Advancing People's Health

in Karnataka:
Vision for Progress
SUMMARY

INTERVENTION INTEGRATION IMPLEMENTATION INNOVATION INVESTMENT

REPORT SUBMITTED TO

Departments of Health & Family Welfare and Medical Education

Government of Karnataka
Title Advancing People's Health in Karnataka: Vision for Progress

Copyright @Directorate of Health and Family Welfare services

Year of publication 2021

Suggested citation Gururaj G and Karnataka Health Vision Group Collaborators.

Karnataka Health Vision Report, 2021

Address for correspondence Commissionerate

Health and Family Welfare Services
Arogya Soudha, 5th Floor
Madagi Road, Bengaluru - 560023
Email: [email protected]

Prof. G.Gururaj
Charmain, Karnataka Health Vision group
Email: [email protected]

Design and printing Peoplecom Technologies (P) Ltd., Bengaluru

Disclaimer Views expressed in this report are those of the authors.

 Advancing People's Health
in Karnataka: Vision for Progress

REPORT SUBMITTED TO

Departments of Health & Family Welfare

and Medical Education
Government of Karnataka

By
Karnataka Health Vision group
 The vision group also consulted a wide range of health
administrators, implementers, program managers,
district level officials, subject experts, other stakeholders to
obtain their perspectives and views on health sector

Preface
reforms and areas for strengthening for the coming days.
Successful programmes are always well coordinated,
resourced, connected, communicated, funded,
Prof. G. Gururaj convergent, monitored and evaluated for results based
Chairman on the principles of evidence base, equity,
Karnataka Health Vision Group responsiveness, resilience and safety. Further, such
programmes are also sustainable, cost effective, people
centric and in today’s world technology enabled. An
On 2 January 2021, the Honourable Minister for Health examination of the status of implementation reveals
and Medical Education informed the citizens of several gaps in the implementation process. The report
Karnataka that a Health Vision Group was constituted for emphasises the importance of these elements to
the state to suggest measures for strengthening and strengthen these components and by placing them in a
reforming the health systems and to develop a roadmap framework for effective implementation.
for health sector improvements. I was invited to be the Five major strategic approaches in healthcare delivery
chairman of this group along with 30 other prominent are strongly recommended in the report. The entire focus
health and medical experts from the state. I was of the report is on implementation of Interventions and
surprised and puzzled in terms of the complexity of this the implementation process. Integration mechanisms
task as the chairman of this group. It was both a are urgently required to avoid duplication and to save
challenge and an opportunity as well as a honour and resources for achieving maximum impact. Strong
privilege to serve the state. The group was constituted at intersectoral platforms are critical. Great opportunities
a time when the state has been making progress in exist in health services for Innovations at all levels.
healthcare delivery through Central and State-supported Undoubtedly, an investment in financial, human and
investments and programs, albeit at a slow pace and hit technology areas and people-centric approaches are
by the Covid - 19 moving pandemic. required. These are crucial for success of our health
While our progress and moderate success with regard to programmes in the coming days.
improving basic water – sanitation - nutrition, control of We are at a stage capable of achieving many things on
communicable and infectious diseases, progress in this planet. Health, education, welfare, safety and
maternal and child health services is worth applauding, security form the bedrock for humans to be happy,
the health scenario in the state is changing fast. The healthy and productive. Ensuring this is the responsibility
demographic and epidemiological transition has led to of the government and this recognition by the
the emergence of noncommunicable diseases, injuries, government is a significant step and noteworthy. I
mental health and several others that are already major sincerely hope the government would examine the
public health problems. People today are living longer recommendations and the suggested mechanisms for
and elderly care demands our focus and attention. The improving health of people.
need for decentralised healthcare services with the
district as the central nucleus is becoming more The efforts of the vision group will be amply rewarded, if
prominent and evident. The Covid - 19 pandemic has our political leaders, policymakers, decision makers,
taught many lessons for everyone to improve our health professionals, press & media, academicians -
systems. The limited capacity to address health researchers - students and people recognise the
challenges of today and tomorrow calls for importance of health and give it a central place in our
strengthening and reforming our health systems amidst policies and programmes and take required steps for
regional disparities and unpreparedness to achieve strengthening healthcare delivery in the coming days. In
better results. today’s world, a child need not die of malnutrition or a
child protected from infectious diseases yesterday need
Against this background, the process started with not be a victim of road traffic injury or an elderly person
developing more clarity on the role, purpose, who contributed for the society need not be left in the
methodology, expected contributions, and to develop a lurch for our deficient health systems as we pursue our
framework for functioning. After several rounds of quest for development. Let’s not forget, health of people
discussions with policy makers and experts, an is required for our progress and development.
approach based on uniform guidelines was developed.
The vision group focussed on 3 domains of strong public The report is not all inclusive as health is a vast subject
health systems, implementing health programmes and without any defined boundaries today. All aspects and
identifying emerging public health topics. The vision concerns are important and we have focused on
group adopted a participatory and scientific approach to essential components of health systems in the available
develop a roadmap for strengthening health systems in time.
Karnataka. A Health systems approach was found The vision group’s road map for the decade 2021 – 30 and
necessary to deliver comprehensive and integrated beyond, as well as for Post Covid times, needs to be
services. It is also a balance of delivering required revisited by 2031 to examine our progress and
services covering preventive, promotive, curative, achievements and to set new agenda for the new decade.
rehabilitative, palliative and all other services to our As said by Winston Churchill, “Healthy citizens are the
population based on the principles and framework of greatest asset any country can have”, and it is a
Universal Health Coverage. continuous process.
Apart from review of previous efforts and on-going
programmes, 20 subcommittees were constituted to Prof. G. Gururaj
examine specific components. The subcommittees
examined the importance, the current state of activities, Chairman - Karnataka Health Vision group
Former Director and Senior Professor of Epidemiology
existing gaps and challenges and suggested measures
National Institute of Mental Health and Neuro Sciences, Bengaluru
for bridging gaps and improving specific areas.
Contents
Acknowledgements i 24. Advocacy, Education and
Communication and Communitization
List of Abbreviations vii
activities 55
List of Figures ix
25. Public health research 57
List of Tables x
List of Box Items x Section 3: Life course perspective
26. Health determinants 59
 Strategic Approaches and Investments 1 27. Health promotion 60
 Learning's from COVID-19 2 28. Women's health 61
29. Child health 63
Section 1: Introduction
30. Adolescent health 65
1. Good health and its greater impact 5
31. Health of the middle-aged 67
2. Karnataka Profile 6 32. Health of the elderly 69
3. Karnataka Health Vision group 7
Section 4: Implementing National
Section 2: Health Systems and and State Programmes
Public Health 33. Health status and burden 71
4. Health systems 9 34. Infectious and Communicable
5. Our goals 2030 and beyond 10 Diseases 76
6. Health policy 16 35. Noncommunicable Diseases 79

7. Health sector action plans 17 36. Injury and Violence 84

(Road safety, suicide, unintentional
8. Health programmes 17 and intentional injuries)
9. Health services 22 37. Disability and rehabilitation 89
10. AYUSH services 22 38. Mental health 92
11. Health infrastructure 27 39. Neurological services 93
12. Health human resource planning, 40. COPD and respiratory health 95
development and strengthening 31 41. Oral health 96
13. Health information systems 41 42. Eye care services 97
14. Public Health Surveillance 43 43. Trauma and critical care services 98
15. Monitoring 44
16. Evaluation 45 Section 5: Specific Topics

17. Technology enabled healthcare 45 44. Environment and health 101

45. Urban health 103
18. Health financing 47
46. Disasters, epidemics and emergency
19. Private sector engagement 50
preparedness 105
20. Public-Private Partnerships 51 47. Tribal health 106
21. Drugs and logistics 52 48. Conclusion and way forward 107
22. Health legislations 53 Annexures
23. Intersectoral coordination 54 References
Acknowledgements

The Vision Group is indebted to and acknowledges the Dr.Chandrashekar (Mandya). Dr. Swathi (Chintamani) and
commitment and leadership of Shri. B.S.Yediyurappa, Dr. Ravindra (Bellary) for sharing information and
Former Chief Miniister of Karnataka and Shri. Basavaraj suggestions. Dr. Mohammed Shariff (DoHWFS) and Dr.
Bommai, Hon’ble Chief Minister of Karnataka State. The Riyaz Basha (Bangalore Medical College) supported this
vision to develop a road map for strengthening health work with information, programme details and
systems and leading to provide best health care to 7 supported this endeavour. Dr.Jagadeesh (DHO-Kolar)
crore people of the state stands tall and remarkable. and Dr. Chandan Kumar S (DFWO-Kolar) provided inputs
for human resource assessment and district
The Vision Group was conceptualised by Dr K Sudhakar, administration scenario.
Hon’ble Minister for Health and Medical Education,
Government of Karnataka. In spite of the on-going Vision group has immensely benefitted from the valuable
COVID-19 pandemic in the state, he spent valuable time advice and suggestions of Dr. Prashant Mathur (NCDIR);
to share, contribute and facilitate deliberations. For Dr. Ashish Satpathy (WHO); Dr. Ravi Narayan-Dr. Thelma
bringing a host of professionals on board, and for Narayan - Dr.Mohan K Isaac- Dr. Prasanna Saligram
providing unstinted support to this endeavour, we remain (SOCHARA); Dr. Sudarshan M K (KIMS); Dr C N Manjunath
deeply grateful to him. (Jayadeva Institute); Dr. S. Sachidanand, Former VC of
RGUHS; Dr Sudarshan Ballal (Manipal Hospitals); Prof. V.
Our heartfelt and deepest gratitude to Shri Jawaid Ravi, NIMHANS; Dr N Shivshankar, NIMHANS; and all other
Akhtar, Additional Chief Secretary, Department of Health, experts. A special note of appreciation to Dr S Pruthvish
Shri Pankaj Kumar Pandey, Formerly Commissioner for his resourcefulness and continuous support. Nearly
Health and Family Welfare Services, Dr Trilok Chandra K 20 prominent NGO teams took part in the stakeholder
V, Commissioner Health and Family Welfare Services, Dr consultations. Not only did they share their views on
Arundati Chandrasekhar, Mission Director, National grass root scenarios, they passionately advocated for
Health Mission, Dr Om Prakash Patil, Director, DHS for improving programmes and services. We are highly
their involvement, guidance and support. Not only did obliged to them for their participation and critical inputs.
they champion the need for, but also enabled this
initiative. Constantly working behind the scenes in a collective
manner, CPH@NIMHANS team – Dr Pradeep B S, Dr
This work is a result and reflection of the concern and Senthil A, Dr Gautham M S and Dr Aravind along with Dr.
contributions of nearly 250+ experts, professionals and Girish, Ms Deepika, Dr Suma R, Dr Runalika, Dr Mahima B
prominent individuals across the state. Our earnest and N and Mr. Manjunath DP supported, networked and
sincere thanks to all the Chairs and each of the members contributed for the Vision group. A heartfelt appreciation
of the subcommittee for Chairman's, Convenor's their and warm thanks to this exemplary collaboration and
invaluable time and dedication which is bound to make contributions.
this vision a reality. The details of individual
sub-committees are available separately. For all administrative support and logistics, we duly
acknowledge at NIMHANS, Dr. Pratima Murthy, Director,
The officers from the DoHFW, Government of Karnataka Dr. Shankarnarayana Rao, Registrar, and Shri. Chandan
extended their utmost cooperation and endearing Kumar, PRO. We also place our sincere thanks to Mr.Giri
involvement. we are grateful to them for their time and Gowda and Mr.Rame Gowda, Secretaries to Hon.Health
contribution in spite of being pre-occupied and busy Minister for all help and cooperation.
during the pandemic - Dr. Parimala Marur; Dr. Venkatesh,
Dr. Raj Kumar; Dr. Prabhu Gowda; Dr. Rangaswamy H V; Mr. Rahul Menon and Dr. Tony Sam George from Christ
Dr. Sridhar; Dr. Padma M R; Dr. Arun Kumar spent long University provided editorial support and Mr Saurabh
hours in discussions and provided state information in Nayak along with Rajeev and Sunil from ‘Peoplecom’
number of areas. Several State Programme Officers designed this report.
contributed as members of subcommittees, joined online
meetings and participated in stakeholder consultation The Vision Group wishes to acknowledge all individuals
and thanks to all of them. Special thanks to the District who supported and facilitated various activities at different
and Taluka Health Officer – Dr. Veerabadraiah (Tumkur), stages of the Vision group work, directly or indirectly.

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 Medical Education and Human Resources in all
Chairman: Dr Gururaj G - Former Director and allied education sectors
Senior Professor of Epidemiology, NIMHANS,
Chairperson: Dr.Sacchidanand S, Former Vice-Chancellor,
Bengaluru Rajiv Gandhi University of Health Sciences, Karnataka.
Convenor: Dr Sathish Babu, Consultant Convenor(s): Dr. S. Pruthvish, Former HOD of Community
Endocrinologist, Bengaluru Medicine, M S Ramaiah Medical College. Bengaluru.
Steering Committee: Shri Jawaid Akhtar IAS, Members
Principal Secretary, DoHFW; Shri. Anil Kumar,
1. Prof. D.K.Srinivasa,Dean (Retd.) JIPMER, Pondicherry
Secretary, Medical Education; Shri Pankaj Kumar and Former Consultant, Curriculum Development,
Pandey IAS; Former Health Commissioner; Dr RGUHS.
Thrilok Chandra IAS, Health Commissioner; Dr Om
2. Dr.S.Kumar, Hon.Former Chancellor,Sri Devaraj Urs
Prakash Patil, Director of DoHFW.
Academy of Higher Education and Research, Tamaka,
Kolar
3. Dr. V. Madhavan, Professor-Research, M.S Ramaiah
Technical Committee and Subcommittee on University of Applied Sciences, Former Dean &
Health Systems and Public Health Services Principal, M S Ramaiah College of Pharmacy, RGUHS.
Chairman: Gururaj G, Former Director and senior 4. Dr.H.Vinod Bhat, Executive Vice President, MAHE,
Professor of Epidemiology and Public Health, NIMHANS Manipal and Representative, IMA State Branch
along with team CPH@NIMHANS - Dr.Pradeep BS, Prof.
of Epidemiology; Dr. Girish Rao, Professor of 5. Dr. M R Dinesh, Former Principal, D A Pandu
Epidemiology and Former HoD; Dr. Senthil Amudhan, Memorial R V Dental College.
Additional Professor of Epidemiology; Dr.Gautham M S, 6. Dr.Savitha Ravindra, Dean, Physiotherapy & Allied
Additional professor of Epidemiology and Dr.Aravind B A, Health Sciences, RGUHS
Additional professor of Epidemiology along with 7. Dr. Vijayakumari, District Programme Officer- RCH,
Ms.Deepika , Ms. Suma, Ms.Mahima and Dr.Runalika Kolar District
Datta ( MPH scholars)
8. Dr. Riyaz Basha, Prof. of Community Medicine, BMCRI
Health Financing 9. Dr. Bindu Mathew, St.John’s Nursing College, Bengaluru
Chairperson: H.S. Ashokanand, IAS, Advisor, Karnataka 10. Dr.Chandan, RCHO, Kolar
Health Promotion Trust, 11. Dr Amruth Kadam, Dy Registrar, RGUHS
Convenor: Dr. Sudha Chandrashekar,Senior Consultant, 12. Dr. P.G. Girish, Director, Medical Education, GoK
World Bank
13. Dr.Ravi Narayan, Senior Advisor, SOCHARA
Members
14. Dr. Arun Kumar, Deputy Director, e-Health
1. Dr.Sudarshan Ballal, Chairman, Manipal Hospitals,
15. Dr.G.Gururaj, Former Director, NIMHANS, Chairman,
Bengaluru
Vision Group
2. K. Leelavathy, IAS, Executive Director, Suvarna Arogya
16. Dr. Satish Babu, Convenor, Vision Group
Suraksha Trust (SAST), Project Director, KSAPS
3. Dr. Suresh Shastri, I/C Joint Director, Ayushman
Bharat-Arogya Karnataka, DoHFW, GoK. Health Determinants
4. Dr.Upendra Bhojani, Director, Institute of Public Chairperson: Dr. Giridhar R Babu, Indian Institute of
Health (IPH) Public Health, Bengaluru
5. Mr. Owen Smith, Senior Economist,Health, Nutrition Convenor: Dr. Pradeep BS, Professor of Epidemiology,
& Population Global Practice, World Bank NIMHANS
Members
1. Dr. Prashant NS, Health equity cluster lead, Institute
Technology enabled for Health Care of Public Health, Bengaluru
Chairperson: Prof. T K Srikanth, E-Health Research 2. Dr. Sharad Nayak, DHO
Centre, IIIT-B
3. Dr. Vijaya, RCHO, Raichur
Convenor: Dr. Girish N, Center for Public Health,
NIMHANS 4. Dr. Rangaswamy, State NCD Programme Officer
Members 5. Dr. Sanjeev Upadhyay, United Nations International
Children's Emergency Fund (UNICEF)
1. Dr. Arun Kumar, Deputy Director, e-Health, DoHFWS
6. Dr. Ashish Satpathy, World Health Organization
2. Dr. Tony Raj, Dean, St John's Research Institute (WHO - India)
3. Sri. Venkatesh, Deputy Director General, NIC 7. Dr. Malini L Tantri, ISEC
4. Dr. Nandakumar B S, Faculty in Com Med, MSRMC 8. Dr. Lekha Subaiya, ISEC
5. Dr. Rajashekar, Secretary, PHANA
6. Prof. Mahadeva Prasanna, IIT Dharwad

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Child Health Communicable and Infectious Diseases Control
Chairperson: Dr. Arvind Shenoi, Senate Member, RGUHS Chairperson: Dr. K. Ravi Kumar, Senior Regional Director,
Convenor: Dr. Senthil Amudhan R, Consultant in Paediatrics Govt of India
and Additional Professor of Epidemiology, NIMHANS Members
Members 1. Dr. Sajjan Shetty, Retired Director of Health Services
1. Dr. Chandrakala G, Deputy Director- Child Health 2. Dr. Nagaraj, Director, Rajiv Gandhi Institute of Chest
2. Dr. Deepti Agarwal, National Professional Officer Diseases
(Newborn & Child Health), WHO-India 3. Dr. Bhanumurthy, Joint Director (CMD)
3. Dr. Naina Rani, Child health Advisor, NHM 4. Project Director, KSAPS.
4. Dr. Phaneendra, Consultant, Divine Mother and Child 5. Dr. Prabhudev Gowda, SNO, NUHM
(NGO)
6. Dr. Ramesh K. Kaulgud Joint Director, NVBDCP
5. Dr. Salima Bhatia, National Consultant, UNICEF
7. Dr. Kiran, Deputy Director, Virus Diagnostic
6. Dr. Sanjeev Upadhyaya, Senior Health Specialist, Laboratory, Shimoga
UNICEF
8. Dr. Ramachandra Bairy, Retired Deputy Director
7. Dr. Sridhar SM, Deputy Director - Nutrition, DoHFW
9. Dr. Poornima, Medical Lecturer cum Demonstrator
8. Dr. Swarnarekha Bhat, Former Professor and Head, HFWTC
Dept. of Neonatalogy, St Johns Medical College
10. Dr. Padma, Deputy Director, SSU
9. Dr. Veena V, Deputy Director - RBSK, DoHFW
Experts Consulted
Special Invitee; Dr. Satish Babu, Convener, Vision Group,
Prof. Savita, Chairperson women’s health sub-committee, 1. Dr. Ramesh Chandra Reddy, Joint Director (National
Dr. Vishwanath, State Consultant- Nutrition, UNICEF; Tuberculosis Elimination Programme).
Special Thanks; Dr. Uthhaya Kumaran for logistic support. 2. Dr. Raghunandan Joint Director (NLEP),
3. Dr. Lokesh Alahari, SRTL, WHO
Health of Middle aged
4. Dr. Prashant Bhat, DVBDCO Udupi
Chairperson: Dr Sreenivasan M V , Retd Chief of Medical
Services – BEL,Past President- Indian Association of 5. Dr. Chethan, DLO Tumakuru
Occupational and Health 6. Dr. Mahendra B.J. RGUHS
Convenor: Dr Gautham Melur Sukumar, Additional 7. Dr. Somashekhar, Director NTI
Professor, Dept of Epidemiology, NIMHANS
8. Dr. V. Chaddha, Adviser NTI
Members
9. Dr. Ravi Chandra NTI
1. Dr Ashok Panchanhalli, Joint Director (Medical), Dept
of Factories, Boilers, Industrial safety & Health, GoK 10. Dr. Uma Shankar NTI
2. Dr Bobby Joseph,Professor and Head, Occupational 11. Dr. Ambika, Prof and HOD Department of Microbiology,
Health Services, Department of Community Health, BMCRI
St Johns Medical College Hospital 12. Dr. Satyanarayana, Assoc. Prof, Department of
3. Dr Kowshik Kupatira, Chief of Medical Services, Microbiology, BMCRI
TKML, Bidadi 13. Dr. Shantala, Assoc. Prof, Department of Microbiology,
4. Dr Narayana swamy BT.Chief Administrative Officer, BMCRI
ESISMS, Govt of Karnataka 14. Dr. Darshan, Research Associate, VDL, Shimoga
5. Dr Ravichandran B, Scientist-E and Officer-in-Charge; 15. Dr. Lalitha, KSAPS
Regional Occupational Health Centre (Southern)
Contributor: Dr Runalika Dutta, MPH Scholar, Department
of Epidemiology, NIMHANS Noncommunicable Diseases
Chairperson: Dr.G.Gururaj, Former Director and Senior
Elderly Health Care Professor of Epidemiology, NIMHANS
Chairperson: Prof Dr. Medha Rao, Sr Prof of Medicine, Members
Principal and Dean, MSR Medical College, Bengaluru
1. Dr. C.N. Manjunath, Director, Jayadeva Institute of
Convenor: Dr Girish N Rao, Professor of Epidemiology, cardiology
NIMHANS
2. Dr. Satish Babu, Convenor, Vision group
Members
1. Dr. Rangaswamy H V, NPHCE State Program Officer, 3. Dr. K. Srinath, Director and Head of Oncology
Government of Karnataka. services, Shankara hospitals
2. Dr. Prabha Adhikari, Professor and HOD Geriatric 4. Dr. Vivek jawali, Consultant Cardiologist, Apollo
Medicine, Yenepoya Medical College, Yenepoya hospitals
University, Mangalore 5. Dr. Ravi, HoD, Department of Medicine, BMRCI
3. Dr.Venkatesh, NPHCE Program Officer, Bruhat
6. Dr. G K Venkatesh, Nephrology services.
4. Dr. Anand Ambali, Professor of Medicine, Shri B M
Patil Medical College Hospital and Research Centre,
Bijapur
5. Dr. Pretesh Kiran, Associate Professor of Community
Health, St. Johns Medical College, Bengaluru

