. they are
dirty and overcrowded, there are long waiting hours, behavior of the staff are rude
and the treatment is not very effective. A large number of positions of doctors
and ANMs were reported to be lying vacant. The service timings of these hospitals
are considered to be inconvenient. Women and adolescents reported lack of privacy
and confidentiality as one of the reasons for their not utilizing government facilities.
The SC and the ST community also perceived discrimination by staff at the health
centers. Corruption and private practice by the doctors were found to be important
causes of dissatisfaction among clients. Despite all these negative perceptions,
the poor and other disadvantaged groups are forced to avail treatment from government
hospitals because of their economic compulsions and free availability of treatment
in these hospitals.
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Surprisingly, in a few government health centres a high client satisfaction was
found. The reason for this contrast was identified to be the good behavior, technical
competence and commitment of the doctors working in these centres.
The community is quite dissatisfied with the services of ANMs due to their infrequent
visits to the villages and their homes. The community also complained that the ANMs
do not provide them the necessary medicines during their visits.
The community expressed a high opinion about private health practitioners and perceives
their treatment to be more effective.
The health service providers have their own set of limitations in providing satisfactory
services to the community. Lack of residential quarter to staff is forcing them
to reside away from the headquarters. Some of the sub center clinics in rural areas
are not held regularly because the public transport facilities are very untimely.
The staff is working in the tribal and remote areas for a number of years without
any appreciation or incentives of any kind. Promotions of the staffs is pending
for a long time. Supervision is weak at all levels. No vehicle is available at the
disposal of PHCs. The community expectations from govt. health institutions and
hospitals are very high.
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There are few grassroots non-government organisations working in the tribal areas
of Chamarjanagara and Mysore districts and are doing commendable job. Some of their
strategies such as tribal ANM, mobile dispensary unit, rigorous monitoring and supervision,
forming local groups, setting up of voluntary counseling and testing centres are
worth replication in other areas.
Need for Specific Interventions in Health Sector for the Vulnerable community
The state of Karnataka is yet to include a separate SC/ST/ Vulnerable community
development health policy under the state integrated health policy. Consequently
there is no specific plan for this group till now. There is no separate budgetary
head/ funding under special component plan (SCP) for SCs and Tribal sub plan (TSP)
for forest dependent tribals. The present budgetary provision being indicated under
Zilla Panchayat sector is only a notional amount towards expenditure of staff salaries
and drugs for functioning of subcenters and PHCs identified under SCP/TSP. No central
assistance is forthcoming in spite of two mobile health units sanctioned to serve
for the primitive tribal groups (PTGs) Identification of health management institutions
to function in SCP & TSP is perfunctory and therefore budgetary allocation/
expense is being shown as flow of funds to the SCP/TSP. Surveys or in-depth studies
are yet to be carried out in the state to explore more details regarding the health
of the SC/ST communities. The availble data are of 1983 and 1995 surveys only. Specific
performance reviews of national and state health programmes directed towards SC/ST
population have not been very serious except the review of expenditure at quarterly
intervals. No incentives as motivation are available under SCP/TSP for the staff
who are working in the institutions sanctioned / identified under SCP/TSP. Management
of PHC, sub-centre, and mobile health units is the only strategy for the SCP/TSP
since last three decades and these units are not fully functional. Karnataka Health
Systems Development Project began implementation of Yellow Card Scheme in November
1996 and extended to all the districts in a phased manner from 1997. Yellow card
scheme (for SC/STs) is discontinued because of constraint of funds.
Legal and Policy
Framework for the vulnerable community
There are certain legal and policy provisions
under the Constitution of India and State Acts to safeguard the health, economic
and other fundamental needs of the vulnerable communities. In 1961 census 100 SC
and 44 ST groups were enumerated in the state. National Health Policy 2002 in the
operational strategies has recommended mobile clinics to promote indigenous systems
of medicine and to sensitise the providers to adopt a burden of disease approach
to meet the special needs of tribal and hilly area communities. During 1997-98 Rural
Development and Panchayat Raj Department of Karnataka identified 20.35 lakh below
poverty line (BPL) families having an annual income of less than Rs.20,000/- per
annum. This is adopted, as the According to the Government of India there are 31.29
lakh BPL families in the state. According to planning Commission estimate based
on NSSO, 20.04% of the population i.e. 104.40 lakh of people in Karnataka are below
poverty line (25.25% urban and 17.38% rural). National Population Policy 2000 in
the action plan among other things has formulated various operation strategies such
as convergence of service delivery at village levels, empowerment of women for improved
health, nutrition, child health and survival, under-served population groups, diverse
Health care providers involvement, collaboration from the NGO sector, mainstreaming
Indian systems of medicine and homoeopathy, contraceptive technology and research
on RCH and information, education and communication. In the Karnataka State Integrated
Health Policy (2003), it has been reiterated that the scheduled castes and scheduled
tribes will receive priority attention. Further the policy mentions that innovative,
flexible and collaborative approaches would be adopted for meeting the health needs
of children, out of school, persons with disability and other vulnerable groups
in the community.
