HEALTH POLICY KERALA 2013

May 2, 2013 in Events, News

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http://www.dhs.kerala.gov.in/docs/draftpolicy.pdf

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GOVERNMENT OF KERALA

HEALTH POLICY KERALA

2013

Health & Family Welfare Department

DRAFT

2

Content Page

No.

Introduction

1. Formulation Health Policy documents in India an overview 4

2. Current scenario 5

2.1 Kerala Statistics 5

2.2 Health Financing 6

2.3 Social determinants of Health 7

2.3.1 Water supply 7

2.3.2 Sanitation 8

2.3.3 Solid and liquid waste management system 8

2.3.4 Climate Change and public health 8

2.3.5 Other social determinants of health 9

2.4. Emerging and re-emerging communicable diseases. 9

2.5 Non Communicable Diseases; 9

2.6 Cancer care Prevention and early detection 10

2.7 Women’s Health 10

2.7.1 Maternal Health 11

2.8 Child health 12

2.9 Adolescent health: 12

2.10 School Health: 12

2.11 Health problems of elderly 13

2.12 Mental health problems. 13

2.13 Health of vulnerable sections: 13

2.14 Health Infrastructure in Kerala as on 31.03.2011 14

3 Overview of Health Service System of the state 15

3.1 Tertiary Care 15

3.2 Secondary care institutions 16

3.3 CHCS: 16

3.4 PHCs 16

3.5 Sub centres 16

3.6 Emergency medical services and management of trauma 17

3.7 Medical Establishment Bill 2013 17

3.8 Human Resource Policy in Health 17

3.9 Nursing Care and Nursing Education 17

3.10 Treatment protocol, referral protocols & management guidelines 18

3.11 Data Management System 18

3.12 Decentralisation and Health 18

3.13 Medical Education 19

4. Private Sector 19

Objective 20

5 Plan of action 20

5.1 Determinants of health care 20

5.2 Enforcement of regulation for good health 21

5.3 Reorganisation of Government Health System 22

5.4 Other specialised services 24

6. Ayurveda 28

7. Homoeopathy 29

8. Oral Health 30

9. Future Developments 31

3

Introduction

Kerala has achieved good health indictors compared to other Indian

states. A prime reason for this has been the stewardship role that

successive governments, before and after independence, have played. This

has become even more important at a time when the state is facing the

emergence and re-emergence of some of the communicable diseases

along with problems resulting from the epidemiological and demographic

transition. In order to navigate the sector through the multiple challenges

faced in the health sector Government of Kerala needs to articulate the

policy framework under which all the stakeholders can develop their

strategies. This document is an attempt to address such a need.

4

1. Formulation of Health Policy documents in India an overview

National Development Committee (Sokey Committee) and Bhore Committee had

developed a very broad and elaborate frame work for the Health policy for the

country even before Independence. Successive Five year plans have been the

guiding documents for national policy in India. Post independence Kerala has, by

and large, followed the guidelines of the national government. The state went on

to achieve most of the targets set out in these documents such as population

stabilisation and control of communicable diseases through a network of

institutions modelled on the national pattern, even though there were a few

differences.

National level expert committee reports like ICMR/ICSSR committee report,

Swaminathan Committee Report on Population Control, Commission on Macro

economics and health and the recent HLEG reports are significant documents

which have guided policy making in the health sector and influenced the health

service system of the country. The national health policy 1983 was the first

articulation of a policy document at the national level. Commencement of the

National Rural Health Mission in 2005 resulted in substantial augmentation of

resources and modification of implementation arrangements. The 12th plan

document sets a target of Universal Health Coverage before the government.

Since Kerala is in a unique position to achieve the targets set out in the 12th plan

document it is important to develop a policy to guide our efforts in this direction.

5

2. Kerala Current Scenario

2.1 Kerala statistics

Sl.No. Category Numbers

1 Districts 14

2 Taluks 75

3 Panchayaths 978

4 Panchayath wards 16680

5 Blocks 152

6 Revenue Villages 1453

7 Towns 197

8 City Corporations 5

9 Corp. Wards 359

10 Municipalities 60

11 Municipal Wards 2216

12 Population (2011 Census Provisional)

Total 33387677

Male 16021290

Female 17366387

Sex Ratio 1084

Urban 7455506

Rural 5932171

Percentage of Population below Poverty

line

Total 12.72

Rural 9.38

Urban 20.27

Scheduled Caste Population (2001

Census)

Total 3123941

Male 1525114

Female 1598827

Scheduled Tribe Population (2001 Census)

Total 364189

Male 180169

Female 184020

Total 0 to 6 Populations (2011 Census)

3322247

Male 1695935

Female 1626312

Sex Ratio (Child) 959

Density of Population (2011 Census) 859/Km2

Literacy Rate (2011 Census) 93.91%

Male 96.02%

Female 91.98%

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2.2 Health Financing

Even before independence the expenditure for health by the Maharajas of

Travancore was significant. As early as in the 1860s the government of

Travancore allotted a little over 1% of its total expenditure to health sector and

the proportion increased to 2% by the close of the century. The unswerving

governmental support for the welfare sectors till the mid 1980s served as a

catalyst for the development of health services in Kerala. This was also reflected

in the expansion of health infrastructure. During the periods between 1960s to

mid 1980s the number of beds in public sector institutions increased from 13000

in 1960-61 to 36000 in 1986.

Health sector investments continued till the mid 1980s but thereafter the

pace of growth of public health care system slowed. The shortage was made

good by the private sector. The public health care expenditure (as a proportion

of the gross state domestic product) decreased by 35% between 1990 and 2002,

making Kerala one of the states with the highest reductions in public sector

contributions and the highest increase in private funding for health care. The

decline in public sector spending for health resulted in an overwhelming

expansion of the private sector.

Budget allocation – Health and NRHM funds

State plan 100 % CSS 50 % CSS

Allo Exp % Allo exp % Allo exp %

2006-07 29.48 18.45 62.59 2.16 1.46 67.59 4.20 1.36 32.59

2007-08 48.44 29.74 61.41 2.16 1.81 83.91 3.20 1.01 31.77

2008-09 74.13 65.82 88.79 2.16 1.76 81.61 3.20 1.59 49.88

2009-10 30.53 27.95 91.55 3.15 3.38 107.55 3.20 2.15 67.34

2010-11 30.89 28.55 92.44 4.89 4.77 97.42 6.80 4.27 62.91

7

NRHM budget details Rs. in lakhs

Allo exp

2005-06 34.45 3.90

2006-07 80.60 17.64

2007- 08 120.00 112.49

2008-09 285.72 266.01

2009-10 230.03 291.80

2010-11 296.53 239.20

Budget for Dept. of Health & Family Welfare

2007-08 2008-09 2009-10

Outlay Exp. Outlay Exp. Outlay Exp.