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Adolescent Health Injury Prevention and Safety Promotion
Chairperson: Dr Veena, Deputy Director, RBSK & RKSK, Chairperson(s): Dr Gururaj G, Former Director and
Department of Health and Family Welfare, Government of Senior Professor of Epidemiology, NIMHANS;
Karnataka Dr Sharan Patil, Chairman - SPARSH Hospitals
Convenors(s): Dr Reynold Washington, Adjunct Professor, Convenor: Dr Gautham Melur Sukumar, Additional
St John’s Research Institute Bengaluru; Associate Professor, Dept of Epidemiology, NIMHANS
Professor, Community Health Sciences, University of
Manitoba, Winnipeg, Canada;Dr Pradeep B S, Professor Members
and Head, Department of Epidemiology, Centre for Public 1. Dr Aruna Ramesh,Professor of Emergency Medicine,
Health, NIMHANS M S Ramaiah Medical Hospital
Members 2. Dr Asha Abikar,Karnataka Road Safety Authority
1. Sri Sateesh L Sajjanar, Deputy Director, Youth Policy,
Department of Youth empowerment and Sports 3. Dr Deepak Shivanna ,Professor of Orthopedics, BMCRI
2. Sri Gururaja Budhya, Bengaluru District Institute, 4. Dr Dhaval Shukla,Professor of Neurosurgery,
Azim Premji Foundation, Bengaluru NIMHANS
Contributors: 5. Dr Pradeep Rangappa, Consultant Intensivist, Columbia
Asia Hospital
3. Dr. Gopinath, State cardiovascular Health
Officer-Karnataka, World Health Organization; Sri. 6. Dr Prabhudev Gowda, EMRI,Bengaluru
Narayana Gowda, Joint director, Mid-day meals; Sri. 7. Dr Selvarajan, Deputy Director, Medical, NHM
Mukund Raj, Project Head, SDGCC, UNDP, Karnataka
;Dr.Salima Bhatia, Health Specialist, UNICEF Field
office, Hyderabad; Dr Lavanya Garady, Senior Trauma and Critical Care Services
Program executive, Ramaiah International centre for Chairperson(s): Dr Sharan Patil,Chairman - SPARSH
Public health innovations, Bengaluru; Sri. Hospitals;Dr Gururaj G,Former Director and Senior
Satyanarayana Ramanaik, Thematic Lead – Professor of Epidemiology, NIMHANS
Adolescent Health, Karnataka Health Promotion
Trust, Bengaluru; Sri. Prabhanand Hegde, Center for Convenor: Dr Gautham Melur Sukumar ,Additional
Advocacy and Research; Sri. Ravi Kumar, Trustee, Professor, Dept of Epidemiology, NIMHANS
Full circle, Yuva Samalochakas and Yuva
Parivarthakas of YuvaSpandana Program, Members
Government of Karnataka. 1. Dr Aruna Ramesh,Professor of Emergency
Medicine, M S Ramaiah Medical Hospital
Environment and Health 2. Dr Asha Abikar, Karnataka Road Safety Authority
Chairperson: Smt. Vanashree Vipin Singh, IFS, Chief 3. Dr Deepak Shivanna, Professor of Orthopedics, BMCRI
Conservat of Forest and Executive Director, Bannerghatta
Biological Park 4. Dr Dhaval Shukla, Professor of Neurosurgery, NIMHANS
Convenor: Dr Suman, Associate Professor, M S Ramaiah 5. Dr Prabhudev Gowda, EMRI, DoHFW
group of Institute. 6. Dr Pradeep Rangappa, Consultant Intensivist,
Members Columbia Asia Hospital
1. Dr. M H Swaminath, IFS, (Rtd) APCCF & the Secretary 7. Dr Selvarajan, Deputy Director, Medical, NHM,
(Forest, Environment & Ecology) DoHFW
2. Dr. K H Vinaya Kumar, IFS, (Rtd) Director EMPRI
3. Shri Mahesh T, Chief Environmental Officer, Karnataka
Diabetes Mellitus
State Pollution Control Board Convenor: Dr. Satish Babu, Consultant Endocrinologist,
Sparsh Hospitals
4. Dr. Veena V, Deputy Director, RBSK, RKSK, SHUCH &
National Program for Climate Change and Human Members:
Health (NPCCHH) 1. Dr. K.M. Prasanna Kumar, CEO and Consultant
Endocrinologist, Bangalore Diabetes Hospital
Disability and Rehabilitation 2. Dr. K. Ravi - Director, Karnataka Institute of
Chairperson: Sri V. S. Basavaraju, Health Vision-Karnataka, Endocrinology and Research
Former State Commissioner- RPWD Act., Govt. of 3. Dr. Vageesh Ayyar - Professor, Department of
Karnataka Endocrinology, St John’s Medical College Hospital
Convenor: Dr. Indumathi Rao, Convenor, Sub Committee. 4. Dr. Somshekar Reddy - Consultant Endocrinologist,
Founder CBR Network. Fortis Hospital
Members 5. Dr. Srinivas -Joint Director, Department of Health
1. Prof. M. Pushpavathi, Sub Committee, Director, All 6. Dr. Belinda George - Department of Endocrinology,
India Institute of Speech & Hearing St John’s Medical College Hospital
2. Dr. Jagadeesha Theerthahalli, Member, Sub Committee, 7. Dr Santhosh Olety Sathyanarayana - Consultant
Head, Department of Psychiatry, NIMHANS Paediatric and Adolescent Endocrinologist,
Karnataka Institute of Endocrinology and Research.
3. Mrs. Rukmini Krishnaswamy, Member, Sub Committee,
Director, Spastics Society of Karnataka
4. Mr. Mohan Sundaram, Member, Sub Committee,
President, Disability NGOs Alliance (DNA)

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Mental Health Urban Health
Chairperson: Dr Mohan K Isaac, Visiting Professor of Chairperson: Dr Suresh GK, City Program Management
Psychiatry, NIMHANS, Bengaluru Officer NUHM
Convenor: Dr Naveen Kumar C, Professor of Psychiatry & Convenor: Dr Arvind BA, Associate Professor, Dept of
Head, Community Psychiatry Unit, NIMHANS, Bengaluru Epidemiology, NIMHANS.
Members Members
1. Dr Pratima Murthy, The Director - NIMHANS, Bengaluru 1. Dr Suresh Shastri, Joint Director-IEC, Department of
2. Dr H Chandrashekar, Professor & Head, Department Health and family Welfare GoK
of Psychiatry, Bengaluru Medical College and 2. Dr Venkatesh T, District Surveillance Officer, BBMP
Research Institute, Medical Adviser, Karnataka State 3. Dr Shalini C Nooyi, Professor of Community Medicine
Mental Health Authority, GoK Vice-Principal, Ramaiah Medical College
3. Dr Suresh Bada Math, Professor of Psychiatry, Head 4. Dr Riyaz Basha, Professor of Community, Bengaluru
of Forensic Psychiatry & Telemedicine Centre, Medical College
NIMHANS, Bengaluru
4. Dr Rajani Parthasarathy, Consultant Psychiatrist, AYUSH Services
Deputy Director, Mental Health, Department of Chairman
Health and Family Welfare Services, Govt. of
Karnataka 1. Prof. B N Gangadhar, Former Director NIMHANS and
Chairman - National Medical Commission, GoI
Neurological Services Convenor
Chairperson: Dr. Muralidhar, Consultant Neurologist, 1. Dr. Kishore Kumar R, Assistant Professor of Ayurveda,
Manipal Hospital Dept. of Integrative Medicine, NIMHANS.
Co-Chairman: Prof. Satish Chandra, Consultant Members
Neurologist, Apollo Hospitals 2. Dr. H R Nagendra, Member, KHVG-CAM subcommittee,
Convenor: Prof. Girish Kulkarni, Professor of Neurology, Chancellor, Swamy Vivekananda Yoga Anusandhana
NIMHANS, Bengaluru Samsthana, Jigani, Bengaluru.
Supported by: Prof. Sanjib Sinha, Professor of Neurology: 3. Director, Member, KHVG-CAM subcommittee, Department
Prof. Ravi Yadav, Professor of Neurology and Dr. L.G. of AYUSH, Dhanavantari Road, Bengaluru,
Vishwanath, NIMHANS, Bengaluru 4. Dr. B R Ramakrishna, Vice Chancellor, SVYASA-
(Deemed to be University), Jigani, Bengaluru,
Oral Health
5. Dr.Ahalya Sharma, Member, KHVG-CAM
Chairperson: Dr K S Nagesh,Former Director of Rajiv subcommittee, Prof. and Principal, Govt. Ayurveda
Gandhi Institute of Public Health Medical College, Bengaluru.
Convener: Dr Revan Kumar Joshi ,Teaching Faculty, 6. Dr. Guruprasad, Principal, Government Homoeopathic
Department of Oral Medicine and Radiology, DAPM RV Medical College, Bengaluru,
Dental College, Bengaluru
7. Dr. B T Chidananda Murthy Member, KHVG-CAM
Members subcommittee, Former Director, Central Council for
1. Dr Jai Krishna H J, Dean, Govt Dental College & Research in Yoga and Naturopathy, Ministry of
Research Institute. AYUSH, Govt. of India.
2. Dr. Girish Giraddi, Dean, Govt Dental College & 8. Dr.Issac Mathai, Member KHVG-CAM subcommittee,
Research Institute. Soukhya Holistic Health center, Bengaluru.
3. Dr. A G Hari Kiran, Professor and Head, Dept of 9. Dr. Munir Ahmed, Member KHVG-CAM subcommittee,
Public Health Dentistry, DAPM RV Dental College. Professor of Homeopathy, Government Homoeopathic
4. Dr. Chandrika B.T, Former,State Nodal Officer for Medical College, Bengaluru,
Oral Health, DoHFW 10. Dr. Mohammed Sayeed, Member KHVG-CAM
5. Dr. Lokesh, State Nodal Officer for Oral Health, subcommittee, Prof. & HOD & in-charge Principal,
DoHFW Govt. Unani Medical College, Bengaluru,
6. Dr. Rajeev B.R , Dental Public Health Consultant 11. Dr. R Balasubramanyam, Coopted member KHVG-CAM
subcommittee, Founder Swamy Vivekananda Youth
7. Dr. Sharth Chandra B, Chief Dental health officer, Movement, Mysore,
Divisional Nodal Officer, Bengaluru Division, NOHP
12. Dr. G Gangadharan, Coopted Member, KHVG-CAM
subcommittee, Director, MS Ramaiah Indic Centre for
Disasters and Emergency Preparedness Ayurveda, Bengaluru,
13. Dr. B T Rudresh, Coopted Member, KHVG-CAM
1. Sekar K , Professor & Head
subcommittee, President, Karnataka Homoeopathic Board
2. Dinakaran D, Assistant Professor 14. Dr. Jayaprakash Narayan, Former President
3. Goyal A K, Assistant professor Karnataka Ayurveda and Unani Practitioner’s Board,
4. Kumar S S, Assistant professor 15. Dr. G Hariramamurthy, Botany expert, Transdisciplinary
Centre for Psychosocial Support in Disaster Management, University, (FRLHT) Bengaluru
NIMHANS, Bengaluru. 16. Shri Amit Agarwal, Director Natural Remedies, Bengaluru

-v-
Reproductive and Child Health We acknowledge the following persons for
Chairperson: Prof. Savitha. C – HOD, OBG, BMCRI providing advise or secretarial support in
Convenor: Dr. Satish Babu , Convener, Vision Group different sub-committees
Medical Education and Human Resources in all allied education
Members sectors: Dr. Srinivas P K, Dr. Aditi Krishnamurthy, Dr. Kiran Kumar
1. Dr. Rajkumar – DD Maternal health H V and Mr. Murugesh J of Ayushman Bharat- Arogya Karnataka
cell, Department of Health and Family Welfare. ,especially Dr.
2. Prof. Ranganath - HOD, Community Medicine, BMCRI
Manjunath and Mr. Shashidhar, Department of Health and Family
3. Prof. Ramesh Masthi – HOD, Community medicine, KIMS Welfare SAST, AB-ArK nodal officers at District level and Private
Sector representatives. Dr. Nagendraswamy (Federation of
4. Prof. Sunanda Kulkarni – Retd. HOD, BMCRI
healthcare association, Karnataka) and Dr. Prasanna (Private
5. Prof. Srinivas K – Professor, OBG, BMCRI hospitals and Nursing home associations, Karnataka) for sharing
their perspectives and data regarding the UHC scheme
6. Dr. Radhika – Asst. Professor, OBG, BMCRI
implementation.Support staff- Mr Ravindra Prasad, Ms Kavita, Mr
Keerthi, Office of VC, RGUHS.
Participants of state level consultations: Dr. Om Prakash
Health Determinants: Dr. Debarati Mukherjee, INSPIRE Faculty,
Patil, Director, DoHFW; Dr.Pushpalatha, Director, SIHFW;
IIPH Bengaluru, Daisy A. John, Research Assistant,
Dr Parimala Marur, AD NHM; Dr.Shilpa.G.R, NUHM, BBMP; IIPH-Bengaluru,Sindhu N.D, Research Assistant, IIPH-Bengaluru In
Prasanna Kumar, ITC CONS; Dr Rekha, DD Leprosy; Dr addition to the subcommittee members, contributions were made
Ramesh Kavalgud, NVBDCP (Health);Dr Indumathi, PD, by:Dr. GVS Murthy, Dr. Dorairaj Prabhakaran, Dr. Gita Sen, Dr.
RCH; Dr NagaRajani, DD, Opthalmology; Dr Rangaswamy, Biswamitra Sahu, Dr. Satyanarayana (Public Health Foundation of
Deputy Director NCD; Dr Lokesh, DD Oral Health; Dr Arun India),Dr. Prashant Mathur,National Centre for Disease Informatics
and Research(ICMR-NCDIR),Dr. Ravinarayan, Society for
Kumar, DD e-Health (Demography); Dr S M Sridhar, DD
Community Health Awareness Research and Action,Dr. A.
NUTRITION; Dr Prabhu SNO NUHM; Dr Rajesh K S, DD Ravindra, Centre for Sustainable Development,Dr. Sumati
Radiation Safety; Dr Veena V, DD RBSK/ RKSK; Dr Rajani Swaminathan, Dr. Prashanth Thankachan, Dr. Reynold Washington,
B.N, DD Immunization; Project Director, PD, RCH; Dr Dr. Pratibha Dwarkanath (St John’s Research Institute),Dr. Upendra
Muralikrishna, Deputy Director NHM AYUSH; Alia Bhojani, Institute of Public Health,Mridula Mary Paul, Abi Tamim
Sultana, IDD; Mrs Pramila, JDDEMO; Dr Gopinath, CVHO Vanak (ATREE),Dr. Uma Ramakrishnan, Dr. Shannon Olson
(NCBS),Utpal S Tatu (Indian Institute of Science),Vedita Agarwal,
Karnataka; Dr Vasanth (Host Hfw) Asst Dep Director, Ajay Raghavan (Initiative for Climate Action),Surabhi Rajagopal,
e-Health; Dr Raghunandan, JD Leprosy; Dr Chandrika Selco Foundation,Dr. Annapoorna Ravichander, Public Affairs
Dep Director Family Welfare; Dr Vasanth Asst Dep Centre,Dr. Akash Prabhune, Ayesha Meher (Public Affairs
Director e-Health; Dr. Chidanand. Gudur Dep Dir in office Centre),Dr.Anupama Shetty, Biocon Limited,Dr. Dhananjay Pandit,
of DJD Bengaluru; Dr. Chandralala DD child health DD RTI International,Farah Ishtiaq, Tata Institute for Genetics and
Child Health; Dr. Selvarajan, Deputy Director Medical; Dr Society,Dr. Lena Robra, Bengaluru Sustainability Forum,Rajesh
Kasthurirangan, Socratus Foundation,Vishwanath S, Biome Trust
Rajani Parthasarathi, Deputy Director, Mental Health; Dr Adolescent Health :Ms. Swati Shahane, Ms. Srividya R N, Dr Suma
GeethaBali, Dep Director SIHFW; Dr. Ganesh. H, Deputy Rache ( Life Skills and Counselling Services Training Program,
Director, SNO UPHC; Dr. Bhanumurthy, Joint director, NIMHANS, Bengaluru)
health and plan; Dr. Anil Dep Director TB.; Dr Padma MR, Communicable and Infectious diseases control: Dr. Ramesh
Dep Director SSU; Dr D Jayaraju Deputy Direcot, Blood Chandra Reddy, Joint Director (National Tuberculosis Elimination
Safety, KSAPS; Dr Vivek Dorai, Deputy director Medical; Programme),Dr. Raghunandan Joint Director (NLEP), Dr. Lokesh
Dr C Poornima, DD Planning; Dr G N Srinivasa, JDNCD Alahari, SRTL, WHO,Dr. Prashant Bhat, DVBDCO Udupi,Dr. Chethan,
DLO Tumakuru,Dr. Mahendra B.J. RGUHS,Dr. Somashekhar,
Director NTI,Dr. V. Chaddha, Adviser,Dr. Ravi Chandra,Dr. Uma
Participants of NGO consultation meeting:
Shankar (NTI),Dr. Ambika Prof and HOD Department of
Smt Susheelamma -Sumangali Sevashrama Trust; Ms Microbiology, BMCRI,Dr. Satyanarayana, Assoc. Prof, Department of
Savitha-Assistant Director- Women and Child Welfare Microbiology, BMCRI,Dr. Shantala, Assoc. Prof, Department of
Dept, GoK- Stree Shakthi Sangha; Wg Cdr Ranjit Kumar Microbiology, BMCRI,Dr. Darshan, Research Associate, VDL,
Mandal (Retd.)- Indian Adolescent Health Association of Shimoga,Dr. Lalitha, KSAPS
Karnataka; Mohan H & Team-Karnataka Health Promotion Disability and rehabilitation: Supported by : Department for
Trust; K R Rajendra & Team-Samarthanam Trust for the Empowerment of Differently Abled and Senior Citizens, Govt. of
Disabled; Dr. Radha Murthy - Association of Women’s Karnataka,NIMHANS & team, Department of Mental Health, Govt. of
Entrepreneurs of Karnataka; Ms Akshatha- Hasiru Dala; Karnataka,SVYASA,Swamy Vivekananda Youth Movement &
Team,CBR Network,Disability NGOs Alliance (DNA) and its Member
Leo Saldanha,Karthik Anjanappa, Shrestha Chowdhury- Organisations,Spastics Society of Karnataka, All India Institute of
Environment support Group; Representative – Basic Speech & Hearing, MYSORE & Team,Dr. Pruthvish Sreekantaiah,
Needs India; Mr Ranganatha-Action on Disability and President, SOCHARA and Former HoD, Community Medicine, M. S.
Development, India; Dr Kumar G S-Vivekananda Youth Ramaiah Medical College, Bengaluru,Prof. Rangasayee, Former
Movement; Dr Prashanth N S-Karuna Trust; Mr. Director, National Institute of Hearing Handicapped, Mr. K. V.
Harirammurthy-Foundation for Revitalization of Local Rajanna, Former State Disability Commissioner, Govt. of
Karnataka,Enable India,Karnataka Haemophilia Society,Carers
Health Traditions (FRLHT); Mr S Premkumara Raja- Worldwide,Dr. Shashikala, Victoria Hospital,Assis Tech
Nightingales Medical Trust; Mr. Shivayya Hiremath-The Foundation, The Association of People with Disability (APD),
Association of People with Disability (APD), India; Dr. Samarthya, Shristi Special Academy
Pragati Hebbar- Institute of Public Health; Dr S Pruthvish AYUSH services: Dr. Umesh, Scientist C, Dr. Shivakumar, Scientist
S ,Dr. Mohan Isaac, Dr. Susanta Kumar Ghosh, Mr. D, Dr. Akhila Soman, Junior Resident, Dr. Kamala Lakshmi Junior
Gurumoorthy M,Dr. Radhika K, Mr. Prahlad I M, H R Resident, Dr. Santhosh Senan Senior Resident,Dr.Kavy Senior
Mahadeva Swamy,Mr. Nagaraja Rao-SOCHARA; Dr. Resident-Department of Integrative Medicine, NIMHANS
Gopal Dabade-Drug Action Forum Karnataka; Mr. Bengaluru,Dr. Manju Prasanna, PG Scholar, Govt. Ayurveda Medical
College, Bengaluru
Prasanna Saligram-JSA – Karnataka,

- vi -
List of Abbreviations
AB ARK: Ayushman Bharat Arogya Karnataka Scheme ENMR: Early Neonatal Mortality Rate
AB HWC: Ayushman Bharat Health and Wellness GOI: Government of India
Centre GOK: Government of Karnataka
ADL: Activities of Daily Living Govt: Government
ADSI: Accidental Deaths and Suicides in India GRAAM: Grassroots Research and Advocacy
AES: Acute Encephalitis Syndrome Movement
AFS: African swine fever HHR: Health Human Resources
ANC: Antenatal Care HIA: Health Impact Assessment
ANM: Auxiliary Nursing Midwifery HIS: Health Information System
ARS: Arogya Raksha Samiti HIV/AIDS: Human Immunodeficiency Virus infection
ART: Antiretroviral Therapy and Acquired Immunodeficiency Syndrome

ASHA: Accredited Social Health Activist HRH: Human Resources for Health

AWC: Anganwadi Centre HRMIS: Health Resource Management Information

System
AYUSH: Ayurveda, Yoga & Naturopathy, Unani, Siddha
and Homoeopathy ICD: International Classification of Diseases

BBMP: Bruhat Bengaluru Mahanagara Palike ICDS: Integrated Child Development Services

BCC: Behaviour Change Communication ICMR: Indian Council of Medical Research

CDC: Centers for Disease Control and Prevention IDSP: Integrated Disease Surveillance Programme

CDs: Communicable Diseases IEC: Information, Education and Communication

CHC: Community Health Centre IHD: Ischemic Heart Disease

CKD: Chronic Kidney Disease IMNCI: Integrated Management of Neonatal &

Childhood Illnesses
CMNNDs: Communicable, Maternal, Neonatal, and
Nutritional Diseases IMR: Infant Mortality Rate

CNAA: Community Needs Assessment Approach IPHS: Indian Public Health Standards

CNNS: Comprehensive National Nutrition Survey of ISC: Intersectoral collaboration

India IT: Information Technology
COPD: Chronic obstructive pulmonary disease JE: Japanese Encephalitis
COVID-19: Coronavirus disease 2019 JSSK: Janani Shishu Suraksha Karyakrama
CSR: Corporate Social Responsibility KEA: Karnataka Evaluation Authority
CST: Centre for Social Transformation KFD: Kyasanur Forest disease
CVD: Cardiovascular Diseases KHSDRP: Karnataka Health System Development and
DALYs: Disability Adjusted Life Years Reforms Project

DDMA: District Disaster Management Authority KJA: Karnataka Jnana Aayoga

DH: District Hospital KPHP: Karnataka Public Health Policy

DHFW: District Health & Family Welfare Department KPME: Karnataka Private Medical Establishments

DHO: District Health and Family Welfare Officer KRSA: Karnataka Road Safety Authority

DM: Diabetes Mellitus KSAPS: Karnataka State AIDS Prevention Society

DMHP: District Mental Health Programme KSDLWS: Karnataka State Drugs and Logistics &
Warehousing Society
DoHFW: Department of Health and Family Welfare
KSDMA: Karnataka State Disaster Management
DPHL: District Public Health Laboratories Authority
DRTB: Drug Resistant Tuberculosis KSHCIM&HC: Karnataka State Health Council for
EBM: Evidence Based Medicine Integrative Medicine & Health Care
EBPH: Evidence Based Public Health KSHSRC: Karnataka State Health System Resource
Centre
EHC: Elder Health Care
KSNDMC: Karnataka State Natural Disaster Monitoring
EHR: Electronic Health Records Centre
EMRI: Emergency Management and Research
Institute

- vii -
List of Abbreviations
KSRRIM: Karnataka State Resource Center for PSU: Public Sector Undertakings
Research in Integrative Medicine RAPPID: The Rapid Appraisal of Preparedness and
KSTePS: Karnataka Science and Technology Performance of health systems in
Promotion Society managing COVID- 19 cases across
KTM: Karnataka Telemedicine Mentoring Districts in Karnataka

MAS: Mahila Arogya Samitis RBSK: Rashtriya Bal Swasthya Karyakrama

MOH: Medical Officer of Health RCH: Reproductive and Child Health

MOHFW: Ministry of Health and Family Welfare RKS: Rogi Kalyan Samitis

MRW: Multipurpose Rehabilitation Workers RMNCH+A: Reproductive, Maternal, Newborn, Child

and Adolescent Health
NABARD: National Bank for Agriculture and Rural
Development RoP: Record of Proceedings