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National Policy for the Empowerment of Women (2001), covers goals and objectives,
policy prescriptions, economic empowerment of women, social empowerment of women
(education, health and nutrition). National Population Policy (2000) prescribes
various operational strategies for enhancement of mother and child health including
women empowerment and convergence services. National Health Policy - 2002 under
the policy prescriptions has given importance to increased access of women to basic
health care. It also recognizes the need to review the staffing norms of the public
health administration to meet the specific requirements of women in a more comprehensive
manner.
An action plan has been formulated in 2001 for elimination of child labour in Karnataka.
The Child Marriage Restraint Act (1976) stipulates that the marriage of girl is
18 years and that of boy 21 years.
The National Population Policy (2000) in the operational strategies has focused
on ensuring access to information, counseling and services including reproductive
health services that are affordable and accessible. The strategy has also to be
planned and implemented to provide integrated interventions in pockets with unmet
needs in the urban slums, remote rural areas, and border districts and among the
tribal populations. Finally developing a health package for adolescents is recommended.
National health policy (2000), has recommended 1) to sensitise, train and equip
rural and urban health centres and hospitals towards providing geriatric health
care; 2) encourage NGOs and voluntary organizations to formulate and strengthen
a series of formal and informal avenues that make the elderly, economically self-reliant;
3) Tax benefits could be explored as an encouragement for children to look after
their aged parents.
National Policy on Older Persons (2001) seeks to assure older persons that their
concerns are national concerns and that they will not live unprotected, ignored
or marginalized. The goal of the national policy is the well being of the older
persons.
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General Mandates that are applicable in Karnataka, India:
The Mysore Public Health Act (1944) was enacted in the state of Mysore for advancing
public health in the state of Mysore. This is yet to be amended. The Model Public
Health Act was communicated by the central government in January 1987. This will
serve as a guide for framing the Karnataka Public Health Act in Karnataka, amendment
of Karnataka Municipal Corporation Act - 1976 and Karnataka Municipalities Act (1964).
The functions listed under item X, item XIX of schedule III of the Karnataka Panchayat
Raj Act relates to drinking water and health and family welfare program guidelines.
Likewise the KPR Act specifies the same issues in taluk panchayat, grama panchayat.
The Section III Chapter 17, of the Act empowers the ward sabha to exercise powers
to discharge the functions relating to public health. Chapter 18 provides regulatory
powers of grama panchayat to ensure control of communicable diseases and public
health outcomes, health regulations to be effectively enforced. Chapter 21 provides
to ensure the control of communicable diseases. The Epidemic Diseases Act - 1897
(Act 3 of 1897) provides for better prevention of the spread of dangerous, epidemic
diseases.
The Karnataka Right to Information Act (2000) received the assent of the governor
on the 10th day of December 2000. The Act provides for right of access to information
to citizens of the state to promote openness, transparency and accountability in
administration and to ensure effective participation of the people in the administration
and thus making democracy meaningful.
Special budgetary provisions for Vulnerable Community
At present there is no special budgetary provisions for health care activities under
Special Component Plan (SCP) for Scheduled Caste or under Tribal Sub Plan (TSP)
for tribal population. Out lay and expenditure towards few sub centres, primary
health centres and mobile health units take the form of notional funding and will
be accounted as flow of funds to SCP or TSP from overall budget of Zilla Panchayats
(Health Sector) Budget. Apart from this there are no specific or exclusive programs/activities/inputs
benefiting the individual clients/communities particularly SC/ST as in other poverty
alleviation programs.
Vulnerable Communities Health Plan
Keeping in view the findings of the study and literature review, strategies for
improving the health of vulnerable communities is being proposed in the report.
The Vulnerable Communities Health Plan (VCHP) has been developed to improve the
health of these communities based on the findings of social assessment study conducted
in more/ most backward taluks, also having high percentage of vulnerable communities
and consultations with stakeholders in two workshops held at Bagalkot and Mysore,
Karnataka, India.
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Prioritisation of Districts for Intervention
The baseline data covered in chapter - 9.3 shows that the distribution of vulnerable
communities is high in certain districts, low performance levels in health profiles
in such districts and also tribal settlement population in ITDP taluks in certain
districts. Considering these criteria sixteen districts needs immediate attention
in terms of important health interventions. These districts can be categorized into
two major groups.
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Group |
Justification |
Category |
Name of the Districts |
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I |
Based on the HDI and other development indicators 7 districts have been selected.