1 Health services Dept. 5746.00 3010.55 5453.00 5433.00 3678.00 3678.00

2 Medical Education Dept. 4691.61 1627.81 3505.00 3505.00 4244.00 4244.00

3 Indian Systems of Med. 149.00 154.78 750.00 750.00 1022.00 1022.00

4 Ayurveda Medical

Education Dept.

404.08 277.58 896.00 896.00 900.00 900.00

5 Homeopathy Dept. 258.00 79.20 607.00 607.00 866.00 866.00

6 Homoeo Medical

Education Dept.

275.00 84.79 325.00 325.00 410.00 410.00

2.3 Social determinants of Health

2.3.1 Water supply: Even though Kerala gets over 3000 cm of rain in a year

poor management reduces the state of near drought conditions in the period

between January and May. With increased reclamation of wetlands and water

bodies and persistent pollution of drinking water sources, water availability is

likely to come under increased strain in future. Added to this is the failure to

provide safe drinking water in hilly regions, coastal and water logged areas.

Unless this is reversed and the state manages its environmental and water

situation better we are likely to witness outbreaks of water borne diseases such

as Cholera and Hepatitis A.

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2.3.2 Sanitation; The availability of sanitary toilets has improved in most parts

of the state except backward regions like coastal areas, hilly, tribal areas and

urban slums. Problems of toilet construction in water logged areas and areas

below sea level in Alappuzha district (Kuttanad areas) and the absence of

appropriate models for areas with water scarcity are unresolved technological

issues of this field. First generation sanitary toilets were without septic tanks

(with ordinary pit)) contaminating the nearby drinking water sources including

the wells. The increasing population density and the migrant situation further

complicate this issue.

2.3.3 Solid and Liquid Waste management system: For last few years this

is the most burning issue with administrative, ecological and public health

dimensions. It is a major problem in Municipal corporations of Trivandrum,

Ernakulam, Kozhikode and Thrissur. This is becoming a major threat to public

health in urban areas and urban townships of the rural areas also. Accumulation

of the plastic waste and the issue of thin plastic carry bags which is still being

used even after repeated legal measures further complicate the scenario.

Ecological degradation and the contamination of the water bodies and

ecosystem in general due to the unscientific use / misuse of pesticides pose a

serious health hazard. Health problems due to occupational pollutants, asthma,

allergy, chronic obstructive pulmonary diseases especially in the context of

raising urbanisation and increase in the automobile use are other related issues

to be addressed.

2.3.4. Climate change and Public Health.

The changing climate will inevitably affect the basic requirements for

maintaining health, clean air and water, sufficient food and adequate shelter.

Climate change also brings new challenges to the control of infectious diseases.

Many of the major killers are highly climate sensitive as regards to temperature

and rainfall, including cholera and the diarrheal diseases, as well as diseases

including malaria, dengue and other infections carried by vectors. Also the issues

of reductions and seasonal changes in the availability of fresh water, regional

drops in food production, and rising sea levels etc has the potential to force

population displacement with negative health impacts.

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Climate Change is a new challenge for the control of infectious diseases

and public health. It leads to change in pattern of infection, emergence /

resurgence /of diseases like H1N1, H5N1, Malaria, Dengue, Chikungunia,

Letospirosis. Similarly many diseases caused, transmitted or harbored by insects,

snails and other cold-blooded animals can be affected by a change in climate eg.

Lyme disease, Tick-borne encephalitis, Salmonella and other food borne

infections. Kerala with a long coastal line and parts of Western Ghats covering

almost all districts except Alappuzha is very much disaster prone. This

necessitates the preparedness for managing all varieties of natural disasters.

2.3.5. Other social determinants of Health: As per WHO’s report on social

determinants of health and HLEG report of GOI other factors like food and

nutrition, regular employment housing, women empowerment etc are very

significant in achieving better health. As per the official figures 12.72 % of the

population of Kerala is below poverty line. But studies have shown that relative

poverty, more than absolute poverty, leads to poor health outcomes. There is an

urgent need for addressing the issue of social determinants of health in a

comprehensive and time bound manner .

2.4 Managing the emerging / re-emerging Communicable diseases;

Waterborne diseases like diarrhea diseases, Hepatitis, Typhoid fever and vector

bone diseases like Dengue fever, Malaria , JE remain a major problem in Kerala.

Leptospirosis which was a problem for few southern districts in the last decade

has become a major communicable disease in the whole state and causing much

morbidity and mortality throughout the year. These diseases follow a seasonal

pattern. Outbreaks of waterborne diseases like diarrhoea cholera are always

more in the monsoon season extending from May to August. Higher incidence of

acute viral fevers along with diseases like Dengue, Chikungunia, leptospirosis,

scrub typhus etc make this as the “season of epidemics”. There is an

apprehension that the presence of migrant labourers from different states might

introduce/ reintroduce diseases that are not prevalent here. A high level of

epidemiological surveillance and outbreak management has to be maintained in

the state.

2.5 Non Communicable Diseases: In Kerala NCDs account for more than

50% of total deaths occurring in the age group between 30 and 60. With 27% of

adult males and 19 % of adult females being diabetic, Kerala is considered to be

the diabetic capital of India. The percentage of Hypertension, Cardiovascular

diseases and Cancer is also very high in the community across all sections of the

society. Yet there was no organized programme to combat these problems till

2010. NPCDCS ( National Programme for Prevention of CVD, Diabetes, Cancer

and Stroke) a national programme in this regard was introduced in

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Pathanamthitta district in 2010 and later extended to Thrissur, Idukki, Alappuzha

and Kozhikode. The State Health department in order to extend the benefit of

the programme to the entire population has introduced the State NCD Control

programme (Amruthum Arogyam) which covers all fourteen districts up to the

sub centre level.

The activities include Primordial and Primary prevention through Health

education, Secondary prevention through early detection and management and

Tertiary prevention by prompt treatment and uninterrupted supply of medicines.

Health education is done through field level workers about Diet, Exercise and

Habits with a motto of Prevention of NCD through Life style modification. This

programme has to be strengthened as the load and complexity of NCDs are likely

to grow in future.

2.6. Cancer Care – Prevention and early detection

Kerala reports nearly 35,000 new registrations and around 1 lakh patients are

under treatment every year. But treatment in Government sector is limited to

Regional Cancer Centres at Thiruvananthapuram and Malabar Cancer Centre at

Thalassery, Kannur. Radiotherapy is available in 5 Government Medical Colleges

and GH Ernakulam leaving the remaining 7 districts with no facility for cancer

treatment in Government sector. The focus has to be on elimination of risk

factors, increased awareness, early detection and prompt. Government proposes

to establish early Cancer detection and follow of Chemotherapy centres in all the

districts attached to district head quarters hospitals. In order to control the use of

tobacco and other tobacco containing products, a major cause of cancers and

other NCDs, COTPA is being implemented in the State. The State aims to

establish tobacco free homes, schools and workplaces.