NACP: National AIDS Control Programme RTA: Road Traffic Accidents

NCDI: National Non-communicable Disease and RTI: Road Traffic Injuries/Right to Information
Injury SAPCC: State Action Plan for Climate Change
NCDIR: National Centre for Disease Informatics SAST: Suvarna Arogya Suraksha Trust
and Research SC: Sub Centre
NCDs: Noncommunicable diseases SCoE: State Center of Excellence
NCRB: National Crime Records Bureau SCRB: State Crime Records Bureau
NDHM: National Digital Health Mission SDGs: Sustainable Development Goals
NDMA: National Disaster Management Authority SDMA: State Disaster Management Authority
NFHS: National Family Health Survey SIFHW: State Institute of Health and Family Welfare
NHM: National Health Mission SIOH: State Institute of Occupational Health
NIC: National Informatics Centre SRS: Sample Registration System
NIMHANS: National Institute of Mental Health and TB: Tuberculosis
Neuro Sciences
THO: Taluk Health and Family Welfare Officer
NITI Aayog: National Institution for Transforming India
Aayog TLH: Taluk level Hospital
NMHP: National Mental Health Programme TMHP: Taluk Mental Health Programme
NMR: Neonatal Mortality Rate ToR: Terms of Reference
NPCDCS: National Program for Prevention and TPT: Tuberculosis Preventive Treatment
Control of Cancer, Diabetes, CVD and U5MR: Under Five Mortality Rate
Stroke
UHC: Universal Health Coverage
NPHCE: National Program for Health Care of the
Elderly UN: United Nations
NRHM: National Rural Health Mission UNICEF: United Nations Children’s Emergency Fund
NSSO: National Sample Survey Office UPHC: Urban Primary Health Centre
NUHM: National Urban Health Mission UTs: Union Territories
NVBDCP: National Vector Borne Disease Control VHSNC: Village Health, Sanitation and Nutrition
Programme Committee
OHA: Occupational Health Authority VPD: Vaccine Preventable Diseases
OHIS: Occupational Health Information System VRW: Village Rehabilitation workers
OOP: Out-of-Pocket Cost WCD: Women and Child Welfare
OOPE: Out-of-Pocket Expenses WHO: World Health Organization
PHC: Primary Health Centre
PHS: Public Health Surveillance
PIP: Programme Implementation Plans
PM JAY: Pradhan Mantri Jan Arogya Yojana
PPP: Public-Private Partnership

- viii -
List of Figures
Figure 1: District wise urbanisation in Karnataka (%) 6
Figure 2: Health systems framework [WHO] 9
Figure 3: Health Systems Strengthening Towards Universal Health Coverage 10
Figure 4: Sustainable Development Goals 12
Figure 5: Comprehensive health policy implementation framework 16
Figure 6: Essential Public Health services 22
Figure 7: Presence of Medical colleges in Karnataka, 2021 27
Figure 8: State Government Public Health Infrastructure 28
Figure 9: Kalyana Karnataka Regional Development Board - Districts 28
Figure 10: Health Human Resource scenario in Karnataka 33
Figure 11: Public Health Surveillance 43
Figure 12: Monitoring health activities 44
Figure 13: Framework for program evaluation in public health 45
Figure 14: District wise variation in pre-authorisation raised by type of provider 49
Figure 15: Proportion of health care providers in rural and urban areas of India. 50
Figure 16: Current health expenditures (2016-2017) 50
Figure 17: Determinants of health (adopted from Dahlgren and Whitehead model) 59
Figure 18: Percent coverage of all basic vaccinations among children aged 12-23 months by district, NFHS-5 63
Figure 19: Evolving work environments 67
Figure 20: Health status of elderly, LASI study 69
Figure 21: HIV Prevalence levels among ANC clinic attendees in Karnataka 71
Figure 22: Trends of early neonatal, neonatal, infant and under 5 mortality rates since 2008. 72
Figure 23: Life expectancy at birth in Karnataka 73
Figure 24: Trends of DALYs due to various diseases in different age groups 73
Figure 25: Major disease burdens across age groups in Karnataka. 74
Figure 26: Leading causes of DALYS in Karnataka in 1990 and 2016. 75
Figure 27: Trends of risk factors from 1990 -2016 75
Figure 28: Trends in Malaria and Pf Cases, 2006-20 77
Figure 29: Trends of total TB Patients notified for treatment, 2010-19 77
Figure 30: Trends of Observed HIV Prevalence among ANC clinic 78
Figure 31: Top ten leading sites of cancers in Karnataka state,2020 80
Figure 32: Trend of RTIs in Karnataka, 1989 – 2019 84
Figure 33: RTIs in Karnataka 85
Figure 34: Five pillars of road safety 85
Figure 35: Burden of injuries in Karnataka, 2020 86
Figure 36: Suicide rate per lakh population, India and Karnataka. 87
Figure 37: Distribution of Suicide in Karnataka, 2019 87
Figure 38: Proportion of different types of disabilities in Karnataka. 90
Figure 39: Elements of effective Trauma Care system 99
Figure 40: Levels of Environment 102
Figure 41: Connection between health outcomes and the urban environment (140) 104
Figure 42: Map of Karnataka with disaster proneness and occurrence 105

- ix -
List of Tables
Table 1: Current health status of Karnataka with respect to Key health related Sustainable
Developmental Goals 14

Table 2: Current health status of Karnataka with respect to Key targets of National Health Policy
of India 2017. 15

Table 3: Flagship Programmes of Karnataka, 2020-21 18

Table 4: Number of AYUSH Hospitals, beds and dispensaries in Karnataka State - 2019 23

Table 5: Estimated persons with various conditions for a district with 15,00,000 population 29

Table 6: Increase in number of seats in 2014 and 2020 with respect to Medical seats 37

Table 7: Number of Institutions in Government & Private sector conducting UG (undergraduate)

Courses during 2019-20 37

Table 8: Number of Institutions Government & Private conducting Postgraduate Courses

Faculty-wise during 2019-20 38

Table 9: Cost of health care and services in Karnataka and India 48

Table 10: Cost effective programmes, strategies and solutions for health and related problems among youth 66

Table 11: Occupational diseases, NCDs, Psychological problems in workplaces(97) 68

Table 12: Oral Health Status of Karnataka 96

List of Box Items

Box 1: Micro-study of human resources in kolar district 36

Box 2: Excerpts from National Education Policy (2020) 36

Box 3: Emerging role of Health Learning Universities in the New Decade 40

Box 4: Epidemiology…. The science behind policies and programmes 44

Box 5: Campaign for helmet use and no-drink driving 56

Box 6: Health promoting schools 64

Box 7: Best buy interventions for prevention and control of noncommunicable diseases 81

Box 8: Voluntary global targets under global action plan for the prevention and control 82
of noncommunicable diseases 2013-2020

-x-
Strategic Approaches and Investments...
Good health of individuals is crucial to the well-being of Implementation science systematically closes the gap
any society; this was known earlier and has been between what we know and what we do (know- do gap).
re-enforced during the COVID pandemic. A healthy This act of putting a programme into action and executing
society reflects the productive contributions of its it correctly such that it accomplishes the program’s
members, showing progress in education, economy, goals is of paramount importance. Poor implementation
safety and security and other areas. In Karnataka, the or the failure to implement prescribed programmes can
health systems and services have evolved over time to be to the detriment of the health of a society.
promote and maintain the good health of all its citizens. Programmes can be implemented in different settings
However, now this requires strategic strengthening and like worksites, schools and educational institutions,
reorienting of our health systems to adapt to the current healthcare facilities, homes and other places to obtain
greater demand; the strategic approach involves five maximum impact at lesser costs. Health impact
aspects. assessments inform whether implementation has been
able to deliver results. A strong focus on implementation,
Interventions, Integration, Implementation, Innovations
as outlined in the report, is required in all policies and
and Investment are required for today and tomorrow.
programmes through strong action plans, dedicated and
Intervention(s) could be one or a combination of several
skilled teams, adequate resources, advocacy –
approaches, including medical, educational, policy,
awareness activities, systematic monitoring and
environment, technology, economic, regulatory or more.
evaluation – all with the goal of making interventions
There are a wide variety of evidence based, cost effective,
deliver results.
sustainable, people-centric, technology-enabled
interventions that are known to benefit the good health of Innovation in health sciences is the continuous process
populations. They are referred to as ‘ Best Buys – low of developing new processes, techniques, services,
hanging fruits – package of’ measures’. These range from methodologies and products over time. There is a critical
fundamental practices such as consuming healthy food, need to innovate in our health programmes, products
regular exercising and working towards good mental and services- examples could range from creating a
health, to more complex disease-specific interventions ‘centre of excellence’ that can bring new vision to
of modern day. The health sector needs to identify these ‘delivering a message for people’ for taking appropriate
effective interventions for individual(s) and population(s) actions. In addition, creative innovation from the health
based on cultural appropriateness, feasibility of its sector around training of human resources at all levels
adaptation and mechanisms for their delivery. A variety of operation is very important to stay updated with the
of such doable, sustainable interventions are highlighted latest knowledge, methods and technologies. With a
in this report for different age groups and situations. changing landscape of health and disease, this is now
more important than ever.
Integration should be the platform to efficiently bring
together multi-modal interventions and deliver them to Investment in the health of people is the need of the hour,
the masses. With the verticalization of programmes, a especially in primary and secondary health care as it can
disjointed and uncoordinated approach has come into greatly lower the need for, and spending on, curative
force with duplication of activities and double spending care. This is the premise of Universal Health Coverage –
on resources in health systems. Good integration efforts a vision where all individuals have access to quality
will avoid such problems to produce a healthcare system health services without financial hardship. Commonly,
that operates seamlessly, smoothly and allow for easy health investment is restricted to increased allocation
navigation by users. A small scale example of good and spending in health care; this is an absolute necessity.
integration is when a healthcare worker is able to However, it should be expanded in scope to investments
undertake multiple tasks during a single patient visit; in health facilities, health human resources, support
while on a larger scale, a well-integrated elderly care systems, technology resources and more. Currently,
facility should be capable of catering to the multiple there is a need for the public and private sectors,
needs of aged individuals efficiently. With well-trained industry partners, philanthropic agencies and media
human resources, it is possible to integrate multiple houses to join the conversation towards increased
tasks into a single task-list towards economy in time and investment in a healthy society.
money. As this report will describe, well thought out
integration within and beyond our health sector is Using this five-pronged strategy, the vision group
urgently required, especially so at district and taluka strongly envisions that the Government of Karnataka
levels. Some ideas to improve the existing integration would take all necessary proactive measures to
are the joint development of plans, sharing of resources, strengthen health systems and services to deliver
common training programmes for core activities and a comprehensive health care for its citizens for 2030 and
unified platform for monitoring. beyond. The immediate next step would be to create a
health sector and multisectoral plan with an actionable
Implementation is the key to the success of the above roadmap for the plan’s implementation. As mentioned
mentioned interventions. As the famous saying goes, earlier, we believe that efficient implementation is the
‘Knowing alone is not enough – we need to act.’ key to success.
1
 Learning’s from COVID-19 Pandemic
Karnataka reported its first case of COVID-19 on 8th March 2020, and thereafter state was gradually engulfed by the
corona pandemic. As per official reports, the state has recorded a cumulative total of 29,06,999 positive cases and
36,587 deaths since the beginning of the pandemic as on 1st August 2021. About 3,88,04,546 lab tests (including both
rapid antigen test and RT-PCR test) have been undertaken during this period. Vaccination in the state was introduced
on 16th January 2021 and as of 1st August 2021, around 24000000 persons have been vaccinated with 1st dose of COVID
vaccine and nearly 6500000 have received the 2nd dose (1). The state government has taken several measures to
contain and control the pandemic, limit mortality and morbidity and support the needy. The whole of the government
system jumped into action to mitigate the effects of the pandemic, with the health system being at the forefront of
managing this pandemic. During this journey, several positive developments and an equal amount of setbacks have
been recorded. Both have provided several valuable lessons for strengthening the state's public health and health
system to avoid mistakes in the future. Few major ones are highlighted below:
Cumulative COVID-19 cases, discharges
and deaths in Karnataka (as on 01/08/21) measures along with regular monitoring and
reporting: all based on the available evidence in a
35,00,000 moving pandemic. During the COVID pandemic, the
Government demonstrated strong political
29,07,000 28,46,246
30,00,000 leadership, and the continuation of these efforts
through strong leadership will significantly enhance
25,00,000
health sector performance over time.
20,00,000
2) Transparency and accountability: The government
15,00,000 and health system should function by considering
transparency and accountability at every stage as
10,00,000 one of its core principles to strengthen people's
5,00,000 beliefs and cooperation towards the system, which is
36,587 one of the essential principles of primary health
00 care. Lack of transparency and accountability would
Total Total Total eventually result in a lack of trust in the
Cases Discharges Covid Deaths Government's efforts to control pandemics and may
impair governmental efforts.
Cumulative number of lab tests, 1st and 2nd dose of
COVID-19 vaccines administered in Karnataka 3) Pandemic Preparedness is more required than ever
(as on 01/08/21) before: Poor preparedness of the health and related
4,50,00,000 system took everyone by surprise especially during
4,00,00,000 38804546 the peak of the second wave of pandemic when
family members could not find beds, ventilators, and
3,50,00,000
oxygen support. In fact, Lockdown was more used as
3,00,00,000 a measure to strengthen the health system to
2,50,00,000 manage the COVID-19 cases-which is akin to
24068139
preparing oneself to sail through the storm during
2,00,00,000
the storm. Hence, governments and health system
1,50,00,000 should be in a state of preparedness for managing
1,00,00,000 pandemics, epidemics and disasters by being
6571876
50,00,000
responsive rather than being reactive.
00 4) Need to strengthen the public health system: The
Total Total 1st dose Total 2nd dose major crusader in the current pandemic was the
Tests done Administered Administered public health system. However, years of
underinvestment and neglect of the public health
1) Strong political leadership: Strong leadership is system challenged the system's capacity to manage
required in ensuring coordinated and integrated the crisis efficiently. Despite the presence of a
actions across departments, swift decision making, private health system, accessibility and affordability
ensuring public cooperation, mobilizing and were significant barriers. Considering the COVID
allocating resources, scaling up infrastructure and situation as an event for realization and as an
resources, confirming availability of beds, oxygen opportunity, the government should strengthen, give
and adequate quantity of drugs-vaccines-equipment importance, and scale up investments in the public
and other supplies, overseeing effective health system now and in the future.
implementation of all prevention and control

2
5) Increase healthcare spending: Most of the issues or surveillance, monitoring, evaluation), efficiently
concerns related to health and public health can only functioning district and taluka hospitals and
be addressed by increasing the health budget. laboratories along with private sector engagement,
Karnataka is spending less than 1% of its GSDP on and general public involvement, all at a district level.
health. COVID has reinforced the need to strengthen Utilizing the present opportunity, the Government
the public health system in the state and can only be should bring in public health and medical cadres
achieved by increasing health care spending by the within the health system at state and district levels.
state government, which in turn requires strong
political leadership and commitment. 10) Pandemic exposed neglected urban public health
system: Though the pandemic affected urban and
6) Build human resource and infrastructure: rural populations, large cities and towns bore the
Deficiencies in health resources was evident at all maximum brunt: for trace – test – track – treat with
levels, in urban and rural areas, in hospitals and non-availability of hospital beds, drugs, and oxygen
health services, in general, and specialty cadres and reported frequently and at times regularly. The
in both public and private health systems for many existing public health workforce in urban areas was
ground-level activities. The Government scaled up often helpless, calling for strengthening the urban
infrastructure, augmented human resources public health system.
(temporary/ contractual/ permanent/ pooling from
various institutions) and made arrangement for all 11) Integrate technology-based solutions in the health
support facilities. The learning is that health systems system: The pandemic also witnessed the use of
cannot function in the absence of an efficient human technology in different ways: helplines (e.g.,
workforce, and these gaps must be filled in both the Apthamitra), tracking patients (Arogya Sethu),
short and long term. communicating test results, , GIS applications,
computerized bed allotment system, teleteaching,
7) Address health inequalities: The inequalities in telemedicine and several others using real-time
availability, accessibility and affordability of health data management. Going forward, , big data
care facilities across districts, regions and between analytics, artificial intelligence and communication
urban and rural areas were evident during the technologies, should integrate the existing and
pandemic. Migrants and those in lower emerging technology-based solutions within the
socio-economic strata were affected health system and optimize the health system
disproportionately during the pandemic. Health outcomes.
inequities should be addressed based on principles
of universal health coverage and better social 12) Communicating for people's health needs a defined
welfare measures. strategy: Incorrect and inadequate information about
various aspects of the COVID pandemic
8) Strong Surveillance is critical: A strong surveillance communicated by health and other departments
system with mechanisms for quick data compilation through various media channels often instilled fear
(at least on a minimum set of data points) – analysis and insecurity among the public, acting as a
by a skilled team – quick actions – support for deterrent in managing and controlling the pandemic.
evidence-based prioritization and decision making, This was evident with regard to testing – tracing-
constant monitoring of the situation, timely treatment and now, vaccine hesitancy. Health
intervention(s), evaluation of the implemented communication needs a strategy to inform people on
interventions are some best practices of the public what, when, how and through what methods to
health response to the pandemic. Though systems communicate. Communicating information to people
for surveillance exist, limitations and challenges should aim at strengthening and strategizing
were in plenty, and real-time data on cases – tests IEC/heath education activities to create community
–hospitalizations – deaths – supplies were lacking. awareness, promote healthy behaviour (COVID
The existing surveillance system was used mainly to appropriate behaviour) and ensure community
report data rather than analyze the data and take participation.
appropriate action meaningfully. The state needs a
strong health surveillance programme for the 13) Channelizing social media is an important means for
coming days which acts as pillars of the invigorated health communication: During the pandemic, apart
public health system from mainstream media, social media emerged as
an important source of information . While, merit is
9) Make district health systems effective: While a factual information, the demerit was misinformation
systems approach in health care cannot be which caused the “infodemic”. COVID-19 pandemic,
overemphasized, managing health care requires a lockdown and infodemic, and other factors severely
robust and resilient district health system in the affected the mental health (more than physical
state, including building capacity of Panchayat Raj health) of all population segments, including
institutions. This can only happen with strong children. Miscommunication and fake information
leadership, adequate funding, appropriate human while utilizing social media calls for some level of
resources, a public health strategy (action plan, regulation.

3
 17) Cooperation and coordination at all levels are vital:
The novel coronavirus, COVID-19, caused a crisis that
people had never witnessed before in decades. With
little understanding of the virus in the past, the
moving pandemic, high transmissibility, the potential
for significant mutational changes, and lack of proven
treatment in early stages led to devastating effects on
communities for which identifying solutions were
challenging for nations across the globe. Tackling such
unprecedented crisis situations requires coordinated
efforts of effective planning and management at all
levels, including engagement with local bodies, NGOs,
voluntary agencies and others. Cooperation and
participation by the private health system during the
pandemic was a welcome move. COVID situation has
emphasized that both public and private health
14) Lockdown and its consequences: Globally, it is now systems can function co-ordinately for a general
well acknowledged that lockdowns of varying nature, cause, which should be further explored and
severity, duration, location have differential impacts continued during the non-pandemic times.
on the population. Proponents and opponents have
their views, and often is a balance between people's 18) National and international coordination is critical:
health and survival. Sudden and prolonged Both during the first and second wave of the
lockdowns have a negative impact, as seen during pandemic, Karnataka is dependent on other states
the first wave of the pandemic, indicating that timing and other countries for drugs, vaccines, oxygen, PPE
is a decisive factor. Although the benefit of lockdown kits, diagnostic test kits, ventilators etc., including
in controlling the pandemic is worth noting, addressing migrant labour issues. COVID pandemic
implementing such measures in the future requires has highlighted the need to structure and streamline
complete planning with measures in place to protect such coordination efforts with mechanisms to
the most vulnerable segment of the population from quickly and effectively respond to crisis situations.
disastrous social and economic consequences.
Along with infodemic, lockdown and other factors of 19) Continuous research is crucial in managing the
managing the Covid 19 pandemic severely affected pandemic: The research output during the COVID
the mental health (more than physical health) of all pandemic in the state was very minimal, and most of
population segments, including children and has them were not of much value to support policy or
been unprecedented as the pandemic itself. program-related decisions. Building the research
capacity and creating an enabling environment for
15) Strengthen public health laboratories: During the research by the state government would have helped
initial stages of the pandemic, the state was it to quickly mobilize them for undertaking
completely dependent on national laboratories to evidence-based actions based on the analysis of
diagnose COVID cases. This limited the state’s ability local data (local data for local action by local people).
to respond effectively. In response, in a short period
of time, the number of labs capable to perform tests 20) Establish a Centre of excellence for microbial research:
was ramped up from 10 to 190 in the state, in both Along with establishing public health labs, having a
urban and district areas, along with the provision of 'Centre of Excellence for Microbial Research' in the state
all manpower and supplies by both self and would support and strengthen microbial surveillance in
Government. It is hoped that these labs would the state. The centre can undertake several activities for
continue to support the much needed broader range supporting state government on both an emergency
of public health activities in the coming days. and regular basis as the state doesn't have such an
apex institute for microbial research.
16) Build a resilient health system: During the COVID
pandemic, general health services (both medical and The focus in a moving - raging - less understood pandemic
surgical) and most emergency health services should be to - (i) reduce the number of deaths and
suffered a lot. Several individuals required routine hospitalizations, (ii) protect all vulnerable sections of
medical care like dialysis, antenatal care, routine society (iii) have an effective and efficent health services,
follow-up care for chronic health conditions, etc. (iv) vaccinate populations with a safe and effective
Services for such needy individuals were severely vaccine, and (v) ensure livelihoods of people.
interrupted during the pandemic. Hence, there is a
need to build a resilient and capable health system Most significant learning from Covid - 19 pandemic has
capable of responding to all types of health services been - health is important, public health is vital and
in all situations, including epidemics and pandemics. mental health is as important as physical health.