Further based on Highest SC population Kolar district has been selected and based
on highest combined SC and ST population two districts have been selected
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Poor Districts
District with high SC population
Districts with high (combined) SC and ST population
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Raichur,Gulburga,Bidar, Bellary,Koppal,Bijapur, Bagalkot
Kolar
Chitradurga and Davanagere |
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II |
Based ITDP Districts and concentration of forest based tribal settlement colonies
6 districts have been selected |
Tribal |
Mysore, Chamarajnagar, Dakshina Kannada, Udupi, Chikkamagalur, Kodagu |
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Plan Approach
The plan covers the Poor, Scheduled Caste and Tribal population in plain areas,
and Women, Adolescents and Tribal groups inhabiting notified tribal areas. Since
the social assessment study has not covered the Elderly and Physically challenged
population, the plan does not include this population. A detailed VCHP plan has
been developed and depicted in a matrix. The VCHP Matrix consists of the issues
to be addressed, strategies to be adopted, departments/ persons responsible for
implementation, implementation details and indicator to assess the output. Keeping
in view the overall objectives of VCHP i.e., to enhance the levels of health status
of the vulnerable communities, considering all the developmental activities presented
earlier, these have been grouped and the time schedule for key activities has been
represented in a tabular form (Please refer the table). The identified strategies
are ennumerated below:
Strategies for Poor, SC and ST Population
¢ Mobile Medical Services
¢ Developing Tribal ANMs
¢ Village Health Volunteers
¢ Capacity building of Health Staff on Health Management and Quality assurance
¢ Streamlining the supply of drugs
¢ Organizing round the clock services
¢ Strengthening Referral systems
¢ Controlling Malaria - Outsourcing Spray Operations
¢ Controlling Malaria - Utilising the Health Volunteers as Depot holders
¢ Providing ASV and ARV services through Identified Institutions and Involvement
traditional Healers
Strategies for women group
¢ Training of health professional on syndromic approach
¢ RCH camp approach
¢ Involvement of Self Help Groups (SHGs)
¢ Part time services of Anganwadi Workers
¢ Sensitisation of Women Panchayat Raj Institutions (PRIs) members
Strategies for adolescents
¢ Initiating adolescent health programs
¢ Disbursement of IFA tablets to adolescents
¢ Special adolescent clinics at identified institutions supported by counseling
facilities |
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Strategies for tribal groups (forest based)
¢ Strengthening of Mobile Health Units
¢ Tribal ANMs
¢ Training of Traditional Birth Attendants (TBAs) or Dais
¢ Health Insurance
¢ Involvement of Traditional Healers and Private practitioners
¢ Performance Based Incentives
Strategies for Improving Nutritional Status of pregnant
Women and Children
¢ Supplementary food to pregnant women and Children
¢ Functional
Co-ordination between Health and Women and Child development department
Operations
Research studies to improve the implementation of project
¢ Evaluation of NGOs involved
in the project activities.
¢ Assessing effectiveness of various IEC strategies.
¢ Assessing utilization and effectiveness of mobile clinics.
¢ Developing strategies
to involve PRIs, SHG in health care activities.
¢ Acceptability and effectiveness
of Village Health Volunteers.
¢ Assessing utilisation of special government schemes.
¢ Assessing the quality of emergency obstetric services at referral centers.
Prerequisites
for effective implementation of VCHP
The major problem with the health care delivery
system in the state is of vacant positions of field staff in most of the institutions.
Large number of doctors has been recruited during the last five years who are not
adequately public health oriented. The existing staff has a low morale and poor
motivation due to issues related to their promotions, postings and working conditions.
There is shortage of regular funds for the routine repairs and maintenance of the
building, furniture and equipment. The monitoring and supervision is probably the
weakest component in the health sector. Hence the following prerequisites have been
specified for the success of the plan:
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¢ Filling up the vacant positions
¢ Developing and implementing Human Resource Policy
¢ Developing training strategy - District Mobile Training Teams
¢ Strengthening the infrastructure in peripheral institutions
¢ Strengthening Logistics Management
¢ Strengthening Monitoring and Supervision
¢ Promotion of government sponsored schemes
¢ Developing an effective IEC strategy and plan
¢ Ensuring potable water and sanitation for the identified communities
¢ Mid-term and end-term evaluation of the project
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Prioritization of the strategies under VCHP
Out of the strategies identified as above it was decided through a series
of meetings with the officials of the directorate and the World Bank team that only
few strategies need to be prioritized for implementation under the project mode
and the rest of the strategies may be carried out as routine activities of the department.
The strategies prioritized for implementation under the project are:
1. Mobile health Clinics
2. Training of tribal girls as ANMs (Tribal ANMs) It was also decided that the supplementary
nutrition would be provided to pregnant women and children in selected areas through
mobile health clinics. These strategies are described in detail in a separate document
entitled, "Vulnerable Community Health Plan (VCHP).
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© ALL RIGHTS RESERVED - IHMR, Bangalore
Address: Institute of Health Management
Research
#319, Near Thimma Reddy Layout,
Hulimangala Post,
Electronic City Phase-1, Bangalore - 560105.
Ph : 080-30533800 / 803, Fax : 080-28521504
Email : info.bangalore@iihmr.org
Last updated on 04-04-2012 |
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