2.7. Women’s Health. In Kerala atrocities against women, domestic

violence, and other related issues are comparable to the national level. Gender

based health management centres which started functioning in major hospitals in

district and taluk levels, in partnership with social justice and home ministries will

be strengthened to manage the physical and psychological impact of such

violence. Similarly the health problems of the elderly women, widows, women

workers of the traditional industries like cashew, coir, fisheries, tribal women,

domestic women workers, agricultural workers, low- paid urban based sales girls

working in shops/ malls etc needs to be addressed in a comprehensive manner

covering the health determining sectors. Rising trends of under nutrition,

anaemia, obesity, infertility etc. among women also need to be addressed. The

declining child sex ratio reported in the 2011 census of India points to the

possible existence of child sex selection and foeticide in some parts of the state.

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This has to be verified and corrected to prevent Kerala going the way of most

other states in India

2.7.1 Maternal Health. Though the maternal mortality rate of Kerala is better

than the all India average it is unacceptably high compared to the international

standards and has been relatively stagnant for the past few years. Government

intends to reduce the MMR by 50% of the current rate by the end of the 12th

Five year plan. Since most of the deliveries in Kerala take place in institutions the

quality of obstetric care has to be improved. A strategy to reduce the maternal

mortality through a standards framework, developed with the support of the

Kerala Federation of Obstetrics and Gynaecology (KFOG) and National Institute of

Clinical Excellence (NICE) of UK, is being piloted in the state. By addressing the

most common obstetrical complications like post partum haemorrhage and

Pregnancy Induced Hypertension this projects hopes to make a dent in maternal

mortality in the state. .

For the last one decade both government and private sector hospitals are

reporting a rising trend of caesarean section touching 40%. Though some

administrative and technical measures have been taken up at the state level, so

far it has not made any major impact. Other issues like maternal anaemia, early

marriage, and teenage pregnancy in some of the districts and tribal areas also

remain intractable.

Maternal and child health indicators during the three NFHS periods

(1993-94, 1998-99 and 2005-06)

Indicators

NFHS-I

1992-93

NFHSII

1998-

99

NFHSIII

2005-06

Fully immunized children (%) 54 80 75

Under weight children (%) 27 27 29

Infant mortality rate 24 16 15

Any antenatal care (%) 88 99 100

Institutional delivery (%) 89 93 100

Total fertility rate ( TFR) 2 2 1.9

Women who are exposed to Spouse’s

violence (%) NA NA 16.4

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2.8 Child Health

While the IMR of Kerala (12 per 1000) is better than most Indian state the rate

has stagnated for the last decade. The state aims to reduce the present IMR to

single digits by the end of the 12th Five year plan. For further reducing the infant

mortality, the Neonatal Intensive Care Unit (NICU), Special New Born Care Unit

(SNCU) and New Born Care Corner (NBCC) and other new born care facilities

attached to the delivery points will be further strengthened.

Government attaches foremost importance to prevention of disabilities among

children. A New Born Screening Programme for congenital diseases like G6 PD

deficiency, adrenal hyperplasia, hypothyroidism and phenyl ketonuria has been

started recently. This will be further expanded to cover other conditions.

Community level disability detection and management through ASHA, Anganwadi

worker and Health worker will be strengthened. Remedial measures in such

cases will be made available free of cost by government.

Though no polio cases were reported in the state since 2000, the VPDs like

diphtheria, whooping cough, measles, and tetanus are still being reported. Health

Department and Social Justice Department will collaborate to achieve universal

immunisation and nutritional monitoring.

2.9 Adolescent health (ARSH):

Government seeks to equip, sensitise, and empower all adolescents of the State

to realise their full potential. To this end their physical and mental health needs

will be addressed. Through the Weekly Iron Folic acid Supplementation

Programme (WIFS) health department will cover 31 lakh beneficiaries in the state

including adolescent girls and boys from class 6 to 12, and out of school

adolescent girls from 10 to 19 yrs for anaemia control.

Hospital based Adolescent Friendly Health Clinics (AFHCs) have been started at

all District Hospitals and selected THQs, CHCs, and mobile AFHCs in underserved

areas. Out reach sensitisation, peer leader motivation, and adolescent health

promotion through NRHM-NSS Teen Clubs, and Parent Teachers seminars at

schools have been started state wide. Large numbers of doctors, nurses, and

JPHNs have been trained in all districts, to serve as the manpower for all these

efforts.

2.10 School Health:

The Modified School Health Program implemented in 7% of the schools of the

state in 2009 was extended to all government schools in 2012-13. The

programme aims to provide school based health support services to all the

students by working collaboratively with different agencies, school teachers,

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parents and community members. The programme will try to establish, with the

support of health and education officials, teachers, students, parents, health

providers and community leaders, health promoting schools, a school “that

constantly strengthens its capacity as a healthy setting for living, learning and

working”.

2.11 Health problems of elderly. At present the percentage of population

above 60 is 12 % and is expected to cross 25% by the year 2050. As in many

other areas the capacity of the health sector has to be scaled up substantially to

deal with the enormity of the problem. This has taken efforts to set up Geriatric

care wards with Geriatric friendly facilities at District and Taluk level Hospitals.

However a comprehensive Geriatric health care programme is yet to be

developed in the state.

A significant achievement has been the Palliative Care Policy in Kerala in

2008. Palliative care programme which, operates in three levels, home based

primary care, hospital based secondary care and major institutions based tertiary

care, is supported by Local Self Governments. At present there are 700 palliative

care units attached to primary health centres and 250 palliative care units

supported by community based organizations. In the secondary level there are

64 hospitals offering palliative care services.

2.12 Mental health problems

The state aims to incorporate the mental health services with the general health

care services up to the primary health centre level. This is done by establishing

district mental health programmes where specialist units visit PHCs, diagnose and

prescribe medication, leaving the management in the hands of the PHC team and

by having psychiatry units in Taluk and District Hospitals. Rehabilitation of

mentally ill persons is done as joint effort of Health, Social Justice and Local Self

Government Departments. We are handicapped by the shortage of mental health

professionals.

2.13 Health of vulnerable sections:

The health status of some tribes is worse than what exists in most parts of

India. This is partly the result of political disempowerment and partly due to their

remote location. Coastal population suffers from diseases that result from lack of

safe drinking water and sanitation. These call for long term efforts and political

commitment to make a difference. Within the constraints government

departments will continue to provide ameliorative measures.