References
1) COVID-19 information portal, Government of Karnataka. available at https://covid19.karnataka.gov.in/storage/pdf-files/EMBJUL21//12-07-2021%20HMB%20English.pdf

4
01. Good health and its greater impact
Health is of paramount importance for everyone in principles of universality, equity, non-
today’s life. The growth and development of every inclusion, nondiscrimination, comprehensive
family and society is increasingly dependent on care, financial protection, protection of
health of its members. Recent years have brought patients’ rights along with accountability,
health to the centre stage of growth and development transparency and community engagement.
and increasingly made the governments to recognise
The Covid-19 pandemic affected everyone in
the importance of people’s health and for people to
the country and in the state. The moving
take care of their health. The definition of health as
pandemic resulted in death of 36,587
per WHO, as a state of “optimum social - biological
persons and 29,00,000 people turned
and emotional well-being and functioning and not
positive as per official reports as on 1st
just the merely the absence of disease” is
August 2021 and disrupted the lives and
recognised as a fundamental requirement for all
livelihoods of everyone in the society; and
activities related to life, growth and development(1).
counting still continues. The need to balance
The right to health, education, welfare, clean air, saving lives ensuring livelihood has become
water and sanitation, employment are all enshrined a central point of all our debates,
in the Constitution of India, and as health is on the discussions and actions. Most significantly,
concurrent list, it is the ethical and moral obligation the pandemic exposed our weak health

Section 1: Introduction
and responsibility of the state and centre to provide systems due to neglect of public health,
good health for its citizens(2). Globally, in India and absence of robust health systems, deficient
in Karnataka, it is well demonstrated that good health resources, unpreparedness of the
can be - achieved by everyone; provided to everyone governments, low importance of health in
irrespective of age, gender, residence and income; and people’s lives and several others. Despite
to be utilised by everyone. Good health of citizens can the increased investments, the inability of
happen when health is everyone's business and the systems to respond to address needs
moves beyond care to address its determinants. and concerns of people’s health came to the
Preserving good health, protecting people from forefront in our societies.
ill-health, promoting wellness and ensuring services
The state of Karnataka has been a pioneer in
for everyone in need is important to develop healthy
implementing policies and programmes
societies; needs commitment and action at all levels.
with strong commitment and stewardship
It is increasingly recognised that good health is a over decades to improve health of people.
product of the interaction of several macro and This is seen with the progress in indicators
micro, intrinsic and extrinsic, biological and over time. Despite its significant growth and
nonbiological, social and economic as well as all development, health has been on the
societal and individual factors operating in a backstage and not central to the process of
continuum. Health is influenced by several factors our growth and development. In this scenario,
ranging from customs and beliefs of people to the Karnataka government constituted the
policies and programmes in health and related Health Vision Group for strengthening health
sectors. In a world that is largely influenced by systems and to develop a roadmap for future;
liberalisation, globalisation, urbanisation, and the reasons were several (Government
industrialisation and several others it has become order dated 31-12-2020). Firstly, the state
increasingly important to deliver health to people by having made progress in maternal and child
the governments, amidst conflicting interests. health and prevention and control of some
communicable diseases areas has to develop
Commitment to deliver health for people dates back
policy frameworks, strategies and
to historical times and is not a new development; it
mechanisms to address many existing and
is only gathering momentum. The Alma - Ata
emerging health concerns of today and
declaration of 1978(3), Health for All movement(
tomorrow (like Noncommunicable Diseases
4-6), and the Millennium Development Goals(7) to
(NCDs), injuries and others). Secondly, the
name a few have influenced us to a greater extent.
fact that health systems and departments
Universal Health Coverage (UHC)(8), Sustainable
have to reorient and redirect in line with global
Development Goals (SDGs)(9) and the recent
and national developments is recognised as a
primary Healthcare declaration in Asthana in
necessity. Achieving accessible and affordable
2018(10) have remained the frameworks to shape
healthcare for all based on equity is the real
our health policies. The five-year development
need of the hour. Thirdly, current disparities,
plans over time have become important in
limitations, gaps and challenges in the
successively reforming policies to scale up
health systems have to be overcome to
activities. The UHC aims at providing
develop more robust mechanisms.
comprehensive health security based on the
5
The need to achieve balance in protecting and promoting Figure 1: District wise urbanisation in
health and treating the sick was acutely felt as neglect of Karnataka (%)
public health services is more evident and glaring.
Finally, the COVID – 19 pandemic informed that health –
public health – mental health is central for our growth,
development and happiness. Bidar

Thus, a vision and a roadmap for the coming years based

on evidence, equity and people centric approaches are Kalaburgi

essential. Achieving good societal health calls for

intervention(s), implementation, integration, innovations Vijayapura
Yadagiri

and investment, all with total dedication and

commitment, based on strong evidence based decision- Bagalkote

making processes and moving away from adhocism and

Raichur
Belagavi

knee jerk reactions. This report is an effort in this

direction to support and strengthen health systems in Dharwada
Koppala

Karnataka towards delivery of health for all citizens and Gadaga

to achieve the goals of 2030 and beyond. Uttara Kannada

Ballary

Haveri

02. Karnataka Profile Davanagere

Chitradurga
Shivamogga

Karnataka is one of the fastest growing states of India Chikkaballapura

and has made significant strides in the last two decades Udupi
Chikkamagalur Tumakuru
Bengaluru Rural
in health, education, income, literacy, standards of living Kolara

and other areas. In 2020 - 21, Karnataka ranked third in Dakshina

Kannada
Hassana Bengaluru
Urban

NITI Aayog’s Sustainable Development Goals (SDGs) Mandya Ramanagara

India Index and is at 19th rank in Human Development Index. Kodagu

With a parliamentary government system, the state has strong Mysuru

administrative mechanisms through a three tired Panchayat Chamarajanagara

system for effective implementation of programmes. The

state has 4 revenue divisions, 49 subdivisions, 31
districts, 237 talukas, 747 revenue circles, 281 towns, 7
municipal corporations, 11 urban agglomerations and Dharwada 57
nearly 6000 panchayats at the grass root levels(11). Gadaga 36
Bagalakote 32
The state’s population is estimated to reach 72 million by Uttara Kannada 29
Belagavi
Division
2021 with nearly 60% living in rural areas. The Belagavi 25
urbanisation has been increasing at a phenomenal pace Vijayapura 23
from 23.9% in 2001 to 38% in 2011, being the seventh most Haveri 22
Ballari 38
urbanised state(12). The literacy levels in the state had Kalaburagi 33
increased to 75.4% in 2011 with an urban and rural literacy Bidar 25 Kalaburagi
rate of 85.78% and 68.73%, respectively. The state ranks Raichuru 25 Division
fourth among Indian states in terms of the GDP Yadagiri 19
contribution to the country. Koppala 17
Bengaluru Urban 91
The urbanisation rate is fast with more than a third of Davanagere 32
state being urbanised ( Figure 1 )Nearly 21% of the Kolara 31
Bengaluru Rural 27
population in the state is Below Poverty Line, though 45% Ramanagara 25
Bengaluru
Division
of the population classified themselves as workers and Chikkaballapura 22
the annual per capita income is 1.43 lakh rupees (year Tumakuru 22
2018). Being an educational and technological hub, the Chitradurga 20
Dakshina Kannada 48
state has been a major contributor to the workforce in Mysuru 41
the country and contributes for 7 % of national GDP. Only Shivamogga 36
27% of the households use LPG as fuel, 62% has tap water Udupi 28
as drinking water source and 88% have electricity Chikkamagaluru 21 Mysuru
Division
connection(11, 12). In contrast there are nearly 56 million Hassana 21
Chamarajanagara 17
mobile phone users. However, this growth has not been Mandya 17
uniform across all districts and in all talukas on all Kodagu 15
parameters. Huge disparities exist across and within
districts in health, economy, education and living 00 10 20 30 40 50 60 70 80 90 100
standards.

6
03. Karnataka Health Vision Group
TOR of the vision group the required pace. The number of grass root level
institutions and health care facilities as well as
1. To review the developments and processes in workers like ASHAs, Anganwadi workers, village
Karnataka health systems and health services rehabilitation workers, health workers, doctors and
covering public health and health care, including specialists were all below the expected levels till
medical and allied education towards delivery of the COVID – 19 pandemic hit the state. During the
comprehensive, integrated, cost-effective, Covid 19 pandemic, the state government has
evidence based and technology supported solutions. invested heavily to augment the infrastructure and
2. To suggest areas of strengthening along with increase the healthcare resources.
implementable and sustainable solutions for As per the assessment of Niti Aayog, the state
improving health systems and medical/ health ranking has improved from 9th position in 2015 – 16
care covering preventive, promotive, curative, to 8th position by 2017 – 18(13).The state has
rehabilitative and other support services at registered noticeable progress in the area of
primary, secondary and tertiary levels. maternal child health, water and sanitation,
3. To provide a roadmap for delivery of equitable, infectious and communicable diseases and a few
accessible, affordable and quality health care to others in terms of completeness, coverage and
achieve universal health coverage for improving quality as seen by a decline in maternal mortality,
health of the citizens. infant mortality, neonatal mortality, under nutrition
and several others; institutional deliveries and
4. To recommend a framework for strengthening childhood immunizations, deaths and cases due to
health systems (including health human vaccine preventable diseases has also registered a
resources) and progress towards a more decline. Tuberculosis, malaria, leprosy, HIV AIDS
decentralized and effective health systems. are showing a reduction over time(14).
Due to epidemiological and demographic transition,
Process and Methods the burden and share of Noncommunicable diseases
The Vision group adopted a scientific, (NCDs) and injuries has increased significantly in the
comprehensive and participatory approach with last decade(15).Today, cardiovascular diseases,
the active involvement and engagement of nearly diabetes, stroke, cancer, respiratory illnesses, injury
250 health and related professionals in Karnataka and violence, disabilities, environmental
state drawn from the fields of public health, health-related problems and several others have
epidemiology, medical/health care, medical increased; reasons are several ranging from
education, health administration, hospital individual to societal factors. As there is no
management, health economics, social sciences, permanent cure, but only lifelong care, the
rehabilitation and others through comprehensive economic impact of these conditions has increased
document reviews, expert committee's deliberations, significantly at a time when health expenditure has
discussions with state and district programme remained at 5.3% as per the data available for 2021
officers, programme appraisals, interactions with – 22(16). People are living longer due to higher life
state level NGOs and discussions with senior state expectancy and consequently many social
policy makers and programme implementors in
economic and health problems of the elderly have
the framing of this report during Jan - July 2021. The
gained focus. In this scenario, the much required
reorientation of health systems and health sector
final report was drafted by the Chairman with inputs
reforms to respond to these new challenges and
and contributions from technical committee and
emerging threats is still not in place. The struggles,
subcommittees of individual areas. Detailed steps
preparedness and inadequacies of health system
and activities undertaken are provided in the main report.
were glaring and evident during the Covid 19 pandemic.
In addition, because of the increasing costs of
Changing Health Scenario health care, huge health inequities persist with
disparities in health care and services. Apart from
Reforms undertaken by successive governments
along with a focus on implementation focus has slow pace of investment in health sector, the strong
resulted in positive outcomes in many areas; health, presence and emergence of private health sector
education, welfare, transport, water and sanitation has only added to increasing out-of-pocket
in the past two decades as reflected in the health expenditures and catastrophic outcomes in the
indicators of the state. With nearly 70 health absence of uniform guidelines and regulatory
programmes and a variety of schemes that directly practices. The absence of robust health Information
or indirectly impact health of people, efforts are in Systems and good quality data has only made the
progress, despite the fact that investment in health problem worse. In this scenario, the need for
sector has only moderately increased : in fact there strengthening – reorienting – reforming health
has been a decline in allocation and underutilisation sector to provide quality healthcare for people has
of available resources . The health infrastructure been acutely felt and requires concerted efforts by
and human resources have improved though not at the state governments and all partners.
7
 Scope and focus of the report
The Vision group – Arogya Karnataka report evaluation and other areas are presented in
covers a broad range of areas related to health section 2 of the report. Across all
systems and services dwelling in depth on subcommittees, these areas also emerged as
various subcomponents required for major action components to be strengthened in
strengthening policies, programmes, services and general, and in specific programmes.
activities from a broader systems perspective. The Section 3 focusses on building systems from a
major focus is on policy/programme strengthening life course perspective covering health
for service delivery and implementation to determinants, health promotion, maternal and
provide a roadmap for the government to reproductive health, child health, adolescent
accelerate and augment efforts to meet goals health, middle aged population and care of elderly.
and targets. As the state has adapted national
goals and targets in many areas, the same Section 4 details implementation of national and
framework is applied for the state as well. state programmes for communicable and
infectious disease control with a focus on TB,
The summary report provides a comprehensive malaria, Leprosy, HIV/AIDs and other conditions
coverage of all areas and domains, while the of state importance. Emerging Noncommunicable
detailed report entitled “Advancing People’s diseases (CVD, diabetes, cancer, stroke, COPD,
Health in Karnataka“ provides detailed mental health, neurological diseases, eye health,
observations on all topics. Individual reports of oral health), injuries, disability and rehabilitation,
all subcommittees in different domains are trauma and critical care issues that are placing a
available as standalone reports huge burden on health systems in the state and
This report is presented in six sections. for which national and state programmes are being
Section 1 covers introduction, current health implemented is also discussed in this section.
scenario, goals and targets to be achieved and a Section 5 highlights some specific topics like urban
broad strategic framework under the 5 ‘I’s of health, environment and health, tribal health,
Interventions, Implementation, Integration, disaster-epidemic-emergency preparedness and
Innovations and Investment. These are further scope and opportunities for AYUSH systems of care.
discussed in individual areas in detail. Section 6 presents an overview of challenges to
A comprehensive coverage of the scope and be overcome for improving health systems and
focus of public health – systems, services, policy, the way forward for implementing findings and
action plans, programmes, AYUSH services, action areas from this report.
human resources, financing, health protection for As health is a vast area with expanding boundaries,
the poor and vulnerable sections, public-private the report is not all inclusive. In each of the
partnerships, public health legislations, covered areas, the basic principles – vision, goals
intersectoral collaborations, health information, and targets, existing scenario, current status of
health technology, management systems, health implementation – gaps and challenges and required
promotion, advocacy and awareness, mobilising actions as recommendations are highlighted.
communities for action, monitoring and

What the report does not cover Target audience

The report does not include discussion on ‘Health is everyone’s responsibility’ and people’s
specific interventions or treatment aspects health can be improved by collective inputs and
related to individual management of people coordinated efforts of all stake holders. The
suffering from one or more disorders, based present report is aimed at all stake holders
on the premise that a strong programme or engaged directly or indirectly in delivering
integrated services addresses needs of all services and programmes and working for
those requiring different/ individual services. improving health of people in the state. This
It also does not cover a hospital or any one includes political leaders and parliamentarian’s,
type of hospital or a disease and moves policy makers, administrators, planners, programme
beyond a particular health problem to bring officers, care providers, district officials,
changes in the larger health systems and economists, academicians, researchers, technologists,
media professionals, NGOs, industry partners,
health of people. The report also moves
private sector, students and youth organizations,
beyond COVID – 19 pandemic (on which
informal organizations and others from health
volumes have been written, discussed and and all related sectors. The purpose is to engage all
debated) and draws on the lessons learnt these partners in building and strengthening
from managing the pandemic in Karnataka. health services and programmes across the state.

8
04. Health Systems
• Leadership in healthcare at all levels of
Robust and responsive health systems should state, district and taluka levels is much
be developed in the state and the current talked about, but found missing most
system fails to meet many requirements of an often. Overseeing the functioning of the
efficient health system. The current systems health system and managing several

Section 2: Health Systems and Public Health

need strengthening, reorganization and programs and activities for protecting
reorientation with more robust mechanisms. public interests are the primary
Improving health of people requires a right mix responsibilities of leadership in an
of interventions, implementation, integration, environment of growing expectations,
innovation and investments for with good pluralistic society, decentralisation and
governance and leadership. an established private sector;
accountability, transparency, direction
for policies and programmes are
Health programmes and services should be absolute necessities. There is no readily
delivered through well organised and efficient available blueprint for effective
health systems. It is essential that a health system leadership and governance but should
framework for organisation, planning, evolve from within the society and also
implementation of policies and programmes is from lessons learnt in the past.
established in which everyone can participate as Governance and administration needs
“health is everyone's business”. Health systems significant improvement in the state at
performance is largely influenced by financial state, district and taluka levels.
resources, health workforce, policies, health
iniquities, legislations, technology, partnerships, • Service delivery is the interface between
public-private models and several others and, health systems and people. Universal
strengthening each one and integrating all, at Health Coverage provides framework for
different places is required for an effective public increasing access to quality care at
health system. affordable costs at all levels of
healthcare facilities. Well-functioning
Figure 2: Health systems framework health infrastructure in sufficient
numbers is an absolute requirement.
SYSTEM BUILDING BLOCKS OVERALL GOALS/
Both NUHM (National Urban Health
OUTCOMES Mission) and NRHM (National Rural Health
Service Delivery Mission) are state flagship programmes
ACCESS Improved Health
aiming to scale up infrastructure across
Health Workforce
COVERAGE
(Level & Equity) the state apart from investments made
Information
under specific programmes.
Responsiveness

Medical Products, Social & Financial • Human resources for health is the
Vaccines & Techno-logies Risk Protection backbone of healthcare delivery. A well
Financing QUALITY Improved performing health workforce is one
SAFETY
Efficiency where a fully equipped workforce is
Leadership/ Governance available, skilled and competent,
responsive, productive and capable of
Source: (17) responding to all health needs of
populations by managing dynamic
The six system building blocks of health system situations. The availability of sufficient
include - service delivery, health workforce, numbers, of proven quality and at
information, product devices and technologies, different levels of health facilities
finances and leadership as well as governance. requires recruitment and deployment,
These six building blocks based on equity (Figure 2), training and skill building ( a continuous
responsiveness and efficiency are required for process), facilitating multitasking,
adequate functioning of health services with the creating support systems, maintaining
inclusion of people as the seventh building high levels of motivation and commitment
block(17). and monitoring of the health workforce.
Several reports and reviews have
identified huge deficiencies in human

9
 resources in public health facilities at different and use of information by different decision-
levels across the state. Deficiencies in the makers at different levels both at regular times
number, quality and efficiency of human and in emergency situations. The current
resource within the health system across systems are fractured and fragmented working
Karnataka need to be addressed immediately. in silos and often unresponsive to programme
requirements. There is a need to integrate
• Health Information Systems are often the programmes across departments and sectors
foundation on which health systems are built by through uniform data collection mechanisms.
ensuring production, analysis, dissemination

Figure 3: Health systems strengthening towards Universal Health Coverage

Equity Quality Responsiveness Efficiency Resilience

Service delivery

Health financing

Governance

Source: (17)

• Accessibility to medical products, drugs, • Health financing includes resource allocation,

vaccines, technologies in terms of quantity, mobilising resources, establishing
quality, safety, efficacy and cost effectiveness arrangements, expanding pooling
based on evidence and scientific practice is a arrangements, generating additional resources,
critical requirement for health systems to spending funds and ensuring assistance
function optimally based on regular planning. mechanisms with transparency at each step.
Health systems should promote the rational use The catastrophic expenditures in emergency
of essential medicines through appropriate and chronic disease care has been reaching
pharmacovigilance, guidelines and strategies, staggering proportions in recent years, pushing
ensure adherence, patient safety, training of the families to greater levels of poverty. Poor health
staff and strong regulatory mechanisms. It is financing and limited coverage of health
evident that people across the state are unable insurance and protection mechanisms has been
to access timely care and required medications a serious problem in the state; situation became
(as seen during Covid times) and technologies serious during covid pandemic.
in emergency and non-emergency situations on The success of a health system depends on an
a regular basis ; when available, it is expensive. understanding the demand for services, delivery of
It is recommended to ensure easy and timely a package of integrated preventive, promotive,
access to required medications and technologies curative and rehabilitation services, organisation of
at an affordable cost to citizens of Karnataka. the entire network, efficient management to
maximise coverage, quality and safety, reduce
duplication and address issues regarding
infrastructure and logistics along with protecting
poor and vulnerable communities. An appropriate
mechanism for delivery of services is essential
considering the network of public and private
providers to enhance equitable access, quality and
safety ( Figure 3). Equity in health care means
everyone in the society is able to get services
irrespective of any financial and structural barriers.

10
 Health Systems Strengthening Towards Universal Health Coverage

Apex Referral Hospitals Palliative

Evidence
Acceptable
based District Hospitals
Rehabilitative

Taluk Hospitals
Curative
Cost Community Health Centres Integrated
effective
Promotive
Primary Health Centres

Health and Wellness Centres Preventive

Sustainable Intersectoral

Equity
Universal
oriented

Health Health Services Health Promotion Drugs and Health Financing

Determinants logistics

Public Sector Human Resources Private Sector NGOs & Legislation

Communities

Programmes Policies Action Plans Health Technology

Monitoring &
Reporting Surveillance Health Information Research Evaluation

HEALTH SYSTEM
11
05. Our Goals 2030 and Beyond
Figure 4: Sustainable Development Goals
• Reduce the proportion of population living
below the national poverty line
• Increase the percentage of Households 1 NO
POVERTY 2 ZERO
HUNGER 3 GOOD HEALTH
& WELLBEING
covered by a health scheme or health
insurance.
• Increase the percentage of Population
getting safe and adequate drinking water
within premises through Pipe Water Supply
• Substantially increase government 4 QUALITY
EDUCATION 5 GENDER
EQUALITY 6 CLEAN WATER
& SANITATION

spending on health and social protection

• Drastically reduce under nutrition among
children
• Significantly reduce anaemia among
pregnant women and children under 5
years of age
7 AFFORDABLE &
CLEAN ENERGY 8 DECENT WORK &
ECONOMIC
GROWTH
9 INDUSTRY
INNOVATION &
INFRASTRUCTURE

• Reduce the incidence of TB and HIV/AIDS

• Strengthen efforts for prevention and
control of NCDs including injuries and

10 11 12
suicides REDUCED SUSTAINABLE RESPONSIBLE
INEQUALITIES CITIES & CONSUMPTION &
• Address on priority physical and sexual COMMUNITIES PRODUCTION

violence among married women

Health of people is getting prominence and gaining

importance in the state; Covid – 19 has only made
health, public health, health care and mental health 13 CLIMATE
ACTION 14 LIFE BELOW
EARTH 15 LIFE
ON LAND

as important societal issues. The state ranked 6th

amongst the large states in India in NITI Aayog’s
composite health index scoring (1), highlighting the
need for much more concerted efforts by the
government. Despite the gains in health over the
years, the state has the potential to take the health
of the population to new heights. The United Nations 16 PEACE, JUSTICE
& STRONG
INSTITUTIONS
17 PARTNERSHIPS
FOR THE GOALS

Sustainable Development Goals (SDGs - 17 goals

and 169 targets) (2), India’s National Health Policy
2017 (3) and NITI Aayog strategy (NITI Aayog
National Nutrition Strategy, NITI Aayog strategy for
new India at 75), the New National Education Policy,
framework for UHC and other recent proclamations
provides direction and a roadmap for the state to
move forward to achieve equitable and optimal
health for all.

12
The Ministry of Statistics and Programme Reaching the goals and targets under various
Implementation (MoS&PI) is primarily responsible programmes as agreed by Government of India and
for monitoring of SDGs at the national level under its different states and based on the action points
the National Indicator Framework (NIF), whereas and framework proposed by NITI AAYOG, Karnataka
NITI Aayog is responsible for overall requires strong policy frameworks, programmes
implementation of SDGs in the country. In the NIF, with vision and mission, implementation
MoHFW is responsible for data management with frameworks, agreed upon goals – targets –
regard to 45 health related national indicators ( indicators by different departments , multi- level
details available in the main report). For nearly 43 and multi-type trained and skilled human
out of 45 health indicators assigned to MoH&FW, resources, adequate funding ( including developing
the metadata and SDG baseline (2015-16) data at innovative funding mechanisms), systematic
National and State level is provided to MoS&PI monitoring and most importantly concerted and
(4,5). Every state in the country has to develop a coordinated action plans with the support of a
framework for measuring progress towards SDGs strong public health work force. Needless to say,
and put in place a mechanism for data reporting to political will and support at both central and state
MoHFW at suggested intervals. Table 1 shows that levels are critical along with effective use of
Karnataka has made good progress with regard to technology. Success depends upon vertical and
some indicators in the areas of water and horizontal integration of policies and programmes;
sanitation, maternal health, child health and for all measured - monitored and evaluated on a
select communicable and infectious diseases. From continuous and real time basis.
the table ( in the main report) it is clear that for
some of the indicators data is not available at the
state level. The need for establishing and or Coming Together for implementation
strengthening data collection mechanisms that
supports computing the required indicator value
and which also help in monitoring or tracking them • Communication
to measure the progress is urgent and important. • Cooperation
Karnataka ranked third in NITI Aayog’s Sustainable • Convergence
Development Goals (SDGs) India Index for 2020-21.
Based on the review of available data it can be • Coordination
concluded that the following health and health
related issues needs to strengthened or improved • Collaboration
by the state for achieving the health related goals
and targets set under SDGs and National Health
Policy-2017 (Table 2)

13
Table 1: Current health status of Karnataka with respect to Key health related Sustainable
Developmental Goals

Status of
Target Indicator
Karnataka

By 2030, reduce the global maternal mortality ratio to Maternal Mortality ratio per 92
less than 70 per 100,000 live births 1,00,000 live birth (2020)

Percentage of women aged 15-49 70.9%

years with a live birth, for last
birth, who received antenatal care,
four times or more (5 years
preceding the survey)

By 2030, end all forms of malnutrition, including Percentage of Children who are 32.9%/
achieving, by 2025, the internationally agreed targets on underweight /stunted/ wasted 35.4%/19.5%
stunting and wasting in children under 5 years of age,
and address the nutritional needs of adolescent girls,
pregnant and lactating women and older persons.

By 2030, end preventable deaths of new-borns and Under 5 Mortality rate (per 1000 28
children under 5 years of age, with all countries aiming live birth) (2020)
to reduce neonatal mortality to at least as low as 12 per
1,000 live births.

By 2030, end the epidemics of AIDS, tuberculosis, HIV Adult Prevalence Rate 0.47
malaria and neglected tropical diseases and combat
hepatitis, water- borne diseases and other Tuberculosis incidence per 133.5
communicable diseases. 100,000 population.

By 2030, reduce by one third premature mortality from Prevalence of hypertension Women-25.0%
non-communicable diseases through prevention and among men and women aged Men-26.9%
treatment and promote mental health and well-being. 15-49 years.

Blood sugar level - high or very Women-14.0%

high (>140 mg/dl) or taking medicine Men-15.6%
to control blood sugar level

Suicide mortality rate, (per 2015-17.4

1,00,000 population) 2020- 17.7

By 2020, halve the number of global deaths and injuries People killed/injured in road 2015- 17.51
from road traffic accidents accidents (per 1,00,000 population) 2018- 16.79

Eliminate all forms of violence against all women and Percentage of ever married women 44.4%
girls in the public and private spheres, including age 15-49 who have experienced
trafficking and sexual and other types of exploitation Physical or sexual violence
committed by their husband

By 2030, build the resilience of the poor and those in Number of human lives lost per 10.24
vulnerable situations and reduce their exposure and 100,00,000 population due to
vulnerability to climate-related extreme events and other extreme weather event
economic, social and environmental shocks and disasters

Implement nationally appropriate social protection ercentage of Households with 28.1%

systems and measures for all, and by 2030 achieve any usual member covered by a
substantial coverage of the poor and the vulnerable. health scheme or health
insurance.

