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GOVERNMENT OF KERALA
HEALTH POLICY KERALA 2013
Health & Family Welfare Department
DRAFT
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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
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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.
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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.
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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
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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
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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
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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:
- 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.
- To ensure availability of the needed financial, technical and human resources to meet health needs of the state.
- 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.
- To regulate practice in health sector to ensure quality and patient protection