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Urban population, especially persons living in slums do not have access to

primary health care services. Urban sub centres and primary health centres has

to reconfigured to provide primary care preventive and curative services.

2.14 Health Infrastructure in Kerala

Sl.No. Institution Number Beds

Teaching hospitals

Government Medical College Thiruvananthapuram 1898

T.D. Medical College, Alappuzha 1033

Government Medical College, Kottayam 1604

Government Medical College, Thrissur 1564

Government Medical College, Kozhikode 3225

Government Dental College, Thiruvananthapuram

Government Dental College, Kottayam

Government Dental College, Kozhikode

Government Ayurveda College, Trivandrum 400

Government Ayurveda College, Thrippoonithura 500

Government Ayurveda College, Kannur 250

Govt. Homeopathic medical College, Trivandrum 100

Govt. Homeopathic medical College, Kozhikode 100

Total Govt. Modern Medicine

Institutions 1250 37021

1 General Hospitals 12 4866

2 District Hospitals 15 4854

3 Speciality Hospital 19 5740

4 Taluk Hospital 80 9502

5 Community Health Centres 230 6527

6 24X7 Primary Health Centres 175 3343

7 Primary Health Centres 660 2182

Total PHC (6+7) 835 5525

8 T.B. Centres /Clinics 17 176

9 Other Institutions 19 198

15

Speciality Hospital Category wise

1 W & C Hospitals 8 1786

2 Mental Health Centre 3 1342

3 T.B. 3 608

4 Leprosy Hospital 3 1916

5 Others 2 88

Total 19 5740

Other Institutions Category wise

1 Govt. Hospitals/Health Clinics 8 116

2 Mobile Units/Mobile Clinics 17 0

3 Government Dispensaries 23 82

Total Ayurveda institutions (Hosp/Disp.) 120/793

Ayurveda Medical Education Institutions 3

Total Homeopathic institutions

(Hosp/Disp.) 30/611

3. Overview of Health Service System of the State

Curative services are provided by Ayurveda, modern medicine and Homeopathy

systems of medicine. While in general modern medicine is the preferred system

for specific conditions Ayurveda and Homeopathy are chosen by a large

percentage of the population of Kerala. Government acknowledges the

importance of the three systems of medicine and will encourage studies of the

comparative advantages of treatments under the three systems. 2.8.6.

3.1 Tertiary care: Tertiary care in government service is provided through

Medical college hospitals. It is likely that in five years every district in Kerala will

have a government medical college. Each of these hospitals would be equipped

for managing cases in all specialties and super specialties. Coupled with a

revamped primary care system, referral linkages between secondary and

teaching hospitals and an ICT enabled networking of care the medical college

hospital can be positioned as the manager of the health care needs of the entire

district, including capacity building, quality and research. But to achieve this,

capacity and standards in teaching of medical colleges will have to be

16

substantially improved and better organisational arrangements made. Diagnostics

and treatments will have to be standardised at all levels and referral linkages

established between hospitals at different levels. It will also mean creating closer

links between institutions under the health and medical education departments.

3.2. Secondary care institutions: General/District hospitals, Women and

Children’s hospitals and Taluk head quarters hospitals, will be strengthened to

provide secondary care. Respecting the burden of non communicable diseases

these hospitals will be equipped to handle routine cases of such diseases. Since

Kerala has good road connectivity and patients expect a minimum level of

sophistication Government’s effort will be to strengthen these hospitals with

specialities and attendant services such as trauma care, dialysis centre,

counselling services, de-addiction centres and physical rehabilitation centres.

3.3 In Kerala the national pattern of one post of Gynaecologist, Paediatrician,

Physician, Surgeon and Anaesthesiologist are not available in every CHCs since at

present the available specialists are inadequate to meet the requirements of

specialists in General/ District / Speciality and Taluk hospitals. When the primary

care facilities are reworked and the health protection agency comes into being

the role of the CHCs will worked out appropriately.

3.4 Primary Health Centres: Primary Health Centres were set up for health

promotion activities including prevention of communicable and non

communicable diseases, disease surveillance, implementation of the maternal

and child health programmes comprising antenatal care, immunisation, post natal

care, adolescent health and implementation of other national health

programmes. But the system, originally designed to address reproductive and

child health issues and communicable diseases, has not been reconfigured to

meet the needs of a population that is well on the way through a demographic

and epidemiological transition. The job description of primary care physicians will

be reworked to resemble that of the Family Physician or General Practioner. Each

team will be responsible for a population of 10,000, provide them preventive,

primitive and basic curative services and help them navigate through the health

system should they need higher level of services.

3.5 Sub Centres: There are 5500 ANMS (JPHNs in Kerala) and 3500 JHIs in

Kerala operating in 5403 Sub Centres. The role and responsibilities of the sub

centres and primary health centres has come down markedly due to changes in

pattern of utilisation of health services. There is a need to better reorganise the

functioning of the Sub Centres in such a manner to address the health promotion

prevention and other primary health care services at the field level. With the

introduction of NRHM, the formation of Ward Level Health and Sanitation

Committee and the implementation of the ASHA scheme have also necessitated

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reworking of JPHN’s job requirements. The lack of job clarity for ASHA, who is

paid to facilitate access in a state where no such facilitation is needed, makes the

revamping of functions urgent.

3.6 Emergency medical services and management of trauma: With

more than 40,000 accidents involving 50,000 persons resulting in 4000 deaths

Kerala needs an efficient system for efficient evacuation and good management

of victims of road traffic accidents. The 108 Ambulance services will be extended

to the entire state. Since management of emergency cases and trauma a

specialist cadre of doctors and nurses trained in life saving and trauma

management techniques will be built up. Post graduate courses in emergency

medicine and emergency nursing will also be started.

3.7 Medical establishment Bill 2013: In the state private hospitals,

laboratories and other diagnostic centre play an important role in providing

medical care. But unfortunately there is no system for mandatory registration

and monitoring of the functioning of these institutions. On line with the Medical

establishment bill of GOI, a comprehensive bill covering the registration and

regulation of the all health care institutions will be adopted in the state.

3.8 Human Resource Policy in Health:

Human Resource is the core building block of any Health system. In order to

ensure a health HR the management capabilities will be improved in all the

directorates. HR policy and job descriptions will be dynamically updated to meet

changes in the sector. An HR cell and another HR Advisory Committee will be set

up to advice government on this. Adequate investments will be made to develop,

manage and implement an HRMIS system that will gather and update HR related

data on a regular basis. This will ensure availability of authentic information on

every individual staff within the department at all levels. This will further aid in

process of transfer, capacity building, HR planning etc. All directorates will have a

systematic capacity building system including induction and periodic training. A

performance appraisal and grievance redressal system will also be

institutionalised.