Substantially increase health financing and the recruitment, Percentage of government 0.8
development, training and retention of the health spending (including current and
workforce in developing countries, especially in least capital expenditure) in health
developed countries and small island developing States sector to GSDP (2016-17)
14
Table 2: Current health status of Karnataka with respect to Key targets of National Health Policy
of India 2017.

Goal/Target Current status of Karnataka

Increase Life Expectancy at birth from 67.5 to 70 by 2025 68.8

Reduce Total Fertility Rate to 2.1 at national and sub-national level by 1.7
2025
Reduce Infant Mortality Rate to 28 by 2019 25
Reduce Neonatal Mortality Rate to 16 and Still Birth Rate to “single digit” NMR-18/1000 live birth
by 2025 Still birth rate-6/1000 live birth
Reduce Under Five Mortality to 23 by 2025 and MMR from current levels U5MR-28
to 100 by 2020 MMR-97
Antenatal care coverage to be sustained above 90% and skilled Care coverage-70.9%
attendance at birth above 90% by 2025 Skilled birth attendance-93.8%
Meet need of family planning above 90% at national and sub national 93.5%
level by 2025
More than 90% of the new born are fully immunized by one year of age 84.1%
by 2025
Reduction of 40% in prevalence of stunting of under-five children by 35.4%
2025
Relative reduction in prevalence of current tobacco use by 15% by 2020 Women-8.5%
and 30% by 2025 Men-27.1%
Achieve and maintain elimination status of Leprosy by 2018, Kala-Azar Leprosy eliminated -2018-19
by 2017 and Lymphatic Filariasis in endemic pockets by 2017 (0.34/10000 population)
Reduce the prevalence of blindness to 0.25/ 1000 by 2025 and disease 1% (2006-07)
burden by one third from current levels
Achieve and maintain a cure rate of >85% in new sputum positive Cure rate-69%
patients for TB and reduce incidence of new cases, to reach elimination Incidence-133.5 per 1,00,000
status by 2025 population
Achieve global target of 2020 which is also termed as target of 90:90:90, 79-85-79
for HIV/AIDS i.e., 90% of all people living with HIV know their HIV status,
90% of all people diagnosed with HIV infection receive sustained
antiretroviral therapy and 90% of all people receiving antiretroviral
therapy will have viral suppression
Establish primary and secondary care facility as per norms in high 1 PHC for every 28715 population
priority districts (population as well as time to reach norms) by 2025
1 Sub-centre for every 7636
population

1 CHC for every 327239 population

Increase health expenditure by Government as a percentage of GDP 0.8% of GSDP
from the existing 1.15% to 2.5 % by 2025
Increase State sector health spending to > 8% of their budget by 2020 3.8% (2009-10)
Decrease in proportion of households facing catastrophic health 8%
expenditure from the current levels by 25%, by 2025
Source: NFHS-5, 2019-20, http://rchiips.org/nfhs/NFHS-5_FCTS/FactSheet_KA.pdf; India TB report-2020,
https://tbcindia.gov.in/showfile.php?lid=3538; Status of National Aids response-2020,
http://naco.gov.in/sites/default/files/Sankalak%20Status%20of%20National%20AIDS%20Response,%20Second%20Edition%20(2020).pdf; Accidental
Deaths and Suicides in India-2019, https://ncrb.gov.in/sites/default/files/ADSI_2019_FULL%20REPORT_updated.pdf; National Sample Survey 76th
Round-Drinking water, sanitation, Hygiene and Housing condition in India-2018,
http://mospi.nic.in/sites/default/files/NSS7612dws/Report_584_final.pdf

15
06. Health Policy
One of the earliest efforts in the state was the
• The translation of state health policy to action development of the Karnataka Health Task Force
requires a well-defined plan, road map and that developed a report with the ‘draft Karnataka
investments along with an implementation State integrated health policy’ included in 2002(21),
process that is well monitored and measured leading to the development of Karnataka state
for its impact. integrated health policy in 2004 and then in 2017(22).
• Health impact assessment of all policies The broad aim of this policy was to improve access
should be an inbuilt activity of policy to health care based on the principles of equity,
implementation process in Karnataka. provision of healthcare, responsive system guided
by the principles of transparency, accountability and
• The state should establish a “Centre of
community participation. In 2008, the Karnataka
Excellence in health policy research” in a
knowledge commission was set up as an independent
public sector or academic institution to
support the government in formulation – body to further strengthen health systems in the
development – implementation – state. The Mission group on public health under the
measuring impact of policies. Karnataka Jnana Ayoga in 2013 developed the
report entitled “towards a community oriented
public health system development in Karnataka”
which paved the way for further reforms(23).
A health policy is a reflection of the vision, direction,
road map and political commitment of the state and The Karnataka public health policy 2017 brought
nation. Karnataka State is one of the pioneering together major health policy elements to establish
states aiming to deliver comprehensive public an administrative and managerial framework to
health services to its population by using defined support measures for improving the health status
policy frameworks. Apart from implementing many of people(22). The policy is focused on the
national policy frameworks like National Health attainment of the highest possible level of good
Policy 2017(18) , National Education Policy(19), health and well-being of all people in the state
National Transport policy(20), National policy to through delivery of comprehensive health care
address environmental concerns and welfare services with universal access to quality and
policies of different departments ; the state has affordable care and the inclusion of health in all
also developed its own policies over time in developmental policies. The policy document includes
different areas. vision, mission, objectives, and provides an implementation
framework in number of areas. (Figure 5)

Figure 5: Comprehensive health policy implementation framework

State Social & Health Development Agenda State Health VISION

(Legislative, legal and administrative commitments) (Department of Health Commitments)

Karnataka Public Health Policy (2016-2026)

Health care policy interventions to promote HEALTH

Service Human Health Medicines, technologies, Health Governance,

Delivery Resources Information infrastructure Financing Leadership

Ministerial MEDIUM TERM RESOURCE ALLOCATION State Strategies

Strategies framework by state Targets, Priorities

ANNUAL WORK PLANS Legislative,

(Priority activities based on state and central govt. resources)
Legal,
Administrative
And Regulatory
PERFORMANCE INDICATORS Framework
(Sub-division/ district/ department wise commitments to achieve priorities/ resources)

Standing Committee on Standing Committee on

Technology Montoring

Source: Karnataka Health policy 2017

16
07. Health Sector Action A specific and well defined integrated health sector
action plan that brings in medium term and long
Plans term vision for health sector is very much required
for the state. For example, the National
Multi-sectoral action plan for prevention and
control of NCDs has 4 strategic action areas of
Multisectoral coordination, health promotion,
The Department of Health and family Welfare health systems strengthening and surveillance –
(DoHFW), in consultation with public health monitoring – evaluation and research. The action
experts and program Directors, should plan was reviewed by 39 ministries and provided
develop a comprehensive – multisectoral and comments during 2015 – 17. The action plan has
integrated state health action plan (with vision, mission, goals, objectives, action areas,
vertical and horizontal integration) for the outcomes and a framework for implementation.
health department and for all state This framework has proposed activity, responsible
implemented programs (at least for flagship implementation partner, year of monitoring and
programmes) and can be revised once in 3 – 5 specific indicators for each of the activity(24).
years. Similar action plans should be Recently, the national NCD risk factor monitoring
developed in each district with help from local survey has been completed to get baseline
medical colleges and public health experts. information which will now be done at periodical
intervals(25). Such a type of framework on a scale
applicable to Karnataka is required for major
To translate policy into action, a written action plan flagship programmes
is a requirement. The health sector action plan
should list activities, work components,
department(s) / agency(y) for implementation,
timelines, resources and monitoring indicators for 08. Health Programmes
achieving health improvements usually based on
systematic needs assessment or a well conducted
situation analysis. The health action plan is based
• The state DoHFW should undertake a
usually on prioritisation of health issues and is a
landscape analysis of status of
process in which the state health department
implementation of all programmes, at both
should be actively engaged once in 3 to 5 years.
state and district levels, in terms of inputs,
Most importantly, the health action plan includes a
activities, progress, resources, outcomes
set of measurable indicators to decide and define
and impact using a set of easily
the direction of implementation.
measurable indicators with technical
Action plans should be developed at both state and assistance from state public health experts.
district levels for efficient implementation. Building
• Capacity building of all programme officers
the capacity of state and district teams is vital for
should be strengthened by State Institute
making action plans and should be facilitated by the
of Health and Family Welfare (SIHFW) for
state planning unit in the Directorate of Health and
overseeing programme implementation in
family Welfare Services. It is learnt that state and
terms of feasibility, community orientation,
districts formulate actions action plan every year
resource planning, sustainability and
for submission to MoH under NHM activities. At
measuring progress.
present, the annual Program Implementation Plans
of the department are considered as action plans, in • All public health programmes should be
addition to programme directives from centre. well monitored and evaluated at periodical
However, this would not suffice. intervals for their effectiveness and impact
at state and district levels. .
Central to the process of policy development and
progress is the fact that health is not a major • Digital technology should be fully
component of non- health sector policy (ies), while integrated into monitoring, evaluation and
the health sector has not measured the health surveillance activities of all health
impact of all policies in detail. This is primarily due programs and services.
to lack of professional expertise in health policy
research within the state.

17
Every citizen should benefit from every health effective public health program. Overall, to improve
program and should be able to access preventive, public health, need based, community driven,
promotive, curative and specialty health care evidence-based intervention(s) should be instituted
delivery within a radius of 50 km in the state of with due considerations to feasibility, cost
Karnataka. Since independence, several national effectiveness, sustainability, community acceptance
and state health programs have aimed towards and availability of technology(in recent days).Public
control/elimination/eradication of communicable/ health programs succeed and survive whenever
infectious diseases, improvement of potable water there is ,
supply and sanitation, raising the standards of i. Innovation to develop evidence base for action;
nutrition, population welfare and control, and for
improving health care access and delivery. In recent ii. A technical package of a group of limited
years, new programmes in the areas of number of high-priority, evidence-based
non-communicable diseases, mental health, interventions that will have a major impact;
elderly care, oral health, adolescent health, iii. Effective performance management of the
prevention of blindness and several others have program with adequate human resources
been developed in addition to the existing combined with robust real-time monitoring and
programmes. evaluation.
A health Program consists of a formal set of aim, iv. Good partnerships and collaborations with public,
objectives, guidelines and procedures that private and community based organizations;
contribute for achieving pre-set goals and
indicators, e.g., National program for Cancer, v. Communication of accurate and timely information
Diabetes, Cardiovascular diseases and stroke to the community and decision makers to
NPCDCS(26). A clear demarcation about the engage civil societies and effect behaviour
activities to be rolled out by a program, nature of change; and
services, target beneficiaries, financial
vi. sustained political commitment to support for
mechanisms and arrangements and man power
effective action
implementing the programs is often required in an

Table 3: Flagship Programmes of Karnataka, 2020-21

Sl No Name of the
2020-21 2019-20 2018-19
Program
01 National • National Health Mission • National Health Mission • National Health Mission
Health (NHM) (NHM) (NHM)
Mission • Aysushman Bharath • Swasthya Bhima Yojane • Arogya Karnataka
(NHM) Arogya Karnataka • Arogya Karnataka • Comminicabe Diseases
• Arogya Sahayavani - 104 • Comminicabe Diseases • Arogya Sahayavani - 104
• Ayushman Bharat Health • Arogya Sahayavani - 104 • EMRI & Call centre (108)
& Wellness Centre
• EMRI & Call centre (108) • Universal Health
• PMNDP - Pradha Mantri Coveage/ AB HWC
National Dialysis • Universal Health
Programme Coveage/ AB HWC
• Health Infrastructure • PMNDP - Pradha Mantri
Strengthening - NABARD National Dialysis
Programme

In Karnataka state, services are delivered through Karnataka has been a progressive state with regard
the implementation of National Health Mission to public health programme implementation,
(NHM) and nearly 75 national and state health despite several challenges and implementation
programmes (details in annexure 1). The Ayushman delays (13). The number of programmes in the area
Bharat program has a target of establishing 11,595 of maternal and child health and communicable
Health and Wellness Centres across the state. In disease control are several, at times leading to
addition, financial support is available through the duplication of efforts at gross root levels. Some of
Ayushman Bharat Arogya Karnataka scheme to the flagship programmes of the state are shown in
offset costs for poor communities. Table 3. Programme officers in the State
Directorate and at district levels are given
responsibility of coordination, delivery, supervision
and monitoring. Programmes in the areas of water
18
and sanitation, immunisation, RCH and public demands, segmentation of health care
Communicable diseases have delivered reasonably system, commercialisation of health care and
good results; programmes like National Programme sustainability, calling innovative methods in
for prevention and control of Cardiovascular diseases, programme implementation.
Diabetes, Cancer and Stroke and National
Programme for Health care of elderly are yet to see Our discussions with stake holders and an
significant results and some (trauma care, appraisal of programme implementation revealed
environment) have not yet been initiated. Some that programmes with (i) leadership,(ii) defined
programmes (eg., deafness prevention) operate with goal and programme directives, (iii) timely release
severe constraints of resources. Collaborative of funding, (iv) focus on implementation in districts,
programmes in partnership with academic agencies (v) sustainability, (vii) continuous community
(eg., Yuva Spandana programme) have delivered good engagement, (viii) coordinated activities, and (ix)
results along with sustainability over time. good monitoring mechanisms delivered better
Demonstration projects in NCD and road safety have results. Due to multiplicity of programmes and
also shown positive results. Most often, guidelines activities, flagship programmes get higher priority,
from MoH is usually followed to facilitate state level while others get side-lined. The vertical nature of
implementation. the programs is also a strong limitation by its
selective focus, prioritised augmentation of
Over time, the context in which public health resources, missed opportunities for integration and
programs have been operating in the state has duplication of services. Selective focus on
become more complex raising demands for implementation of programmes has led to
accountability from policymakers and other verticalisation of programmes leading to greater
stakeholders. Major challenges in programme importance, focus and resources for few, while
development and implementation include relegating others to periphery. In addition to the
situational context, inadequate knowledge about governmental schemes a wide range of common,
the existing bottlenecks at the field level, lack of speciality and super speciality services are
awareness and misconceptions about the program provided by the private sector in urban, peri urban
among the implementers, limited man power and and semi urban areas, which is largely unregulated.
finances, lack of intersectoral coordination, As all programmes are important for health of
absence of tailor-made evidence based planning for people, every programme must be implemented in
the state or district, difficulties in engaging with true spirit and action.
private sector, urban – rural disparities, community
participation and acceptability/availability of
services for the beneficiaries. Adding to the
complexity of public health programs for its
Critical Areas for Improvement
implementation are challenges such as inequity,

• Health determinants
District focus research activities • Strengthen human resources
• Monitoring and evaluation
• Assessment of human resources • Technology applications
• Survey on NCDs - risk factors – • People’s engagement
determinants
• Health financing and health protection
• Health impact assessment
• Verbal autopsy study Priority areas for action
• Population-based registry
• Pilot project on technology integration • Urban health
• Integration of Ayush in healthcare • Adolescent health
• Survey on disabilities • Mental health
• Integrated surveillance • Environment health
• Assessment of emergency, trauma, • Elderly health
and critical care services

19
 National Rural Health Mission
National Rural Health Mission (NRHM) was launched on 12th April 2005 under the NHM, a
flagship Programme of the Ministry of Health & Family Welfare, Government of India to
provide accessible, affordable and quality health care to the rural population, especially the
vulnerable groups. The thrust of the NRHM is to bridge the gap in rural healthcare services
through improved health infrastructure, augmentation of human resources, enhanced
service delivery and decentralization of the programme to the district level to facilitate
context specific, need based interventions, improve intra and inter-sectoral convergence and
promote effective utilization of resources.
A State specific programme implementation plan, by integrating district health action plan, is
being prepared and implemented under NRHM since the year 2008-09. It is based on the
district specific health needs and comprises of most of the components of NRHM. The main
approaches of NRHM includes communitization, improved management through capacity,
flexible financing, innovation in human resource management and monitor progress against
standards.
NRHM has contributed to improvement in the functioning of public health system and better
health profile in the state. Under NRHM the state has made considerable progress in
enhancing availability of human resources in public health system especially by recruiting
more medical doctors, staff nurse and ASHA workers. The gaps in availability of sub-centres,
primary health centres and community health centres have been closed. The range and
quality of services available within the public health system has been enhanced which is
reflected upon the health indicators for the state. The overall health management capacity at
the district level has improved with district health action plan being developed in all districts
and with regular meetings of district health society. Involvement of communities in managing
public health facilities and other community monitoring activities is showing signs of
improvement.
Despite the significant achievements, as per the findings of an evaluation study of NRHM by
Karnataka Evaluation Authority (KEA), the rates of fund utilization in the State needs
strengthening (An amount of 988 crores INR was sanctioned and 578 crore INR was spent
for NRHM activities in the Financial Year 2017-18 in the State). Health officers have a broad
understanding about the overall goals and strategies of NRHM, however their perceptions
about planning and monitoring were limited. Moreover, the Southern Districts of the State
reported ill equipped PHCs with high shortage of human resources and in districts of
Gulbarga and Belgaum, it was reported to have reduced field presence of field-based
personnel, lagging health infrastructure and health indicators. Also, the NRHM
documentation follows multiple and overlapping reporting formats, inefficient reuse of
existing data, and lack of trained personnel for data entry.
Recruiting staffs like MHWs, JHA, LHVs in the state for field presence can reduce the work
overload on ANMs and ASHAs. The clerical and administrative positions at the grassroots
level need to be filled. Staffs should also undergo capacity building and training about NRHM
and its activities. Single database to streamline reporting activities and merge data
requirements will help in improving planning, analysis and monitoring of activities. Allocating
a demand-based funding will contribute towards promoting effective utilization of resources
based on needs and demands for better implementation of NRHM.

20
National Urban Health Mission
National Urban Health Mission (NUHM) is the sub-mission of National Health Mission and
was launched in the year 2013. It aims to improve the health status and well-being of the
urban poor, particularly the slum dwellers and other disadvantaged sections such as
homeless, rag-pickers, street children, rickshaw pullers, construction workers, brick & lime
kiln workers, commercial sex workers and other temporary migrants. NUHM facilitates
equitable access to quality health care through an upgraded public health system and with
the active participation of the urban local bodies.
NUHM covers all the District headquarters and other cities/towns with a population of 50,000
and above whereas the cities and towns with population below 50,000 are covered under
NRHM. As per census 2011, State has 236.25 lakh people (31.57%) living in urban localities and
36.31 lakhs urban slum population placing a huge challenge for public health service delivery
in urban areas. NUHM is playing a key role by effectively providing adequate primary health
care to the urban poor focusing on preventive, promotive and curative aspects of health and
illness.
On the norms of one UPHC (Urban Primary Health Centre) for every 50,000 population under
NUHM, 361 UPHCs across the state have been made functional supported with required
human resources including specialist doctors. Evening clinics have been made functional in
almost all UPHCs for the benefit of urban daily wage earners. Adequate resources for
establishing laboratories and for procuring of generic drugs are provided to prevent the
out-of-pocket expenditure of the urban poor. Communitization through selection and training
of ASHAs and Mahila Arogya Samitis for every 50-100 households are other initiatives under
NUHM.
Since NUHM is being implemented in the state from 2014 onwards there has been no formal
evaluation of the program and the achievements of NUHM in improving health of the urban
population are unclear. However, NUHM has certainly contributed to improving the resources
for urban health care especially through increased funding, establishing new urban primary
health centers, strengthening existing primary health centers, recruiting more health
personnel, improving community participation through ASHA, mahila arogya samithis and by
strengthening lab services. A baseline community needs assessment focussing on urban
poor and resource mapping has been undertaken across 23 cities/towns of the state to help
in health planning.
Challenges in implementing NUHM includes: increasing population in the urban areas and
the uneven infrastructure development in cities, fostering intersectoral coordination and
public private partnerships; increasing burden of various lifestyle diseases and emerging
infectious diseases among urban population and in-effective fund utilisation. A
well-structured plan for implementing NUHM in the state, collaborating with multiple
stakeholders across different sectors and an authority responsible for monitoring the
implementation of NUHM are urgently required. To ensure effective implementation,
augmenting the manpower especially for Urban Primary Health Centres will help along with
nd capacity building of health systems.

21
9. Health Services
The 10 essential components of public health
The state should commission a well-designed services include - monitoring population health,
and scientific study, in three districts to begin responding to threats at an early stage, effective
with on a pilot basis, to document the communication, community empowerment, clear
comprehensive range of services and framework for policies and plans, strong
interventions (required and to be delivered) in legislations and regulatory mechanisms, ensuring
different facility based settings to identify the equity, strong workforce, strengthened monitoring
investments to be made in the coming years: and evaluation with a strong and well-functioning
with implementation as the focus. organisational infrastructure (Figure 6). The optimum
health of people can be insured and promoted only
when all these are integrated and work to their
Public health services include a broad range of fullest capacity.
activities for delivery of services, based on equity,
enabling provision of services to all citizens, based Figure 6 : Essential Public Health services
on a continuous and evolving needs assessment
through a wide range of policies and programmes.
Public health services delivered should be an Build and
maintain a strong Access and

optimum and required mix of preventive, promotive, organizational

infrastructure for
public health
monitor
population
health
curative and rehabilitation services. Services Improve and Investigate,
delivered should cover all age groups and in urban, innovate through
evaluation, research,
and quality ASSE
diagnose, and
address health

rural and difficult to reach areas. These services SS hazards and root
improvement ME causes
N
range from the most essential and basic services

T
provided at a village level to a wide range of
ASSURANCE
Communicate
complex and advanced services delivered in an Build a diverse
and skilled
workforce
EQUITY effectively
to inform

apex referral healthcare facility through a

and educate

POL
combination of central and state-supported

ICY
DE
programs. In addition to health sector activities,
VE
LO
Strengthen,
PME

number of partners from many other sectors is

support, and
NT
Enable mobilize
equitable communities

essential to improve healthcare of the people of the

access and partnership

state. For example, the ICDS program implemented Utilize

legal and
Create,
champion, and
implement
in collaboration with the Department of Women and regulatory
actions
policies, plans,
and laws

Child development to rehabilitation programs delivered

by the Ministry of social welfare and empowerment
needs to work in unison for the benefit of people. Source :https://phnci.org/uploads/resource-files/EPHS-English.pdf

10. AYUSH Services

• The Government should establish an • The analytical capabilities of existing testing

overarching implementation body, the laboratories need validation and certification
Karnataka State Health Council for for quality of products as well as for
Integrative Medicine and Healthcare that adherence to Indian public health standards
links education, healthcare, research, drug as per existing licensing rules and regulations.
manufacturing and IT platforms in the Ayush
sector in a comprehensive manner for robust • All Ayush institutions should be accredited to
healthcare management. ensure quality and standards of care as well
as standards in teaching and training
• A district Ayush care model should be methods.
implemented across four districts of the
state as demonstration projects to integrate • Infrastructure in all existing Ayush
Ayush services into existing services for dispensaries and Ayush hospitals needs
identifying areas of stand-alone management unpgradation for need-based and uniform
of Ayush effective interventions and setting services at PHCs, CHCs and health and
up a wide range of integrated services through wellness centres for expansion of services
standardised and integrated approaches. and integration.

22
 • Bridge courses in the Ayush curriculum as • Research should be scaled up through pilot
well as in modern medicine should be projects, feasibility testing for data safety and
established to promote an interdisciplinary a strong research culture should be
understanding of all medical systems among introduced in the Ayush systems of medicine.
students. In addition, the Ayush faculty
should be tried in evidence-based methods • The existing Ayush grid project encompassing
of medical diagnosis and treatment – both the government and private sector
monitoring, along with initiating short term should be strengthened to assess patient
diploma or certification courses for therapists, well-being and create Ayush health service
nursing and paramedical professionals. database for all public health services.

The Indian Systems of Medicine (ISM) are of great Homoeopathy (AYUSH) are the oldest systems
value and known for its traditional systems by originating nearly 2000 years ago and evolving over
playing a crucial role in ensuring healthy living of centuries. The ISM has also come into prominence
communities by prevention of diseases, promotion at a time, when new infectious diseases are
of health as well as management of illnesses. emerging and lifestyle disorders are on the
Ayurveda, Yoga and Naturopathy, Unani, Siddha, increase.

Table 4: Number of AYUSH Hospitals, beds and dispensaries in Karnataka State - 2019

System Government Hospitals No. of Dispensaries

No. of Hospitals No. of Beds
Ayurveda 115 1821 564
Unani 18 392 56
Homeopathy 18 260 43
Nature Cure 05 46 05

The Department of Indian systems of Medicine and equipment and supply are evident as compared to
Homoeopathy established in March 1995 was modern systems of medicine. Poor recruitment
renamed as Ayush in the year 2003. With the policies, deficient utilisation of available manpower,
creation of a dedicated Ministry of Ayush in 2014, shortfall in scientific documentation of benefits are
there is a Department of Ayush in GoK which some major obstacles in the integration process of
includes both Ayush health and Ayush medical Ayush with the mainstream healthcare. The lack of
education services. The District Ayush officers look uniform training of Ayush students in modern
after the services in the district hospitals, taluka systems of medicine and scarcity of well-qualified
hospitals and in dispensaries. In Karnataka, there Ayush paramedical staff due to accreditation
are 159 government Ayush hospitals with 2534 beds deficiencies are also major barriers. The medicinal
and 662 Ayush dispensaries (Table 4). The 101 Ayush flora conservation and cultivation is an area of
colleges with an annual intake of 7215 students in concern as it is the backbone of the entire system.
medical education offer a great human resource The traditional community health practices which
pool for healthcare programmes and services (27). have its roots in Ayush systems need validation. In
Under the Ayushman Bharat scheme, health and addition, the utilisation of information technology in
wellness centres have been established with a the Ayush sector is totally inadequate and nonuniform.
target to develop 10% of the total health and
wellness centres. These centres are envisaged to
deliver range of comprehensive primary healthcare Strategic Pillars
services with a major focus on prevention of
diseases and promotion of good health and • Public engagement
wellness. Yoga is an important activity promoted in
all centres along with support services in terms of • Building evidence base
medicines, diet and lifestyle modifications.
• Establishing cost effectiveness
Despite the developmental efforts, Ayush is in
fragmented state in terms of its functioning, • Strengthening technology
implementation of services and integration into the • Ensuring sustainability
existing health system. Huge disparities in
infrastructure, diagnostics and assessment,
23
Ayushman Bharat Health and Wellness Centres
Ayushman Bharat attempts to move from sectoral and • Institutionalize participation of civil society for social
segmented approach of health service delivery to a accountability.
comprehensive need-based health care service. It
• Partner with not for profit agencies and private
adopts a continuum of care approach to holistically
sector for gap filling in a range of primary health
address health (covering prevention, promotion and
care functions.
ambulatory care), at primary, secondary and tertiary
level and comprises of two pillars namely Health and • Facilitate systematic learning and sharing to enable
Wellness Centres (HWC) and Pradhan Mantri Jan Arogya feedback, and improvements and identify innovations
Yojana (PM-JAY) for scale up.
Health and Wellness Centres • Develop strong measurement systems to build
accountability for improved performance on measures
The National Health Policy, 2017 recommended
that matter to people.
strengthening the delivery of primary health care,
through establishment of "Health and Wellness Centres" Comprehensive Primary Health Care (CPHC)
as the platform to deliver comprehensive primary health
care and called for a commitment of two thirds of the The aim of CPHC is to provide a seamless continuum of
health budget to primary health care. care that ensures the principles of equity, quality,
universality and no financial hardship. The
Key principles announcement was made in the context of the annual
In order to ensure delivery of Comprehensive Primary budget presentation, assigning financial resources to the
Health Care (CPHC) services, existing Sub Health National Health Policy 2017, which commits two thirds of
Centres covering a population of 3000-5000 would be the budget to primary health care, and explicitly
converted to Health and Wellness Centres (HWC), with mandates a move from peripheral centres providing
the principle being “time to care” to be no more than 30 selective primary health care to 150,000 HWCs acting as
minutes. Primary Health Centres in rural and urban the first point of contact for an expanded set of
areas would also be converted to HWCs. health-care services closer to the community.
• Transform existing Sub Health Centres and Primary
Health Centres to Health and Wellness Centers to
ensure universal access to an expanded range of ESSENTIAL PACKAGE OF SERVICES
Comprehensive Primary Health Care services.
• Care in Pregnancy and Child-birth.
• Ensure a people centered, holistic, equity sensitive
response to people’s health needs through a process • Neonatal and Infant Health Care Services
of population empanelment, regular home and
• Childhood and Adolescent Health Care Services.
community interactions and people’s participation.
• Family Planning, Contraceptive and other
• Enable delivery of high quality care that spans health
Reproductive Health Care Services
risks and disease conditions through an expansion
in availability of medicines & diagnostics, use of • Management of Communicable Diseases
standard treatment and referral protocols and including National Health Programmes
advanced technologies including IT systems.
• Management of Common Communicable
• Instill the culture of a team-based approach to Diseases and Outpatient care for acute
delivery of quality health care encompassing: simple illnesses and minor ailments.
preventive, promotive, curative, rehabilitative and
palliative care. • Screening, Prevention, Control and
Management of Non-Communicable Diseases
• Ensure continuity of care with a two- way referral
system and follow up support. • Care for Common Ophthalmic and ENT
Problems
• Emphasize health promotion (including through
school education and individual centric awareness) • Basic Oral Health Care
and promote public health action through active • Elderly and Palliative Health Care Services
engagement and capacity building of community
platforms and individual volunteers. • Emergency Medical Services including
Burns and Trauma
• Implement appropriate mechanisms for flexible
financing, including performance- based incentives • Screening and Basic Management of Mental
and responsive resource allocations. Health Ailments

• Enable the integration of Yoga and AYUSH as

appropriate to people’s needs.
• Facilitate the use of appropriate technology for
improving access to health care advice and
treatment initiation, enable reporting and recording,
eventually progressing to electronic records for
individuals and families.
24
Key Inputs to be provided at a HWC are listed below:

1. Primary health care team to deliver the expanded 8. Community Mobilization – for action on social and
range of services. environmental determinants, would require
intersectoral convergence and build on the
• At the upgraded SHC – A team of at least three
accountability initiatives under NHM so that there is
service providers (one Mid-level health
no denial of health care and universality and equity
provider/MLHP, at least two (preferably three)
are respected.
Multi-Purpose Workers – two female and one male,
and team of ASHAs at the norm of one per 1000. 9. linkages with Mobile Medical Units – Linkages with
Mobile Medical Units (MMU) could serve to improve
• At the strengthened PHC – PHC team as per IPHS
access and coverage in remote and underserved
standards. In 24*7 PHCs having inpatient care, an
areas where there is difficulty in establishing HWCs.
additional nurse for cervical cancer screening is
In such cases, medicines and other support could be
planned. In PHCs that are not envisaged to provide
provided to frontline workers, with periodic MMU
inpatient care, the existing nurses should receive
visits. MMUs could also be linked to nearby HWCs,
modular training in certificate course for primary
where medical consultation could be arranged on
care. In urban areas, the team would consist of the
scheduled days, for those unable to travel to referral
MPW- F (for 10,000 population) and the ASHAs (one
sites.
per 2500).
Financing
2. logistics – Adequate availability of essential
medicines and diagnostics to support the expanded Suitable payment mechanism for primary health care
range of services, to resolve more and refer less at will need to be explored. Once the systems for population
the local levels, and to enable dispensation of empanelment and record of services are streamlined,
medicines for chronic illnesses as close to the possibility of financing on a per capita basis can be
communities as possible. explored. In addition, team based incentives would be
initiated. This will be done to facilitate accountability to
3. Infrastructure – Sufficient space for outpatient care, for outputs/outcomes and provide individual centred care.
dispensing medicines, diagnostic services, adequate
spaces for display of communication material of health Essential Outputs of HWC
messages, including audio visual aids and appropriate
1. The HWC data Base: Population enumeration and
community spaces for wellness activities, including the
empanelment implies the creation and maintenance
practice of Yoga and physical exercises.
of database of all families and individuals in an area
4. Digitization – HWC team to be equipped with served by a HWC. This is planned such that every
tablets/smart Phones to serve a range of functions individual is empanelled to a HWC.
such as: population enumeration and empanelment,
2. Health Cards and Family health Folders: These are
record delivery of services, enable quality follow up,
made for all service users to ensure access to all
facilitate referral/continuity of care and create an
health care entitlements and enable continuum of
updated individual, family and population health
care. The health cards are given to the families and
profile, and generate reports required for monitoring
individuals. The family health folders are kept at the
at higher levels.
HWC or nearby PHC in paper and/or digital format
5. Use of Telemedicine/iT Platforms – At all levels, ensuring that every family knows their entitlement to
teleconsultation would be used to improve referral healthcare through both HWC and the Pradhan
advice, seek clarifications, and undertake virtual Mantri Jan Arogya Yojana or equivalent health
training including case management support by schemes .
specialists.
3. Increased access to Services: HWCs would provide
6. Capacity Building – Mid Level Health Providers will access to an expanded range of services as shown
be trained in a set of primary healthcare and public above. The availability of services would depend on -
health competencies through an accredited training the availability of suitably skilled human resources at
programme that combines theory and practicum the HWC, the capacity at district/sub-district level to
with on the job training. Other service providers at support the HWC in the delivery of that service, and
HWC will also be trained appropriately to deliver the the ability of the state to ensure uninterrupted supply
expanded range of services. of medicines and diagnostics at the level of HWC
7. Health Promotion – Development of health
promotion material and facilitation of health
promotive behaviours through engagement of “Medical education does not exist
community level collectives such as – Village Health
Sanitation and Nutrition Committee (VHSNCs), to provide student with a way of
Mahila Arogya Samiti (MAS) and Self-Help Groups
(SHGs), and creating health ambassadors in schools.
Enabling behaviour change communication to
making a living, but to ensure the
address life style related risk factors and
undertaking collective action for reducing risk health of the community”
exposure, improved care seeking and effective
utilization of primary health care services. - Rudolf Virchow

25
Essential Outcomes of HWC To achieve above goals, paradigm shift is
1. improved population coverage: Active empanelment
required at 5 levels
and HWC database will improve the population 1. Innovation in human resources: Services at the HWC
coverage. The HWC database would enable HWC at the most peripheral level, will be delivered
staff to monitor and identify the left out population through a team, led by a new cadre of non-physician
and improve coverage of national health health worker, a mid-level health provider,
programmes. supported by one or two multipurpose workers, and
ASHAs – as India’s community health workers are
2. reduced out of pocket expenditure and catastrophic called.
health expenditure: Improved access to expanded
services closer to the community, assured 2. Dispensation of free medicines for chronic care, at
availability of medicines and diagnostic services and the HWC, to avoid patient hardship, reduces
linkages for care coordination with Medical out-of-pocket expenses and enables improvement
Officers/specialists across levels of care will reduce in treatment adherence. Needs planning and
financial hardships faced by community. uniterupted supply of medicines.
3. risk factor mitigation: Health promotion efforts by 3. Financial reforms, including capitation-based
primary health care team would support in payments to HWCs and performance-linked
addressing the risk factors for diseases. payments to the mid-level health provider and to the
team of front-line workers. The salary of the
4. decongestion of secondary and tertiary health mid-level health provider is blended – consisting of a
facilities: A strong network of HWCs at the sub fixed component and an incentive component linked
district level would facilitate resolving more cases at to key outcomes, which are measured using
primary level and reduce overcrowding at secondary monitoring data captured through an IT system.
and tertiary facilities for follow up cases as well as
serve a gate keeping function to higherlevel facilities. 4. Use of digitalised technology and information and
communications technology (ICT) platforms to
Expected impact of HWC ensure continuity of care through universal
1. improved population health outcomes: Improved population empanelment and registration to a
availability, access and utilization will in turn particular HWC, enabling, inter alia, treatment
contribute to equitable health outcomes measured adherence and tracking of referrals, facilitating
through periodic population based surveys for key performance payments and ensuring continuity of
indicators listed in Section 10.1- Monitoring. care
2. increased responsiveness: Provision of care by 5. Every year, 5 % of HWCs selected in a random
primary care team will be based on principles of manner with representation to all districts should be
family led care including dignity and respect for evaluated for its progress and performance by
individuals and communities with particular focus on external public health experts to bring continuous
marginalized, information sharing, encouraging improvement.
participation, including intersectoral collaboration
that will lead to increased trust building, comfort in
access to care and enable addressing social and
environmental determinants.

26
11. Health Infrastructure
Figure 7: Presence of Medical colleges
• The district administration should have a in Karnataka, 2021
“directory of resources on a digital
dashboard” to know the presence, location, 01

availability of beds, costs, and, status of Bidar

health care agencies to develop

mechanisms for effective coordination as 04
well as to share responsibilities in all Kalaburgi

emergencies based on good resource 02

mapping. Vijayapura
Yadagiri
• All health care institutions should undergo 01

accreditation process within the next 5 01

02
years for quality care improvement in
Bagalkote

Belagavi
services, teaching and training and product Raichur

usage for maintaining quality services with 01

01

adherence to prescribed norms.

02
Dharwada Koppala
Gadaga
02
01
Uttara Kannada Ballary
As per data available from the DoHFW, there are Haveri
5917 wellness Centres, 8871 sub centres, 2299 02
01
PHCs, 207 CHCs, 146 taluka hospitals and 17 district 02 Davanagere

hospitals run by DoFHW (Figure 8). The Department Shivamogga

Chitradurga

of Medical education is in charge of 60 medical 01

colleges for undergraduate and postgraduate 02

02
medical education, at the rate of 2 per district; most
Udupi Chikkaballapura
Tumakuru
Chikkamagalur
of them run by private establishments (Figure 7). 08
01 Bengaluru 10
Rural
01

The cities of Bangalore and Mangalore have 14 and Mangaluru

Hassana Bengaluru
Urban
Kolara

9 medical colleges surpassing the norms of any 02

regulatory authority(11). In addition, nearly 1000 01 Mandya Ramanagara

institutions education institutions are functioning to Kodagu

02

develop manpower in related areas of nursing,

01
Mysuru

physiotherapy, dental, pharmacy and other areas. Chamarajanagara

Allied professional courses in many disciplines (

like laboratory technology, etc.,) are run in both
Government ( 14 disciplines) and private sectors. 01
Medical College Present
There are nearly 100 Ayush colleges, 178 hospitals Medical College Absent
with 3096 beds , 662 Ayush dispensaries are Medical College in Bengaluru Urban
present in the state with huge variations across
districts(11). College. In addition, a school, an Anganwadi center,
a panchayat function in most places of the state. The
Within a district, most villages have a sub centre /
district wise distribution of health care facilities in
health and wellness Centre at the rate of one per
the state is provided in annexure 3.
5000 population in plain areas and one per 3000
population in difficult to reach areas(26). Nearly The situation in urban areas is very different. Urban
3360 health and wellness centres have been health infrastructure comprises of both public and
established under the Ayushman Bharat program private healthcare facilities. An urban PHC is
by upgrading existing sub centres performing available for a population of approximately 50,000
expanded roles and coverage of activities. Two along with other health care facilities run by state
thousand more are likely to be added in 2021 - 22. government and local municipal bodies. The
Most districts have PHCs as per prescribed norms availability of tertiary care facilities is much higher
of I per 30,000 population. The CHCs are located for in the private sector with the presence of super
an approximate population of 1.5 lakhs providing speciality corporate hospitals in many of the major
clinical services in addition to a range of preventive cities of Karnataka. The private sector has wide
promotive services. A taluka hospital for every five range of facilities from a simple clinic in a village to
lakh population has been recommended as per the corporate super speciality hospitals in the city.
IPHS guidelines. Every district has a district The number of these facilities at the state and
hospital or a district hospital run by a medical district levels is not clearly known.

27
Figure 8: State Government Public Health District Health and Developmental
Infrastructure Programme: Need of the hour
….if ‘Local people are not engaged – Local data is not
available – Local implementation does not happen’,
Medical Colleges 57 impact is likely to be lesser.
Autonomous and Teaching Hospitals 36 A district is the nucleus of all health, welfare and
development programmes. Karnataka has 31 districts
District Hospitals 15
catering to populations ranging from 560990 in
Taluk/General Hospitals 146 Kodagu district to 5426096 in Belagavi district (11).On
Community Health Centres 207
an average, a district caters to an approximate
population of +/~ 2.5 million with urban districts and
Primary Health Centres 2359 cities covering larger populations. Each district has
Sub Centres 8871 about 5 – 10 talukas per district with each one
catering approximately to ~ 3 – 5,00,000 population.
Health and Wellness Centres 5829
Each district and taluka is different with some
commonalities and significant variations.
Source: Health and Family Welfare Annual Report 2020-21 The policies, programmes, action plans, guidelines
of Karnataka and directives generally flow from top to bottom,
being formulated in national and state capitol and
Data from NFHS indicate that nearly 70 to 80%
implemented in a district. It is well acknowledged that
of healthcare is provided by the private health
the involvement of a district team in planning health
sector, confirmed with a recent assessment of
and welfare activities are generally limited.
trauma care facilities and mental health care
services in Kolar district of Karnataka(28-30). Every district health administration should be able to
provide comprehensive preventive, promotive, curative,
The populations are also served by many other
rehabilitative, palliative, laboratory, telemedicine
support facilities like laboratories, blood banks,
services to its population through implementation of
x-ray centres, CT scan centres, MRI centres and
health programmes / schemes. Within each district,
others and a significant proportion of them are
departments of education, welfare, women and child
in the private sector. Dialysis services are also
development and others also implement schemes
available across all the districts in the state with
that benefit health of people.
some of the districts having higher number of
dialysis units. The central and state governments are focussing on
district level strengthening with decentralisation
The establishment or addition of new facilities mechanisms as all programmes are to be
over time is based on expansion, addition, up implemented at district and taluka levels. The 100
gradation, administrative bifurcation, programme Aspirational Districts development programme based
operations and political considerations resulting on the core principles of Convergence, Collaboration,
in wide disparities in the availability of and Competence has selected Yadgir and Raichur
infrastructure and an uneven distribution across districts from Karnataka(31).The state government
different districts. A number of public facilities has The Kalyana Karnataka Regional Development
have been upgraded recently during the Covid 19 Board to strengthen the districts of Bidar, kalaburagi,
pandemic with additional manpower and Yadgir, Raichur, Koppal and Bellary for inclusive
infrastructural facilities. Hence, the number of growth and comprehensive development (Figure 9)(32).
facilities may not exactly match as per IPHS Additional resources are provided to few other poorly
guidelines. performing districts and also for specific
programmes in the state (eg., SNCUs for child health)
In addition there are a host of other agencies to accelerate programmes.
within a district (both urban and rural) which
includes hospitals run by factories, industries,
Bidar

missionary agencies, philanthropic organisation

Kalaburgi

and several others. Given the wide range and

Yadagiri

variations in formal and informal, public and

Raichur

private, corporate- noncorporate organisations

Koppala

for health care sector in a district the numbers

Ballary

and population covered, the quality of services

needs systematic assessment and monitoring. Figure 9: Kalyana Karnataka
Challenges lie in the lack of effective Regional Development Board
coordination mechanisms with resources being - Districts
unavailable to the needy patients.
28
Table 5: Estimates for Major Health care needs for a district with 2 million population in Karnataka

Measure Estimated persons

(Prevalence per 100,000) (for 2 million population)
MATERNAL AND NEONATAL DISORDERS
Protein Energy Malnutrition 3295 65900
Maternal disorders 289 5780
Neonatal disorders 1250 25000
Maternal and child health needs
Expected Number of pregnancies# NA- 37840
Expected Number of pregnancies registered at any given month# NA- 18920
Major Disease Categories
COMMUNICABLE DISEASES
Respiratory infections and tuberculosis 38905 778100
HIV/AIDS and STI 13671 273420
Malaria 357 7140
Dengue 94 1880
NON-COMMUNICABLE DISEASES
Cardiovascular diseases 5656 113120
Ischemic Heart Disease 3096 61920
Ischemic Stroke 525 10500
Intra cerebral haemorrhage 251 5020
Hypertensive Heart Disease 78 1560
Neoplasms 3332 66640
Breast cancer 92 1840
Cervical cancer 47 940
Lip oral cavity cancer 33 660
Colorectal cancer 25 500
Chronic respiratory diseases 5992 119840
COPD 3196 63920
Asthma 3174 63480
Digestive diseases 29790 595800
Cirrhosis 18632 372640
Gallbladder and biliary disorders 2794 55880
Mental disorders 12786 255720
Depressive disorders 3601 72020
Anxiety disorders 3200 64000
Bipolar disorders 381 7620
Alcohol use disorder 1342 26840
Neurological disorders 34335 686700
Headache disorders 33820 676400
Idiopathic Epilepsy 404 8080
Alzheimer’s disease 318 6360
Diabetes and kidney diseases 14385 287700
Diabetes 7765 155300
Chronic Kidney Disease 8954 179080
Musculoskeletal disorders 17891 357820
Low back pain 5270 105400
Osteoarthritis 4899 97980
INJURIES
Self-harm and interpersonal violence 4601 92020
Unintentional injuries 12244 244880
Falls 6927 138540
Road injuries 6658 133160
Elderly heath care needs
Cardiovascular diseases (CVDs) among older adults age 60+yrs 35%** 80500
Diabetes mellitus among older adults age 60+yrs 19.10%** 43930
Anaemia among older adults age 60+yrs 10.20%** 23460
* The estimates are derived from India State-Level Disease Burden Initiative as part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 that use various data sources
and robust statistical modelling and hence may not reflect the estimates of individual studies
# Using Birth rate 17.2/1000 for Karnataka from Vital Statistics Division, Office of the Registrar General, India, Ministry of Home Affairs, Govt. of India. SRS Bulletin (2020).
** Longitudinal Ageing Study in India (LASI) Wave 1, 2017-18, India Report, International Institute for Population Sciences, Mumbai 2020. An estimated 11.5% of total population was used for 60+ in
Karnataka from Report of the Technical Group on Population Projections 2019 by National Commission on Population Ministry of Health & Family Welfare, Government of India.