3.9 Nursing Care and Nursing education: Though the services of the

nurses of Kerala is well appreciated all over the world, in Kerala itself the

profession has not been allowed to realize its full potential. The potential of

nursing cadre as an independent professional need to be identified and

propagated. The role of nurses in initial work up and counseling of the patients

in outpatient sections, and the right to administer key drugs at times of

emergencies in OP / IP sections based on a protocol would be very much helpful

in improving the patient care. In time Kerala will need to move to the concept of

nurse practitioner which is available in all advanced health systems of the world.

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3.10 Treatment protocol, referral protocols and management

guidelines

The absence of proper guidelines/ protocols for treatment, medical investigation

and case management is a problem identified in Kerala long back , and efforts

were made to develop these . But unfortunately these efforts did not succeed.

The recent attempt for developing referral guidelines for some of the

departments as a coordinated effort of the doctors of Health Services and

Medical education department is a step in this direction. Kerala will move towards

adoption of standard operating procedures to ensure quality and transparency in

health.

3.11 Data Management System: Health sector generates a large amount of

data. This should be analysed and form the basis for managerial decision making

and policy formulation. Recently Kerala has begun to use data from IDSP and

Health Management Information System for decision making. However there is

no system to integrate this data and present it in a manner useful to managers at

different levels. Kerala will set up a data management unit that can come up with

identification of information needs of managers at different levels, identify the

data inputs that are needed, analyse them and provide feedback to persons

inputting the data and to managers who need to use them. With the support of

the IT wing of GOI health services department has started the implementation of

a comprehensive IT project on pilot basis. Through this ambitious project it is

expected to compile all the household level data including that of the medical

care from the government and private in a soft ware.

3.12 Decentralization and health

By middle of the 1990s in Kerala administrative decentralisation and

decentralised planning paved the way for transfer of health care institutions up to

the district level to the Panchayathi Raj Institutions (PRI). All health care

institutions except General Hospitals, Women & Children Hospitals and Speciality

Hospitals have been transferred to the three tier PRIs and up to 40 % of the

plan fund of various sectors including that of health sector is being disbursed

through these institutions. Thus, Kerala became the first state in the country to

initiate administrative decentralisation in an extensive way including that in the

health sector. But the government level expert committee has identified some of

the lacunae a like the lack of technical support from the department and in the

absence of public health perspective in planning, unnecessary construction work

was taken place at the PHC /CHC levels and most of the projects were repetitive

in nature focussing the field level medical camps and drug purchases.

Since the state is still continuing the decentralization in health, support

structures need to be developed at the block, district and state levels to take up

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a lead role in effective implementation of decentralization. The proposed Public

Health cadre at all levels may be made responsible to shoulder this responsibility

through appropriate HR development.

3.13 Medical Education

Till 2000 almost all institutions of medical education was under government

control. When entry of private sector was allowed growth of the private sector

was rapid and in decade there were 18 private medical colleges as against 5 in

government. Growth in nursing, dental, Ayurveda and paramedical courses was

even more rapid though there were hardly any investors in Homeopathy.

Entry of private sector has increased the supply of medical professionals though

it could be argued that there has been a dilution of quality. It is also pointed by

health education professionals that the quality of teaching even in government

colleges have dropped below desired levels. The Kerala University of Health

Sciences has had a salutary influence in maintaining the quality of institutions

and instruction.

One would have assumed that the banning of private practice would have led to

greater research activities. But Kerala is yet to develop a sub-culture of research.

Government will encourage research activities and innovation in health care

delivery and management.

4. Private Sector

The private sector in Kerala grew to meet the demand that was unmet when

government cut back their investment due to fiscal strain. Currently the private

sector accounts for more than 70% of all facilities and 60 of all beds. The types

of ownership range from corporate to single proprietor. They vary in

sophistication from single doctor hospital to multi-speciality hospitals and have

become the preferred providers for the affluent and the middle class. As

secondary care in government services became restricted to Taluk hospitals and

above it was the private sector that provided services in some remote areas of

the state. These small hospitals, which fulfilled an important role in the health

sector in Kerala, are threatened by increasing cost of operation and the

preference of patients for more sophisticated hospitals.

In the past there was very little engagement between government and

private hospitals. That changed with government officials being allowed to access

care in private hospitals under some conditions. This was further accentuated by

the Rashtriya Swasthya Bima Yojana and the Karunya Benevolent Fund. However

any proposal to systematically engage spare capacity in private sector to provide

health coverage is derided as a sell out to the private sector. When the Clinical

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Establishment Bill 2013 is passed the engagement will be formalised.

Government and the private sector will collaborate in purchasing services,

ensuring quality and working together to address problems of the health sector.

Objective:

1. To position good health as the product of development agenda including

water supply, nutrition, sanitation, prevention of ecological degradation,

respect for citizens’ rights and gender sensitivity.

2. To ensure availability of the needed financial, technical and human resources

to meet health needs of the state.

3. To effectively organise provision of health care from primary to tertiary levels

through referral networks managed by primary care providers to maximise

efficiency and reduce costs.

4. To regulate practice in health sector to ensure quality and patient protection

5. Plan of action :

For achieving the above objectives this policy propose specific plan of action as

discussed in the following sub sections.

5.1. Determinants of health care: Many of the factors that determine health

status of the population lie outside the purview of the health sector. These

include clean drinking water, proper management of solid and liquid waste, food

safety. Many of these have been delegated to local self governments under the

73rd and 74th amendments to the constitution. Health department will leverage

their representation in the local administration to effect convergence of efforts to

improve such determinants.

(i) Clean drinking water: Responsibility for provision of safe water is now

shared between the Kerala Water Authority, water resources department,

local self governments and a host of community based water supply

schemes. There is scarcity of drinking water in many parts of the state,

leading to a host of health problems. The state will continue the efforts to

provide adequate drinking water of good quality in these areas. Health

department will access technologies to test the quality of water being

provided in all the schemes and by adhoc providers in times of scarcity or

natural calamity.

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(ii) Sanitation facilities: In addition to providing sanitary latrines in all

houses Kerala has to deal with issues created by first generation toilets

which have no septic tanks and the lack of scientific system for

management of septage. In the absence of such a system many agencies

dump such waste abandoned areas and water bodies causing serious

public health hazard. Government will access and implement technologies

that can treat septage in water logged areas and high density residential

areas.

(iii) Solid Waste Management Policy, and Plan of action; The system of

collection of waste without segregation and dumping them without a

scientific system of management has resulted in an ecological and social

crisis. By legislative means and education of the public generators of the

waste, including households will be asked to assume responsibility for the

waste, segregate them and participate in decentralised scientific system of

management. Banning of thin plastic carry bags and other administrative,

managerial and legal measures will also be enforced.