29
Focussing on a district, and developing that as a hub is more feasible, sustainable and economical in
of implementation activities for completeness, the long run at a district level.
coverage and quality is achievable and advantageous
• Information systems can be better managed and
as it helps in improving health of local populations.
supervised in a district level to data managed
• A district is the administrative nucleus for all programmes as per local needs while state can
present and future growth and development provide guidelines, frameworks and directives.
activities with regard to health, education,
• The district and taluka population can be actively
welfare, transport and other areas.
engaged in health matters , also leading to
• Developing district programmes covering a innovative, people – driven and people – centric
population of approximately ~ 2.5 million is possible, programmes.
feasible, sustainable and manageable from an
• The burden of various health impacting
administrative viewpoint with decentralisation
conditions as shown in Table 5 indicate that
mechanisms.
district hospital and medical college hospital can
• A district provides the right opportunity and a serve as referral hospitals for the population
manageable population for implementation, with strengthening of facilities and required
monitoring and evaluation purposes. manpower and most health problems can be
effectively managed within a district.
• Many programmes implemented at the district
level and can bring convergence, integration and • Linkages with community medicine
improved coordination. With a good district departments and other health care and allied
management, programmes can be moved further medical schools can strengthen public health
to taluka areas for more focussed implementation. capacity, monitoring and evaluation through an
agreed framework.
• Each district has a wide network of health care
facilities, district hospital, medical colleges in • Establishing a strong public health surveillance
almost all (except 8) districts, private health care team in a district can address local epidemics,
providers, local NGOs, industries and educational disasters, communicable diseases, NCDs and
institutions and are led by the District Commissioner, injuries by further liasoning with state level
CEO – ZP, District Health officer and a District agencies and academic institutions.
Surgeon. Selective investment can be made by the
• Converting all sub enters to Health and wellness
state in focussed areas for improvement. Developing
centres in a district can effectively strengthen
intersectoral approaches which are scientific,
number of health promotion and wellness
sustainable and cost effective becomes easy in a
activities to defined populations with integration.
district based on good quality data.
• Some districts can be identified and centres of
• Capacity building and strengthening of district
excellence can be established in medical
officials from health, education, transport,
colleges subject to quality performance.
police, rural development, municipality, welfare
and others is possible and can lead to better • Regional specialised care centres in cardiology,
planning, implementation and monitoring nephrology, neurology, cancer care, trauma care
through intersectoral coordination mechanisms. can be established and developed for 4 – 5
neighbouring districts.
• All district training centres can plan and implement
human resource development activities as per their • Most significantly, implementation, monitoring,
needs and at their times with coordination from state. surveillance and evaluation become easy to
Local medical colleges can provide support through implement at a district level and brings in
agreed upon frameworks. convergence and coordination of activities.
• Each medical college can be given the • Greater CSR funds can be mobilised for
responsibility of providing care and services in 3 programmes and services in a district for
primary health centre areas (as per earlier practice general or focussed activities
subject to overcoming administrative barriers)
For example, NIMHANS Bengaluru, developed the
• Optimization and sharing of health manpower District Mental Health Programme in Bellary district
(through integrated training programmes for Karnataka in 1984 which paved the way for National
health personnel) brings greater benefits and can Mental Health Programme in all 700 districts and
avoid duplication of activities. With decentralization state wide DMHP (implemented in all districts) by
of activities, personnel can be trained together on 2020(33).The District Road safety and injury
health matters and programmes. ( eg., health and Prevention programme in Tumkur in 2014 district
education , health and welfare, etc.,) programmes, demonstrated the feasibility of road safety in an
organizational structures and integration, Indian district(34).The Yuvaspandana programme of
Karnataka for youth mental health promotion by
• The possibility of implementing existing rules
GOk and NIMHANS has got expanded to all 30
and regulations (in health and different sectors)
districts of the state by 2021(35).
30
The state has major responsibilities of coordinating channels, building strong surveillance division,
and funding all activities based on administrative ensuring drugs and logistical supplies, advocacy
and regulatory frameworks. To build robust district and awareness, developing set of monitoring
health programmes, there is need to invest in indicators and mobilising communities for action
developing annual action plans, capacity building of along with greater autonomy. Implementing
programme officers, training all categories of health interventions, integration, investments and
staff, filling up all required posts, investment in innovations are possible and sustainable in a district
other resources, strengthening implementation

12. Health Human Resource Planning, Development

and Strengthening

1. A Health Human Resource Development manpower and funding along with external
Policy should be developed for the state-by technical support from leading state level
the state with a focus on structuring - academic institutions for redefining the scope
augmenting – rationalizing - distribution and of on-going training in different domains of
efficient utilization of manpower in different public health for better implementation of national
geographical areas, in diverse disciplines, in health programmes through an annual training
emerging health priorities by active plan to develop efficient health managers.
participation of public and private sectors.
6. Capacity building programmes for all senior
2. Manpower Study of Health Human Resource and midlevel officials should be undertaken
(HHR) in the State of Karnataka is urgently by SIFHW, public health institutions and
required to (i) determine the existing departments in the state to sensitize and
workforce of all categories of Health Care orient them in scientific and evidence based
Professionals in Government, Public Sector health planning- management- implementation
Undertakings (PSUs), Private sector and – monitoring and evaluation through short term
medical and health universities and (ii) programmes of 1 to 2 weeks.
quantify the gap between current
7. District wise resource mapping of health care
requirements and availability of different
institutions and human resources along with
categories of health professionals and
needs assessment should be undertaken to
workers by a systematic gap analysis study.
identify vacant positions and projected needs
3. Establishment of a quality monitoring and for district health management and measures
enhancement cell in the state government is have to be taken to fill all vacant positions on
an absolute requirement in view of the a year to year basis .
increasing number of health education
8. Adoption of three primary health care centres
institutions, the number of courses started in
by each medical college should be
both medical, dental, nursing, pharmacy,
re-examined for its merits for its
Physiotherapy and allied professional areas,
implementation in the state as it has the
increasing number of admissions, correcting
advantages training and teaching
the imbalance in post-graduate and
opportunities along with availability of
undergraduate courses, avenues for
medical graduates in rural areas.
improving quality – standards – accreditation
across all existing courses, consideration of 9. Pilot demonstration project under the
the job opportunities and promotional leadership of RGUHS should be undertaken
avenues, and others. urgently in a district (with a good mix of urban
and rural population) to demonstrate the
4. The State Directorate of Health should be
feasibility and effectiveness of integrated
reorganized keeping in view the increasing
human resource development based on a real
burden of NCDs and injuries for better
time needs assessment study.
implementation of programmes with
well-defined roles and responsibilities to create 10. Universities to be encouraged to come
a public health and a clinical cadre based on together with RGUHS to identify future human
recommendations of Halagi Committee report requirements in upcoming areas (e.g.,
and discussions with concerned stake holders. tele-medicine, geriatric care, specialties in
Nursing (Eg. ICU Care), dialysis technicians
5. State Institute of Health and Family Welfare
/nurses, dental chair assistants, etc) to
and the 4 regional health and family welfare
design – implement short term (ranging from
training centres should be supported with
1 – 6 months) courses.

31
 Capacity strengthening of Policy
makers/Decision makers
Capacity building involves ensuring that a
combination of staff and support systems along
with required tools and skills are available and
functional and building the capacity of policy
makers/ programme managers/ administrators/
grass root level healthcare workers and
communities in their required areas is a critical
requirement for an effective and robust health
system. Institutional capacity building requires a
wide variety of roles to be performed by institutions
to catalyse different stakeholders, building
technical support, establishing think tanks,
developing observatories, strengthening
managerial capacity, harmonizing policies and
“Health Human Resources” (HHR) is the foundation linking activities to different action areas, both
of health systems and is the backbone of health within and outside the health sector. In Karnataka,
care delivery. A well performing health workforce is very few programmes are undertaken for senior
one, where a fully equipped workforce is available, health managers and decision makers in public
has the right mix, skilled and competent, health areas and are usually Master Trainer
responsive and productive , capable of responding programmes. This vacuum needs to be bridged by
to all health needs of populations as well as engaging with national and state institutions in the
managing dynamic situations(36). Real time state.
assessments and evidence-based approaches
should lay the foundations for developing a Public Health Human Resources
well-equipped health workforce.
The state does not have - a clearly defined HHR
Based on the review of current scenario, policy covering public health, clinical care and
recommendations of the public health and health medical and allied education; coordinating units and
systems subcommittee, report of the Health HR mechanisms that can direct HR policy and
subcommittee on Planning, Development and programmes; balanced distribution of manpower
Strengthening with regard to manpower, education development process in public and private sector; a
and training of Medical, Dental, Nursing, Pharmacy, dedicated public health cadre; capacity
Physiotherapy and allied profession, micro study of strengthening programmes for decision makers
human resource availability in Kolar District, and policy makers; integrated and shared
observations made with regard to human approaches due to verticalisation of programmes;
resources made by all subcommittees, it is specified matrix in availability of specific and
observed that there is a major gap in defining health specialised manpower across districts; equal
work force requirements , quality output in both deployment of staff ; short term integrated public
health and medical education sectors and to health programmes in health and medical
develop the required manpower ; both in quantity education sectors, and most importantly, any
and quality. well-defined monitoring and evaluation activities.
This scenario is unlikely to change, if proper and
Human resources in health are of a wide variety in
scientific mechanisms are not put in place on a war
nature, ranging from administrators to gross root
footing and actions are not initiated by the state
level workers: all need to be skilled, competent and
department.
committed in their respective tasks. Broadly, they
can be categorized under the headings of (i)
administrators - policy makers and decision
makers, (ii) Public health workforce for delivery of
health services, (iii) medical categories and
specialists to provide clinical services (iv) medical
and allied education and (vi) well informed and
empowered institutions. Interestingly, recent years
have witnessed growth and development of
specialty clinical services, while many others have
lagged behind. The current state workforce is of a
diverse nature in both public and private sectors.

32
Deficiencies as well as maldistribution of human • Introspection on HR situation in Karnataka with
resource personnel in public health services and data available from DoHFW, GoK during end of
medical education sectors are glaring and June 2021 informs the deficiencies in the health
visible(36, 37). Notable to mention is the deficiency sector (annexure 4). In the State of Karnataka,
among peripheral health workers, general doctors, there are 40,744 ASHA workers, 3214 health
specialists in district and taluka hospitals and workers male, 6543 health workers female, 156
support staff in laboratories and radiology centres. programme officers, 6838 nurses, 1886
In addition to generating the required human pharmacists, 1840 lab technicians,228
resources, retaining different categories of workers physicians, 237 surgeons, 477 OBG specialists,
in healthcare institutions essentially requires 375 paediatricians, 289 dentists, 462
building a strong motivation to work, dedication, radiologists, 1127 other specialists, working in
commitment to patient care, ethics, ensuring the public sector(11, 38). Crucial to note that
adequate service standards, financial parity, wide disparities exist in their distribution and
in-service training programs as well as availability across and within districts as well as
promotional and career opportunities overtime ; all deficiencies in availability of these personnel in
these have been contentious and unresolved each of the districts and Talukas.
problems even today.
• The State Institute of Health and Family Welfare,
In the report entitled " Human resources for Health four regional health and family welfare training
in District Public Health Systems of India: state wise centers, district training institutions (19/30) and
Report 2020" (data with reference to 2019 as per a dedicated Karnataka state health research
IPHS guidelines) by the National Health Service and training center undertake a wide range of
Resource Centre of the MOH, GOI, it is observed that training programmes for different categories of
- a strong human resource policy and the health personnel at state and district levels for
implementation of a human resource information varying durations, in both general and specific
system for estimating the availability of a dedicated areas under various health programmes. Many
public health cadre to manage public health medical colleges, centers of excellence, apex
programs is lacking in the state (Figure 10); in tertiary institutions, NGOs conduct – facilitate
comparison of required versus sanctioned posts, a –participate in a wide variety of general and
deficit of 14% for ANMs, 33% for staff nurses, 32% for specific HR development programmes.
lab technicians, 17% for medical offices at MBBS
level, 22% for specialists and 5% for dentists has • The committee for reorganization of health
been reported. The overall vacancy including the services in Karnataka, popularly known as
regular and the contractual posts was lower with Halagi Committee report strongly
deficiency in the availability of specialists at 38%, recommended the creation of public health
ANMs at 30%, nurses at 11%, medical officers of cadre and clinical cadre along with internal
MBBS at 10%, laboratory technicians at 13% and reorganization measures as well as clear
dentists at 22%.The situation in urban health care guidelines for proper staffing as per
facilities is no different as huge deficiencies exist in needs(39).The findings of the committee are
all categories . However, this situation has changed under the consideration of state government for
in recent times due to COVID – 19 pandemic with 7 years.
appointment and filling up of certain specified posts
in district level and also in urban areas .

Figure 10 : Health Human Resource scenario in Karnataka

HRH Governance Required Vs Sanctioned Posts

Sanctioned Contractual
Specialist Cadre Required HR
Sanctioned Regular 5%
as per IPHS
Required

HR Policy 32% 22%

14%
33%
17%
Implementation of HRIS

HR Integration Initiated
69% 47% 81% 52% 79% 113%

Public Health Cadre ANM Staff Lab MO Specialist Dentist

Nurse tech MBBS

33
Management Training for Health professionals :
Need for multipronged approaches
It has been strongly recognized at all levels by Approach III: Management and Health
senior administrators and the experts that there Communication Training of Community leaders,
is a need to design and develop a mechanism Arogya Raksha Samithis, Zillah, Taluk and
for enhancing leadership and managerial skills Panchayat Samithis should be strengthened with
of Public Health Personnel. This will definitely core principles through short orientation courses.
contribute to working towards reaching goals of
SDG 3. Focus needs to be on Planning, Approach IV: Civil Surgeons, Deputy Civil
Budgeting, Programme delivery, Monitoring, Surgeons, Medical Superintendents of Taluk,
Evaluation, Information management and Sub Divisional Hospitals, District Hospitals,
utilization, Inter agency and interpersonal Municipal Hospitals of Urban areas , Medical
communication, reaching out to communities, Officers of PHCs should be encouraged to (and
Risk communication during Pandemic and sponsored) enroll for distance learning
disaster situations and other topics covered in Programmes offered by various agencies like
the public health and health systems section of PGDHHM (Post Graduate Diploma in Health and
this report. This is required to create a strong Hospital Management), Geriatric Care, MCH
health workforce in the state and at district (RCH), Certificate Course in Health Care Waste
levels. This needs to be enhanced in the existing Management Offered by Institutions like IGNOU,
system by following five approaches: Diploma in Health and Family Welfare Offered by
Institute of Health and Family Welfare GoI,
Approach I: The team of senior Programme Officers Diabetes care by PHFI and other short term
at state level, Management Experts from programmes. There are several institutions
IIM-Bangalore, Public health experts and State across the country that offers Health
Institute of Health and Family Welfare should management and leadership courses.
join hands and develop short capsules of:
Approach V: Efforts should be made to
• Fifteen day Induction Training of DH and FW encourage Medical Officers to pursue MPH
officers and District Surgeons, District courses or other short-term focused courses (
Programme Officers before being posted or in select areas) offered by RGUHS, NIMHANS,
at the time of their posting as DH and FW other Institutions and Universities before they
Officers/District Surgeons. are posted as Taluk Health Officers, District
Programme Officers, District Health and Family
• Fifteen day Induction training for Taluka Welfare Officers in a phased manner.
Health Officers.
The SIHFW and District Training Institutes (19)
• Two -month induction training of Medical should be strengthened and involved more in
Officers of PHCs, Senior Pharmacists, delivering training - collaborating with RGUHS -
Senior Nursing Staff, Nutrition Officers. Deemed Universities and Health Professional
Institutions across the State.
The current training curricula should be
reviewed by a team of public health Similar approaches should be examined for
professionals and mechanisms designed and health care disciplines and specialties to
developed, implemented and monitored within provide opportunities for skill and competency
the State at SIHFW/IIM-Bangalore/BMCRI/ building in district and taluka levels. This could
Divisional HQ at Mysore, Belgaum, Gulbarga/ be considered in need based areas considering
other locations deemed fit. all other factors of availability and need. For
example, doctors and nurses can be provided
Approach II: The Health management training training opportunities in specialized areas of
curricula of all Health Profession Institutions to cardiac, neuro, trauma and other vital areas.
be revisited, strengthened in Health
Professional Education –MPH, Medical, Dental, A committee should be set up to study these
Nursing, Pharmacy, Allied Health Profession, programmes, develop state specific programmes,
and other courses to bring a public health focus. implement in a time bound manner and monitor
the same in a scientific manner for its impact
and outcomes.

34
Highlights of the Halagi Commission report
The Halagi Commission was constituted by the 6. Development of a mandatory up gradation of the
Government of Karnataka in 2011 to recommend seniority list in both public health and medical
measures for reorganisation of the Department of cadres in the state including GDMOs,
Health and family welfare to strengthen healthcare specialists/senior medical officers, senior
delivery system in the state. The committee reviewed specialists/Deputy Chief medical officers and
several previous recommendations made by different other categories, and publication of this
committees from 2004 onwards, reviewed existing mandatory upgradation list on the department
legislation, rules and acts, held large number of website on an annual basis. A government order
brainstorming discussions with different officers in to this effect to be issued every year in the month
the Karnataka health cadre and examined the existing of February with regard to the same.
structure of the Department at district, taluka, 7. The committee recommended putting in
community health centres, primary health centres measures for promotion which should be in
and others. The need for reorganisation of the accordance with the feeder cadre and merit and
Department was felt to improve the quality of the as per norms for all specified posts. Promotions
delivery of healthcare services, amidst increasing to be strictly based on required qualifications and
workload of the staff of the health and family welfare experience and not just on seniority.
Department, role of institutions that were created in
the past, the nature of the emerging burden of 8. Three levels in the public health cadre at taluka,
noncommunicable diseases and injuries, increasing district and state-level to be created in the state.
number of programs and demands on the health The entry-level for a public health cadre should be
systems, the motivation and commitment level of the at the level of the taluka health officer and over
staff different levels and the need for better delivery time, people could be provided opportunity to
of services. The following recommendations were put move up the ladder.
forth by the committee in different areas for 9. In order to bridge the shortfall of qualified public
implementation. health professionals, it was recommended that
1. The establishment of a Public Health Directorate the government should conduct counselling in
is highly required to provide coordination, service state health services with immediate effect to
integration, monitoring, evaluation, data integration identify medical officers interested in pursuing
and technical supervision. Towards this, the public health cadre as well as to a public health
committee recommended that a position of qualification.
Director General of Public Health be created for 10. Training opportunities for all professionals
coordination and to provide leadership for efficient working as Deputy Directors, Joint Directors and
public health delivery system to ensure goals set programme officers from established public
under all different national health plans are met. health institutions either at national or state-level
2. A technical core group should be formed at the should be provided.
Commissionerate to act as a think tank consisting 11. Reorganisation of the State Institute of Health and
of different members drawn from diverse Family Welfare to be undertaken to develop this
disciplines to guide state health policy matters. as an apex Centre for excellence for training all
3. The state health services should have defined officials under health and family welfare services.
public health and medical care cadres to look 12. The committee also recommended examination of
after public health and clinical services at the functioning of the Health and Family Welfare
different levels. training centres in Mysore, Bangalore, Gulbarga
4. Divisional level officer’s to oversee functioning of and Hubli with additional roles and
the districts by creation of a district divisional responsibilities.
level officer of Additional Director grade with 13. Urgent reforms to be undertaken at the state drug
specific responsibilities and for coordination. In logistics society with the appointment of a
this direction, 4 regional Additional Directors in Regional Additional Director to oversee all
the districts of Gulbarga, Belgaum, Mysore and aspects of drug procurement, supply, distribution
Bangalore are to be created without incurring and logistics.
additional expenditure with specified roles and
responsibilities. 14. The committee also recommended restructuring
of several existing schemes of the Department
5. Director of Medical services should be appointed like plague control unit, leprosy control unit,
to oversee functioning of District Surgeon's, malaria control unit, TB hospitals, KFD and others.
taluka hospitals and CHCs and to look after the
different programmatic units of the Department at 15. Greater financial allocation and independence to
state and district levels. be given to district and taluka levels for speedy
implementation of programmes.

35
 Medical, Dental, Nursing, Pharmacy
Box 1: Micro-study of human resources in kolar and allied professional education
district
A Micro-study was undertaken in Kolara district to The subcommittee chaired by Dr. S.
map infrastructure and human resources during Sacchidanand, Former Vice Chancellor, Rajiv
April – May 2021. Data collected from the district Gandhi University of Health Sciences
administrations revealed that – (i) there was a (RGUHS), Bangalore, examined and reviewed
higher concentration of facilities in Kolar, the current manpower development scenario
Mulbagalu and Srinivasapura Talukas as along with quality standards in medical,
compared to other talukas, (ii) density of dental, nursing, pharmacy, physiotherapy and
allopathic doctors and nurses per lakh population allied health sciences in Karnataka.
in Kolar district was 37.6 and 53.8, (iii) the number
of Sub Centers ( less by 15%), Community Health
Centers (less by 88%) and Village Health
Box 2: Excerpts from National
Sanitation and Nutrition Committee (less by 18%)
Education Policy (2020)
in the district (suggestions from UHC, NHM and
NHP 2018)( table 1) were less as per ….…Healthcare education shall be
recommended norms, (iv) requirements with re-envisioned such that the duration,
regard to ASHA workers, Anganwadi workers, structure, and design of the
village rehabilitation workers and multipurpose educational programmes are as
rehabilitation workers were adequate (v) required for the roles that graduates
deficiencies in general and specialist manpower in will play. For example, every
public sector with greater availability of all healthcare process/intervention (e.g.,
categories of medical manpower in the private taking/reading an ECG) does not
sector (265 vs 666),(vi) services of specialized necessarily need a fully qualified
manpower from private sector is not easily doctor. All MBBS graduates must
available for services in public hospitals, even at possess (a) Medical skills, (b)
times like COVID – 19 pandemic, (vii) lesser Diagnostic skills, (c) Surgical skills,
numbers of nursing officers, pharmacists, and (d) Emergency skills. Students
laboratory technicians and female health will be assessed at regular intervals
assistants (viii) specialist category manpower ( on well-defined parameters primarily
specific to specialists manpower) for trauma care for the skills required for working in
was higher in private facilities, including primary care and in secondary
availability of visiting specialists from Bangalore, hospitals. Quality of nursing education
(ix) only 41% of the total doctor and 14% of the total will be improved; a national
nurses in emergency rooms were trained in accreditation body for nursing and
trauma life support, and (x) all the above indicating other sub-streams will be created.
poor planning of facilities and resources in the Given that our people exercise
district. The deficiencies in specialist manpower pluralistic choices in healthcare, our
services in public sector results in patients healthcare education system must be
seeking care in private facilities despite the integrative: this would mean,
presence of several good programmes and illustratively, that all students of
services in the district. allopathic medical education must
have a basic understanding of
This scenario is likely to be different in different
Ayurveda, Yoga and Naturopathy,
districts of Karnataka. Only a systematic
Unani, Siddha, and Homeopathy
assessment will enable us to develop required
(AYUSH), and vice versa. There shall
manpower in different categories for public health
also be a much greater emphasis on
services and clinical care services and calls for an
preventive healthcare and community
assessment in all the districts based on work load
medicine in all of healthcare
to rationalize facilities and human resources. A
education(19)
complete resource mapping of facilities and
human resources in a district will help in
organizing health care and referral services in the
district. Furthermore, such a mapping will help the
district administration to organise human
resources at times of epidemics, pandemics and
disaster situations.

36
• Despite the growth of educational institutions in departments of medical colleges has been
the state, (i) the number and type of health and experienced affecting quality of teaching and
allied professionals required and available on training.
an annual basis for the state of Karnataka is not
clearly known and, (ii) manpower requirements RGUHS in Bangalore, established in 1986, is
for health sector in urban and rural areas, affiliated to nearly 168 institutions from medical,
public and private establishments, primary and dental, nursing, pharmacy, physiotherapy, Ayush
tertiary care, established and emerging health and other courses (www. https://www.rguhs.ac.in).
priorities and for implementation of number of Total number of students admitted to UG & PG
national health programmes has not been courses in different institutions affiliated to RGUHS
undertaken (filling up of posts is based on during academic year 2019-20 was 56,048
programme requirements) ; primarily due to (Admission data). In addition, the state has 9
lack of research and policy directives in the Deemed to be Universities, 2 private universities
state. In recent times, an acute paucity of trained and 2 institutions of National importance
medical teachers in pre and para clinical (NIMHANS, AIISH, Mysore).

Table 6: Increase in number of seats in 2014 and 2020 with respect to Medical courses

2014 2020 %

Medical colleges 381 539 Increase by 45%

UG seats 54,348 80,312 Increase by 48%

PG seats 23,903 54,094 Increase by 79%

DNB / FNB 4845 8394 Increase by 73%

• Based on policy initiatives of central and state uptake has increased from 4845 in 2014 to 8394
government, India has witnessed an increase in by 2020 , registering an increase by 75 % to fill
medical colleges by 45 % during 2014 – 20 with a the gap of specialists in health care. (Table 6 and
corresponding increase in student intake in both Table 14 of the detailed report of Health HR
undergraduate and post graduate courses subcommittee on Planning, Development and
(Table 7). With introduction of DNB courses, the Strengthening).

Table 7: Number of Institutions in Government & Private sector conducting UG (undergraduate)

Courses during 2019-20

Faculty Total Govt Pvt Institutions Institutions Institutions Paramedi Total

number of Institutions Institutions under under Pvt under cal Board,
institutions Deemed to Universities NIMHANS GoK
affiliated to be (Diploma
RGUHS Universities courses)
Medical 56 19 37 8 64
Dental 37 2 35 7 1 45
Nursing 429 15 414 7 1 765(18)* 437+765
=1202
Physiotherapy 80 2 78 7 1 88
Pharmacy 88 1 87 6 1 95
Allied Health 124 13 111 7 1 565(34)@ 132+565
Sciences =702

* Diploma courses; @ Certificate courses; Numbers in Parenthesis indicate Government institutions.