(iv) Poverty: Poor persons have greater load of morbidity without the means

of paying for treatment. RSBY, Karunya Benevolent Fund, Janani Sishu

Suraksha Programme, free distribution of generic drugs and similar

schemes have increased financial risk protection in the state. However

government will also introduce other measures to ensure that the poor

have access to preventive and curative services free at the point of

consumption.

5.2. Enforcement of regulations for good health. Enforcement of enabling

and preventive measures, if necessary by coercive means remains a necessary

element of public health any where in the world. Due to outdated laws and poor

enforcement public health in Kerala has not benefited fully from such regulatory

support. Government will revise such laws and move towards their effective

enforcement relying on democratic institutions in the state to prevent their

abuse.

(i) Food Safety. With the passing of the FSSA in India now has a legal

framework for ensuring food safety. However the enforcement

machinery lacks the capacity to effectively implement the provisions of

the act. In addition to strengthening the Commissionerate of Food

Safety Government will leverage capacities available in other

departments for technical support (e.g: Laboratory tests) or to

administer areas that fall into other areas as sanitation. To respond to

increased awareness of food safety and the demand for quality food

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government will scale up the machinery to ensure safe food and

beverages.

(ii) Public Health Act: Government proposes to enact a unified Kerala

Public Health Act combining the existing Travancore-Cochin Public

Health Act 1955 and Madras Public Health act 1939 and incorporating

current public health needs. The proposed health protection agency

and the public health cadre will be able to implement the provisions of

the act effectively.

5.3. Reorganisation of Government Health System:

Government health services currently function as a conglomeration of stand

alone institutions. This creates high degree of inefficiency. Government will aim

to link them in a networked care system with the primary care team providing

initial care and assisting individuals navigate through different levels of health

system. This calls a higher level of organization and management than what

health services currently possess.

i. Primary Care

The primary care system in Kerala has concentrated on family planning, maternal

and child care and prevention and management of communicable diseases. It is

not designed to respond to some of the current challenges as non communicable

diseases, mental health issues and geriatric care. Government intends to revamp

the primary care provision to make them assume responsibility for population

allotted to them.

The primary care team will be trained to function as a general practice team

dealing with a smaller population. Currently fresh graduates are assigned charge

of primary care duties which in many countries are discharged by family

physicians with post graduate qualifications and specialized training. Kerala will

develop a cadre of primary care providers like General Practitioners or Family

Physicians. Initially they would receive specialized training before posting.

Concurrently Kerala will start a PG course on Primary Care and gradually create a

cadre of qualified doctors to provide primary care.

Using ICT the Primary Care Team will keep track of health care needs of persons

assigned to their care. They will be trained to provide basic services themselves

and to refer to appropriate levels when specialist care is needed. Using ICT

framework they will develop appropriate messaging and track compliance. Since

every interaction of the referred patients with the government health system is

tracked and available on the central data server the primary care team will be

able to guide the patients on treatment compliance and prevention. Referral

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protocols and systems will regulate their interaction with secondary and tertiary

levels of the health system. The Primary care team will be the prime managers of

the Electronic Health Record of every individual that will be developed from the

ICT framework.

Developing the new system would involve identifying the knowledge and skill

sets needed by the crucial members of the primary care team and building them;

shifting some of the tasks currently discharged by the medical practitioner to

nurses and paramedics; fine tuning referral protocols and developing the

managed referral networks around Primary Care and developing a monitoring

framework.

Primary health centres: Staffing of Primary health centres will be reworked

with three teams of a doctor and a nurse managing a population of 10,000 each.

Only OP and field activities will be discharged in PHCs and OP would be managed

in evening hours by turn. The job responsibility of nurses will be revised to assign

more patient care responsibilities to them. Laboratory services will be available at

all PHCs. The primary care in difficult to reach areas will be configured

differently.

Community Health centres:

Community Health Centres are the block level institutions expected to provide

basic speciality services. Considering shortages in specialists such services will be

provided only after the requirements of higher level institutions are addressed.

Facilities at the CHC would be utilised as Coordinating Centres of Pain and

Palliative Care, terminal care and Community Mental Health Programme.

Community Health Centre will be the lowest unit of the Health Protection Agency

and Public Health Cadre.

ii. Taluk Head Quarters Hospital

A Taluk Head Quarters Hospital with all major and minor specialities, with

average bed strength of 300 provides an optimal level to provide secondary care.

It will have such supporting services as emergency services, laboratories, blood

bank/blood storage centres, units for maintenance dialysis, physiotherapy and

rehabilitation and de-addiction centres.

iii. District/ General Hospitals

One District or General hospital in the district will have in addition to all major

and minor specialities a few super specialities built up over time subject to

availability of doctors. These would be Cardiology, Neurology, Nephrology and

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Urology. To ensure adequate attention to the needs of mothers and children

Kerala will have a Women and Child Hospital in every district.

iv. Specialty Hospitals

With advances in pharmacology specialist hospitals like TB and Leprosy

have lost their relevance. Mental Health care is also increasingly being managed

at general hospitals. While it will not be possible to close them down now

increasingly their role would be brought down and the institution developed for

alternate uses.

v. Medical College hospitals.

In time all districts in Kerala will have a government medical college. Some of the

existing medical college hospitals have become unmanageably large. With better

referrals linkages and teaching hospitals coming up in every district it should be

possible to restrict such hospitals to 1000 beds and focussing on quality and

research. All teaching hospitals, in addition to providing specialist consultation

services to other hospitals in the districts, will also be involved in training and

quality control of services in other hospitals. They will provide the top most level

of the networked care system managed by primary care providers.

Upgradation and renaming of hospitals without a clearly spelt out norm has led

to considerable confusion in health planning in the state. For the purpose of

planning of health care services the state will follow demographic/administrative

norms: a subcentre catering to 5000 population or the ward of a panchayat, a

Primary Health Centre serving one Grama Panchayat or 30,000 population, a

Community Health Centre for a block panchayat or 1,00,000 population, Taluk

Head Quarters Hospital for each Taluk and a District Level Hospital for every

district. Disparities that exist between hospitals in different regions will be

rectified before sanctioning or upgrading hospitals.

5.4. Other specialised services

i. Public Health cadre and Health protection Agency:

The absence of a dedicated public health cadre with adequate skill and

knowledge to lead the public health functions of the health services department

25

is one of the reasons for the repeated failure of public health work which we

come across. Dedicated Public Health Cadre of doctors and other non medical

supervisors from block level and above is very much needed for this purpose. A

Medical Officer who is busy with the routine clinical works may not be able to

deliver the necessary public health functions at the field level. And he / she may

not be in a position to supervise guide and monitor the activities of the field level

functionaries and their supervisors. At the block level a post of Public Health

cadre doctor will be created and the candidate opting this cadre will have

opportunity to go for Public Health qualification. The block level supervisors

namely Health supervisors and Senior Public Health Nurse would be similarly

equipped with similar courses and the designation of the officers may be

appropriately changed.

At the district level also dedicated Medical officers and Non medical Officers with

public Health Qualifications would lead the team. Strengthening of the Public

Health cadre at the state level without bifurcating it as a separate directorate

would be done. Public Health laboratories and State Institute of health and

Family Welfare and SHSRC would be important partners in capacity development

of this cadre. Providing appropriate Public Health Qualifications for around 250

doctors and 600 non medical public health cadre officers is a major task

requiring necessary course formulation, developing a mechanism for providing

the courses etc. It is to be provided in a time bound manner through the medical

colleges, public health institutes and the institutes referred above. Effective

enforcement of the Public health act would be the responsibility of this cadre.

Enactment of an updated public health act would further strengthen the Public

Health cadre.

ii. Communicable disease surveillance and execution of control

measures; For last many years Directorate of Health Services is maintaining a

daily and weekly surveillance system of communicable diseases through the IDSP

system. There are many shortcomings in this system. Most of the data from the

private hospitals are not covered and many a time increase in the number of

cases is not timely detected. Under the leadership of the Public health cadre and

health protection agency referred above these activities need to be further

streamlined and strengthened. The IDSP system with the contract staff has its

inherent weakness of frequent changes and lack of motivation . The existing

posts of IDSP including the data entry operators, data managers, epidemiologists

etc at the district level, and the posts at the state level and the laboratories need

to be made regular posts so that over the years the system will be improved.

The proposed health protection agency under the public health cadre will have

representation from the other health determining sectors like water resources ,

LSGI, total sanitation mission, Social Justice departments and will be empowered

26

with the revised and updated Public health Act and other acts through necessary

enactments / rules.

iii. Non communicable Disease control:

Considering the multiple dimensions of social determinants of Non Communicable

Diseases multiple levels of policy decisions and activity plan from various

departments LSGIs and other agencies would be required. Inter-sectoral actions

for health promotion activities prevention and early diagnosis are very critical.

Educating and encouraging hotel and bakery group for promoting NCD food and

banning of junk foods in schools and govenment run canteens.

School health screening / incentives for keeping fit/ walking /cycling/involving in

outdoor exercises / health education in schools

The policy is to be crafted with an aim to improve the quality of health, by

restricting the incidence, prevention of complications and reduction in mortality.

Specialised diabetic, hypertensive clinics will have to be started in General

Hospitals, District hospitals and Taluk hospitals on a step by step manner.

Dedicated diet counsellors and other supporting staff to be provided in these

units to work with the specialist doctors as a team so that follow up of cases,

counselling, awareness generation etc are organised in a better manner.

The public health cadre and the health protection agencies would impart health

promotion activities at work places, schools and other institutions. Physical

fitness centres with adequate machineries and equipments for doing exercises

and for outdoor games to be started at LSGIs level and at major works sites,

offices etc. Promotion of household level backyard kitchen garden, linking the

ward level health and sanitation committee activities with exercise and outdoor

game promotion, group farming, community kitchen (with healthy diet )etc

would be other activities.

iv. Cancer care

Cancer control programs in Health sector aims at decentralizing cancer treatment

from tertiary hospitals to district / general hospitals in districts and organizing

detection camps and screening programs for promoting early detection of

cancers. This year one major hospital in a district where there is no cancer

treatment facility in Government sector was provided with funds and manpower

for setting up day-care chemo therapy centres. Oral cancer detection clinics were

started in every district hospitals and funds were provided for conducting cancer

27

detection camps at the peripheral level as part of this package. All these activities

need to be more expanded and strengthened with better community

participation. Anti tobacco activities which was started in recent years would be

also part of this programme.

v. Measures for reducing the Road Traffic Accidents other trauma and

developing systematic trauma care services:

Around 4000 road traffic deaths through 30000-40000 road traffic accidents is

the pattern seen in the recent years. The ongoing activities of the Road Safety

Authority at the state level and the limited activities at the district level through

the district collectors are not yielding the expectant results. Effective enforcement

of the existing rules and regulations, and enactment of new laws like giving

registration for the vehicles only on the basis of the available road facilities,

restricting single passenger (own vehicles) in peak hours, improving the road

facilities and constitution of an “Act force “system involving police, LSGI ,

voluntary workers etc at locations identified as black sots with more probability of

accidents to be attempted.

This policy envisages to extent the 108 Ambulance systems to all districts. For

the time being it is available only at Thiruvananthapuram and Alappuzha districts

only.

vi. Community mental health care and services: Considering the higher

prevalence of the mental health problems suicides, alcoholism etc department

has already extended the District Mental Health Programme and NRHM

supported community mental health programmes to all districts in the state by

this year. But the integration of the activities with the primary health care at the

PHC, CHCs and with the health care providers namely doctors and field workers

has not materialised so far. This policy envisages a package of preventive and

primitive mental health activities through the field workers, supervisors, ASHA etc

at the field level and early mobilisation of those requiring the counselling /

treatment. Similarly for providing effective systematic follow up, the patient is

identified and treated at the peripheral institutions. From the ASHAs in the block

a selected group of ASHA s will be given specific training and certification for the

working as part of the block level team and empowered with necessary skill and

knowledge for the household level counselling of the patients/ family members.

As per the policy frame work and activity plan proposed in the revised state

mental health policy activities would be conducted.

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vii. Strengthening Laboratory Net Work in the State

Government will take steps to ensure quality in laboratory services in the

Government and private sector. Registration is being made compulsory and

periodic quality assurance checks will be insisted upon. The paramedical council

will be activated to function as a watchdog for training institutions and

laboratories. In government sector the State and Regional Public Health

laboratories will be strengthened and District Public Health Laboratories started in

all districts. All government laboratories will be covered by internal and external

quality assurance systems. Laboratory facilities will be made available at PHC

level to support management of life style diseases like hypertension, diabetes

and health problems of the elderly.

6. Ayurveda

Ayurveda is an integral part of Kerala’s health landscape, its treatments

ranging from common household remedies and prevention to specialised

treatment for stroke rehabilitation and cardio vascular care. However the system

faces many challenges today due to shortage of raw materials, lack of

enforcement of standards and diluting the system by unqualified providers.

Government will work with leading ayurveda practitioners to improve the sector.

i. Research and documentation.

Ayurveda is considered efficacious to treat certain type of ailments and is

commonly accessed by most persons in the state. However due to poor

documentation and systematic research it has not been able to prove this.

Government, in partnership with leading Ayurveda practitioners, will support

systematic clinical trials to prove the comparative efficacy of such treatment.

Since Institutional Research Boards of any institution cannot approve research

proposals cutting across systems of medicine, Government or the Kerala

University of Health Sciences, will set up the IRBs and ethical committees to

oversee such research.

ii. Quality Assurance

Due to the popularity of Ayurveda treatment many spurious manufacturers

and treatment providers have sprung up in Kerala in recent years. Due to poorly

equipped and staffed enforcement agencies and legal loopholes these

manufacturers have been able to achieve spectacular growth affecting the

reputation of the Ayurveda system itself. Drug Regulatory facilities for Ayurveda

in the state will be separated and strengthened. Proper implementation of Good

29

Manufacturing Practices (GMP), Good Agricultural and Collection Practices (GACP)

etc. for proper manufacturing and marketing of Ayurveda drugs will be

supported. Government will work with joint initiatives like care Keralam to

achieve this.

Standardisation of Ayurveda hospitals will be achieved with the

implementation of the Clinical Establishment act including qualification of persons

staffing these institutions.

iii. Support to manufacturing

Availability of raw materials for manufacture of Ayurveda medicines has come down due

to destruction of forest cover and reclamation of waste lands. The State Medicinal Plants

Board will work with cultivators and manufacturers to augment availability of raw

materials at required quantities. They will also be supported to achieve quality

parameters in preparation and packaging.

iv. Awareness regarding the benefits of Ayurveda.

The overwhelming prominence given to treatments under modern

medicine has obscured the comparative advantage of Ayurveda for some

conditions. After these have been documented and validated government will

endorse and propagate these therapeutic procedures in India and abroad.

Government will also work with experts in the field to develop appropriate

communication strategies for better acceptability of Ayurveda.

7. Homeopathy

Homeopathy enjoys a long and honourable history in Kerala. In 1928 The

Maharaja of Travancore acknowledged Homoeopathy as an acceptable system of

treatment. First government facility for homeopathy as established 30 years late.

Currently government has a policy of providing a homeopathic institution in every

panchayat in the state. Now Homoeopathic health care services are delivered

through 31 Homoeopathic Hospitals, 611 Homoeopathic Dispensaries, 348 NRHM

Homoeo Dispensaries and 29 dispensaries at SC/ST dominant areas, 5

Homoeopathic medical college hospitals, 13 dispensaries and 1 hospital under

ESI and a few municipal and corporation dispensaries. Also about 4000

Homoeopathic physicians are engaged with private sector. According to Economic

survey Report of the State Planning Board for the year 2011-12 24.39% of the

patients utilized Homoeopathy.

Recently Department of Homoeopathy has evolved many such

programmes like, “Seethalayam”- gender bases programme for women health

care, “Ayushmanbhava”- an integrated approach of main AYUSH systems to

30

control NCDs, “Jyothirgamaya”- The School Health Programme, “Chethana” the

cancer palliative care programme, Adolescent health care programme, Mother &

Child care Programme, Regional Communicable Disease Prevention Programme,

Geriatric Care Programme.

Government strategy on homeopathy will seek to achieve in addition to

increasing the availability of services the improvement of homeopathic medical

education and research and the standardisation and growth of homeopathic

drugs industry. In addition to dispensaries in every Panchayat every Taluk will

have a 25 bedded hospital and district a 100 bedded one, both with specialised

care. Experts in the field will be brought together to develop standardize

treatment protocols for management of different health conditions. Clinical

research that focuses on therapeutic out comes and multi branched,

individualized, interventions rather than single and uniformly applied drugs will

be encouraged. A drug testing and standardizing unit for homeopathic drugs will

be set up for homeopathy.

8. Oral Health

The prevalence of oral diseases is increasing especially among the poor

and disadvantaged population groups. Of concern are dental caries(especially

among young), periodontal disease, oral cancer, (more among adults),

malocclusion, and fluorosis and maxillofacial trauma. These problems are

exacerbated by lack of access to quality dental care and other equity issues.

Government will scale up the availability of dental care by opening dental

clinics in district and Taluk hospitals and making dental check up and treatment

part of the school health programme. Free dental treatment facilities to senior

citizens will be part of geriatric care programmes. Gradually District hospitals will

have the specialties of Oral Surgery, Prosthodontics, Orthodontics, Conservative

Dentistry, Periodontics and Pedodontics and supporting staff. They will also

function as early detection centers for oral cancer and oral manifestations of

AIDS. The possibility of operating Mobile dental units will also be explored.

For skill up gradation of dentists their retraining at least in the health

services every five years will be made mandatory. Dental Colleges should also

serve as research centers focusing on popularizing and adapting advanced

clinical techniques and implementing projects of public health importance.

Faculty of the departments will be trained to sharpen their clinical and research

acumen.

The Kerala Dental Council will be encouraged to work on quality up

gradation of dental clinics with emphasis on infection control practices and waste

disposal and to assist clinics to obtain NABH accreditation.

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9. Future developments

i. Quality up gradation in health sector

Since Kerala has had many achievements in conventional parameters it is

time to raise the bar and aspire towards higher levels of quality and efficiency.

Ensuring quality in every interaction with patients, being transparent, avoiding

medical errors, avoiding systemic pitfalls such as hospital acquired infections and

medical errors are some of the target the health sector in the state should aspire

to. This would mean evolving statements of standards to be maintained, building

capacity of service to comply with them, monitoring that they are adhered to and

taking corrective measures when they are not. Improving efficiency to ensure

better results and managerial efficiency to prevent bottlenecks, giving autonomy

for hospital management are also needed.

Technical support for these reforms may not be available in state. Kerala

will try to get such technical support from wherever needed but will try to build

such capacity in one of the institutions in the state with external support.

Wherever possible attempt will be made to put in place a certification programme

for one of the academic institutions so that technical capacity is institutionalised.

ii. Universal Health Coverage

The High Level Expert Group on health set up by the Planning Commission

had recommended that India move gradually along the road to achieve universal

health coverage. This would involve the state using the essential health care

package, either building capacity to provide in government sector or purchasing

services from the private sector.

Achieving universal health coverage would call for substantially scaling up

health expenditure. In view of the low level of expenditure by the Government of

India during the first two years of the plan it is unlikely that the target would be

realised at the end of the 12th plan. But Kerala will prepare a template for

Universal Health Coverage. Components of this package would get funded from

available sources of health financing such as RSBY, NRHM and funds for Local

Self Government. Some resources would also be freed up by efficiency

improvements. To begin with the persons below poverty line would be covered.

This would provide a goal of good health for all people that the state health

sector could move towards and achieve in future

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