37
Table 8: Number of Institutions Government & Private conducting Postgraduate Courses
Faculty-wise during 2019-20

Faculty Total Govt Pvt Constituent Constituent Constituent Total

number of Institutions Institutions Institutions Institutions Institutions
institutions of Deemed of Pvt of
affiliated to Universities Universities NIMHANS
RGUHS (Pvt) (Pvt)
Medical 46 18 28 7 1 54
Dental 36 1 35 7 1 44
Nursing 196 6 190 7 1 204
Physiotherapy 31 0 31 7 1 39
Pharmacy 56 1 55 6 1 63
Allied Health 26 1 25 1 27
Sciences
Fellowship 124 48 76 35 3 2 164
Courses

(Data source : Data Collection by structured format through email March/April 2021 by the Subcommittee from RGUHS, Deemed to be Universities,
Private Universities, NIMHANS)

In total, the state of Karnataka has nearly 700 o In addition, some medical colleges and tertiary
institutions that generate human resources in care centres also provide super speciality
undergraduate medical courses covering medical, training ( DM courses) in specialised areas like
dental, nursing, physiotherapy, pharmacy and Allied cardiology, neurology, emergency medicine,
health sciences from a wide variety of institutions. child mental health, Geriatric mental health and
Similarly, there are 164 institutions covering these others. Total number of super specialists
diverse areas offering postgraduate medical graduating from within the state may be smaller
courses. In 2019 – 20, 49112 undergraduate and 6936 numbers and not be a real reflection of actual
post graduate students passed out from RGUHS, available numbers.
apart from 6936 students in other institutions.
o There are nearly 7000 Aush practitioners of
o DNB courses were started in Government varying types AYUSH doctors graduating from
district and general hospitals of the state in 100 + colleges every year. In recent times Ayush
2016-17 to bridge the gap in specialist positions doctors are also employed in Government
by providing opportunities in public and private healthcare facilities to provide preventive
sectors and make them available under bond promotive healthcare services.
Scheme. Totally 7 specialties are accredited
with 19 hospitals for DNB courses with 8 o A number of healthcare institutions belonging
accredited in the 12 district along with 2 general to both Central and State governments as well
hospitals at KC General Hospital - Jayanagar as medical colleges offer in-service training
General Hosptial in Banagalore. It is gratifying to programs to wide variety of professionals in
note that 5 taluka hospitals in Holenarasipura, specialised areas (eg., NIMHANS in mental
Doddaballapura, Sira, Basavakalyana, health, AIISH in speech language disorders, NTI
Gangavathi have also started the course. in Tuberculosis and others).
Number of seats accredited as on 2020-21 are o Many professional bodies also conduct
108 (Primary 63 and Secondary 45) spread over manpower development programmes and
34 courses with an annual intake of 158 in-service training programmes in the state (
candidates(Primary 121 and Secondary 37) (for eg., society of hospital administrators)
three years) with a pass rate of 8/12 ( 66%)in
year 2020. Number of courses in various stages o A paramedical board established by the
of accreditation is 15 as on 2021. government also offers Diploma in Nursing
course in 765 institutions(18 government) and
certificate courses in 565 (34)courses across
the state.

38
Challenges in the Current Scenario • Especially during COVID -1 9 times, telemedicine
and tele teaching have come to the forefront
• Overtime, several questions have risen with with a mix of formal and informal programmes
regard to the quality of medical education in and found useful. National Digital Academy of
terms of the graduate’s preparedness to deliver NIMHANS offers a variety of Diploma and
primary and secondary care services in rural Certificate courses in the field of mental health
and community settings. Many concerns with as per approved standards. There is need to
regard to teaching methods, curriculum, bring strict regulations into such courses to
availability of qualified medical teachers, quality maintain quality of education as similar
improvement have been expressed by several programmes are being started in other centers
committees and in anecdotal media reports. and in other disciplines.
• Karnataka has highest number of medical State Initiated Responses
colleges in the country (60 in 31 districts) at the
rate of two colleges per district with an annual Acknowledging the paucity of health human
output of 49112 from RGUHS affiliated Government resources in the state, successive governments
and Private Medical Colleges every year. Based on have initiated several proactive measures in
the analysis made by the subcommittee towards collaboration with number of state agencies,
the availability of graduating students for services academic institutions, internal and external
in Karnataka based on a few assumptions, it is agencies Major changes have been implemented
estimated that 750 to 1000 MBBS doctors and with regard to recruitment, distribution,
1-2000 nursing graduates are available every promotions, salary structures, special allowances,
year in the state ( after excluding all those transfer policy, on the job training, capacity building,
mentioned above). Similar calculations for other introduction Health Resource Management
categories are required to understand Information System (HRMIS) and several others.
availability of manpower in different areas. The Karnataka Private Medical Establishment
Act(42) came into effect along with mandatory
• Physiotherapy (nearly 90 colleges), nursing ( registration and monitoring of private medical
700 schools), pharmacy and dental colleges (36) establishments to share relevant information on
and courses need strengthening in several manpower infrastructure in the private sector.
years. The timing of starting these courses,
course contents, quality of teaching, Two recent developments are worth highlighting at
accreditation of these colleges and regulatory this stage and requires further follow-up over time
mechanisms of these institutions need a closer to see its impact on public health system in the state.
examination and setting standards. Recently the
• Firstly, in view of HR deficiencies observed
National Commission for Allied and Healthcare
during COVID 19 times, the state DHFW has
Professions Act has been passed in the
appointed 1700 doctors, including specialists
Parliament in March 2021(41) and further
into state services (it is learnt that these are
measures are awaited towards implementation,
permanent positions) along with large number
• In addition, there is also a greater need to of nurses, technicians, and others (nearing 4000
developing need based human resources in in number) in 2021.
emerging areas of NCD care, elderly care,
• Secondly, it is learnt from reliable sources that
chronic care, disaster and pandemic
the state department is in the final stages of
management, disabilities, health informatics
reorganizing the DoHFW with the introduction of
and other areas along with creating job
“Public health cadre and clinical cadre” in health
opportunities. A felt need has been expressed
systems along with associated and additional
by many health care providers and technology
changes in recruitment, promotions, cadre
specialists to employ a variety of trained and
strengthening, roles and responsibilities at
skilled categories of health personnel like -
state and district levels; indeed, a long-felt need.
nursing aides, data information personnel,
instrumentation usage technicians, NCD As per the world Development Report of 1993
counselors, geriatric care givers, psychologists, entitled “Investment in Health“, good health
telemedicine technicians, technical people in increases the economic productivity of individuals
radiology – anaesthesia - cardiology - critical and the economic growth of country; undoubtedly,
care - dialysis operations and other areas, good health is a goal in itself (43). For this to be
rehabilitation personnel, dental assistants, achieved, it is important that an investment in
personnel for disaster management, pandemic health systems and health resources, especially
management, disabilities and other areas in health human resources is one of the fundamental
both urban and rural areas to support health requirements. Human resources should be
care in hospitals and community as well as to adequate, efficient, and capable of delivering quality
strengthen technology applications on a services.
regular basis.

39
Box 3: Emerging role of Health Learning Universities in the New Decade
Traditionally and for too long, health universities and medical colleges have played a major role
in bringing out hundreds of students in different disciplines; all get a degree and a certificate that
helps them in procuring a job or starting on their own – for some, in the country, and for others
outside. Medical and allied science students during their course are taught by faculty in a subject,
equipping them with knowledge and some skills. In recent years, a lot of concern has been raised
on their preparedness to be health managers for populations they are intended to serve. Many
educationists and policy directives like National Health Policy, National Education Policy 2020,
Universal Health Coverage and others emphasize the need for a new breed of health and allied
sector graduates to be health managers to meet the emerging needs of the state and country. In
this new and emerging scenario, it is crucial to introspect and build a new vision for health
learning universities and institutions.

• Fundamentally, students – teachers – • Apart from teaching by dedicated faculty,

administrators – policy makers need to Officers in Public Health – public health
communicate, coordinate and converge in experts – community leaders – health
their goals and skill building process that entrepreneurs should be engaged for
are essential in education along with life orientation and knowledge sharing about
skills, empathy and value systems. existing and emerging health scenarios as
part of regular teaching.
• Developing a new breed of leaders,
champions and mangers for health care • Preparing students to volunteer during
who understand broader public health emergencies and bring a sense of
principles and practices, and health care volunteerism in all areas of health acre
needs should be an essential goal of regularly, and not just during disasters/
health universities Pandemics/Emergencies.
• There is need for proactive role by Health • Adoption of Villages, urban wards by
Professional Institutions and Public Health institutions / Public Health system for
System to work together towards teaching and training students and faculty
generating human resources for is possible in several areas ( eg., RCH,
comprehensive health care of the Immunization, Health and Wellness Centre
communities. Preparing and equipping activities, Investigation, mitigation of
students for this, requires a new way of outbreaks, trauma care and emergencies
teaching and training. and others) and can be examined.
• Health Professional Universities and • Working in talukas and district hospitals
Institutions need to expand their vision during student days will be a good
towards orienting students on UHC, opportunity for students to learn about
National Health Policy, Primary Health culture, life styles, health issues and
Care, National Health Programmes, concerns and other aspects and
Disaster preparedness, mitigation, opportunities to be created by universities.
disability rehabilitation and other
contemporary topics. • The need for interdisciplinary research is
greater today and collaborative research
• Opportunities should be created for between diverse areas (health and
students to work in talukas, district technology, health and urbanization, health
hospitals and in villages and slums and determinants, etc.,) should be promoted by
communities during student days to learn universities.
about culture, life styles, health issues and
concerns and other aspects to develop
empathy, values and equity issues.

Health Professional Institutions and Health Professional Universities have the opportunities to
demonstrate leadership in strengthening/developing/evolving medical and allied education to
develop health managers and this opportunity should not be missed.

40
13. Health Information Systems
mobile phones across different levels of health
Accelerating e-Hospital on cloud in all public care). In addition, repeat surveys to identify / update
health facilities (ii) Developing an integrated beneficiaries are done under 12 different programs/
dashboard of all programs at the state, district schemes: CNAA, ICDS, RCH, NVBDCP, NPPCF, NCD,
and sub-district levels ,(iii) Short term RNTCP, NLEP, NMHP, NPPCD, NIDDCP, NFHS, etc.,
orientation program for data analytics for
Not surprisingly, recognising the duplication of data
program managers, (iv) Formulating and
collection in the government sector by the
piloting a district integrated Health Information departments of Health and Women and Child
System and (v) Establishing a State level Task Welfare (WCD), and challenges in reconciling the
group to envision the federated architecture two datasets, Government of Karnataka initiated
for HIS in Karnataka are some measures to be e-sameekse, (Comprehensive Family Health
implemented in the state. Survey) a combined data collection endeavour by
the two departments of Health and Child welfare.
HMIS data is widely used by States in preparing
The National Health Policy, 2017, underscores the Program Implementation Plans (PIPs) under NHM.
importance of a robust Health Information System Indicators from HMIS (like Institutional Deliveries, C
(HIS)(18), to record information on disease / health - Section deliveries, Immunization, IPD, OPD,
events and also about the quality of services Surgeries, etc.) are used to evaluate the performance
rendered. Data generated needs to be of good of the individual states during National Programme
quality, relevant and timely. With a focus on Coordination Committee (NPCC) meetings. With
Universal Health Coverage, HMIS should aim to increased funding, introduction of new programmes
reduce inequity and the catastrophic costs for and strategies, the PIP process has been made
health care. With digitisation of data and online with effect from 2020-21. HMIS data is also
computerisation of health events on the ‘mobiles used to prepare the state Annual report of the
and smart phones’, patient care, surveillance, health department. The general and schema flow of
monitoring, evaluation and research have got information is from subcentre upwards. Beginning
increasingly integrated; also disjointed in some 2019-20, NIC HMIS has shifted focus from monthly
areas. A big ounce of caution is that ‘big data’ and summary to daily summary data entry from
‘digitalization’ does not automatically mean better individual PHCs and other health facilities.
patient care3 or improvement in health systems. “,
far too often, health decision-makers at all levels B. Challenges in the current system
lack tools and approaches to act on existing health
data (44)”. Health data generation challenges are observed at
all levels and all interfaces of data collection. Two
A. Current systems in public health generic challenges are: (i) Computerisation v/s
Digitisation (ii) complexities and difficulties in
The Demography and Evaluation cell created in the health system analysis.
DoHFW is the entrusted entity responsible for HMIS
in Karnataka. The NRHM-HMIS (Health The process of computerisation in several instances,
Management Information System)(45) web portal like scanning and uploading filled up formats make
launched on 21st October 2008 is envisaged as a digitisation of data untenable. Secondly, inadequate
"Single Window" Government to Government (G2G) training in health information sciences and health
web-based Management Information System to staff who did not comprehend the need for
monitor the NHM and other Health programmes of structured data flow, result in Computerised HMIS
the MoHFW, GoI. The physical progress of health being unwieldy and unfriendly for use.
programmes in general, and RCH programmes in
particular, are captured from around 12,593 health Hesitancy in use of electronic devices for data entry,
institutions on the HMIS web portal. Based on the inadequate training, incorrect or missing entries,
infrastructure availability and services being problems related to device and its maintenance
provided, the performance of health facilities is (poor battery life, low specifications, no repair or
graded. It is acknowledged that private sector replacements, poor after sales service, etc.,),
participation is minimal(46) : several challenges nature of the population, demographics and
have been identified for its involvement. characteristics (migrants, homeless persons,
perceived stigma, vulnerability), huge turnover,
In addition to HMIS several programs have their acute shortage and vacancies of staff, etc., are key
own information systems, which are stand alone for challenges for ensuring good quality data. Recently,
individual programs (NIKSHAY for TB; IDSP for non-payment of incentives has resulted in failing to
Communicable Diseases, etc.,108 call centre, 104 capture even the basic data needed under some
call centre; the NPCDCS program application quite a programs. The design of the software and
complex one supports data entry on tablets and

41
applications often for administrative and legal 4) The District Mental Health Program under
reasons do not permit data comparison and thus Innovation of NHM has developed a data
the problems of irreconcilable data continue to visualisation for the Mental health program
plague the system. A key issue of concern, review and dashboard in collaboration with
especially at the sub-district levels is the weak NIMHANS and IIITB. The dashboards are
monitoring and scrutiny of data, whilst data is available at every level of data entry and help to
progressively transmitted upwards without review review progress made and take corrective
or interpretation at local levels / contexts. actions.
Duplication of data collection often leads to
different set of results, pointing towards the 5) The Bruhat Bengaluru Mahanagara Palike has
felt-need for developing and maintaining a undertaken several initiatives which include:
federated system of structured health databases. a. Public Health Information and Epidemiological
Stand-alone and adhoc data collection “programs”, Cell collecting health related data of both
silo and incompatible databases are making the Communicable and Non-communicable
available information redundant. Another diseases prevailing in Bangalore city limits,
dimension to this issue is the small to large scale from both Government and Private sector
pilot projects which do not sustain beyond the health institutions, on-line through
period of MoU posing difficulties to evolve systems. web-enabled, pre-designed & pre-tested
Additionally legacy softwares and non-standard formats and issues health alerts to local health
database outputs pose challenges for authorities for remedial actions and
inter-operability and or porting. Thus, the need for a interventions ; endemic/epidemic disease prone
vision and mission at the state level for better areas and vulnerable population can be easily
utilisation of data and information has been realised identified and mapped out within Bangalore city.
and efforts needs to be accelerated to kick-start b. Vulnerability Assessment software "Namma
this initiative. Samudaya-BBMP" in slums and Housing and
Residential Associations
C. Developments in the state
c. Comprehensive Community Based Assessment
Proof of concepts which laid the ground for Checklist (CBAC) Format for NCDs
computerised HMIS in the state include:
1) Primary Health Centre (PHC) Management Building on the experience of establishing the
Information System (MIS): During 2017-18, at Digital Nerve Centre (DiNC) within the District
primary level, Karnataka state initiated the of Kolar with support from Tata Trusts, a
Primary Health Centre (PHC) Management similar effort has been made in the district of
Information System (MIS), using digital tablets Tumkur. The patient care co-ordinator (addon
in select PHCs across the state. This was helpful
human resource) in each facility liaisons and
in centrally consolidating information such as
patient treatment, delivery details, disease enables the patient access to information about
report and drug availability along with GPS services and facilities. The multi-pronged
information. Despite it duplicating the approach termed as “primary health care
NHM-HMIS, this proved as a good starter for transformation”, includes call-centre services
setting the agenda for computerised HMIS on a (for appointment, followup reminders, etc.,)
daily basis. Currently it is not operational. and tele-consultations (referral, etc.,) which
gets integrated with the existing public health
2) Integrated Dashboard: The Single Integrated facilities across the district (Report by
Dash Board using the GPMS Transportal for IIIT-Dharwad)
Universal Healthcare of Indian CST facilitated
real time data capture at source and
aggregation at institutional, District and State
levels of all existing 21 software applications for D. Building capacity for data analytics
Policy interventions based on data. and utilisation
3) The e-Hospital@NIC application is the Hospital Poor quality data often restrains any further analysis
Management Information System (HMIS) for and if data is subjected to newer data visualisation
internal workflows and processes of hospitals and analytical techniques it could give better
as a one-stop solution to connect patients, results as witnessed in the mental health program.
hospitals and doctors on a single digital
platform. The e-Hospital application is being Formal sensitisation of program managers at
offered as an as-is product to the government district level in techniques of program review and
hospitals across the country through SaaS management, Involvement of medical colleges for
(Software as a service) model and eHospital on third party audit along with structured short term
cloud is operational in nearly 201 institutions courses in Information sciences would enhance
(District and sub-district hospitals) across good quality data
Karnataka.
42
E. Creating the nucleus for HIS Nothing can be done in public health without
surveillance: that is where public health begins.
The future HIS in Karnataka needs to develop Surveillance is an important tool in public health
architecture for real-time and event-related data that helps in systematically defining public health
entry, cutting across different facilities and makes problems, collect and compile data report on the
health information patient-centric rather than problem and its associated factors , analyse and
program-centric. Adequate and appropriate interpret these data to provide solutions and
budgetary allocation (factoring technology provide this information to policymakers/
obsolescence) should lead on to build a strong IT decision-makers to take appropriate actions and
team within the Health Department. That the Vision monitor the usefulness and quality of surveillance
2035 for Public Health Surveillance in India has to improve it for future use ( Figure 11). In essence,
been articulated is indeed a welcome surveillance is collecting small quantities of good
opportunity(46).Five themes for way forward are – quality data for action and moves beyond routine
(i) Uncluttering chaos, (ii) Life cycle strategy for field visits, reporting and monitoring. Most
case management , (iii) 360degree clinical decision significantly, surveillance empowers
support, (iv)Village to Vidhana Soudha, and (v) decision-makers and key stakeholders to lead and
Evidence Based Medicine and Evidence Based manage problems more effectively based on
Public Health. The urgent need is to dedicate a team evidence.
at the District level: Integrated District Program
Management Unit and develop and integrated
program dashboard. Several related posts have
been approved under the RoP for Karnataka for Community Surveillance
2021-22 which need to be brought under a single Facility Centre
umbrella at the district level for integrated outcome. Health system

Analysis, Interpretation
Reporting

14. Public Health Surveillance Event Data

Planning, Evaluation,
Policy Formulation
Action Information
• A robust state-level institutional Feedback
mechanism for timely dissemination of Recommendations
information to key stakeholders should be
established in DoHFW.
• The scope of surveillance should extend
beyond communicable diseases to include Figure 11: Public Health Surveillance
noncommunicable diseases and injuries in
the next 2 to 3 years with state and district
Integrated Disease Surveillance Programme (IDSP)
level integration.
with a focus on communicable diseases is
• Building a skilled and trained health operational in Karnataka since 2005 (47).It's a
workforce dedicated to surveillance decentralised program for initiating effective public
activities should be undertaken through health action at district and state levels. The
capacity building exercises with each programme has been strengthened overtime with
district team having a team of surveillance more than 90% of districts collecting weekly data
managers. and analysis at district and state-level. Surveillance
program is adequately supported through a strong
• Norms and standards for uniform and laboratory network at districts and in medical
regular monitoring needs to be clearly colleges to confirm disease outbreaks with data
established along with generating captured from the village level for 33 disease
performance indicators to measure the conditions.
quality of surveillance.
• Public health surveillance should be
strengthened at the district level through
" The greatest medicine
citizen centric and community-based
surveillance activities.
of all is to teach people
how not to need it"
- Hippocrates

43
The scope of surveillance in Karnataka needs to be
expanded to cover more diseases of public health 15. Monitoring
importance like NCDs and risk factors, road traffic
injuries, suicide attempts and several others. Initial
demonstration projects have shown the feasibility • The institutional capacity at the state level
and possibility of establishing surveillance in these needs to be accelerated with a strong
areas in select districts of Karnataka. monitoring framework using set of core
Despite the progress made, IDSP has major indicators and clearly defined process,
limitations with regard to data quality, timeliness rules and responsibilities along with
and sensitivity due to system level factors resulting coordination mechanisms.
in no action or limited action. Digital technology, though • All programs implemented should be
used to some extent has scope for further applications. monitored at the district level with a set of
simple program indicators for appropriate
decision-making and periodic assessment
Box 4: Epidemiology …. The science behind of program performance.
policies and programmes
The most significant public health
achievements of the 20th century are built on Monitoring is the routine and continuous tracking of
epidemiology. Epidemiology (the science of implementation and overall performance of a plan
public health) provided the foundational or a programme(50).It is essential to undertake
knowledge to measure the disease burden and monitoring so that problems are identified on a
changes in outcomes over time. Epidemiology continuous basis. Monitoring is different from
identifies the distribution of diseases, factors surveillance or reporting. Information collected
underlying their source and cause, and through monitoring process feeds into systematic
methods for their control; this requires an evaluations and also involves appraisal that can be
understanding of complex interaction of used for informing the development of policy,
political, social and scientific factors that planning and programme (Figure 12)(51).
exacerbate disease risk, making epidemiology Monitoring helps in tracking the progress, ensuring
a unique science(48). It is a multidisciplinary that targets are met, improvements are measured
approach to studying human health and disease based on indicators, identifying problems to take
through formulation, testing, and modification corrective actions, developing a basis for
of hypotheses using the scientific method of readjusting resource allocation and bringing in
systematic observation. Epidemiology has accountability within the system.
made some remarkable contributions to
humanity, including the eradication of smallpox,
fluoridation of drinking water, improved motor Figure 12: Monitoring and evaluation within
vehicle safety, and recognition of tobacco as a Programme Implementation
health hazard(49).
Unquestionably, epidemiology has saved Assessing risks;
millions of lives, from both infectious and prioritizing public
non-communicable diseases, through health threats;
interventions and preventive programs that assessing existing
have been implemented as a result of systems
systematic research. It may not be possible to
precisely estimate the exact number of people Evaluating
outcomes and Developing
whose lives have been benefitted or saved by
impact strategic plan of
epidemiological research. However, its crucial
action
role in improving longevity and quality of life
quality and cannot be overlooked. Epidemiology
is at the forefront of public health in preventing
and controlling diseases, promoting health and Monitring
progress Plan
well-being by forecasting epidemics and implementation
pandemics, identifying diseases that are likely
to be a burden in the future, and implementing
planned targeted and collaborative interventions
(48). Teaching in Epidemiology should be a part of
all public health training programmes.

44
Indicators are an important tool for effective all programs are evaluated at different time points.
program monitoring. Nearly 75 national/state In recent years, health impact assessment of policy,
programs and about 300 schemes are implemented program or project on a population is recognised as
in the state of Karnataka requiring a robust and an important activity for improving people's health
strong mechanism to monitor all these programs at and for strengthening program performance based
the state and district levels. Some programs on the principles of democracy, equity, sustainable
(flagship programs, exclusively funded programs) development and use of evidence(56).
have some inbuilt monitoring mechanisms and
does not exist for many others. In 2021, the DoHFW Figure 13: Framework for program evaluation in
has introduced a new system to strengthen public health
monitoring activities at the district level for
program implementation. The effectiveness of this
method is to be seen in the coming days. This
system should enable state program officers to
Ensure Use
implement monitoring that goes beyond and Share
Engage
Stakeholders
supervisory reviews and reports. Lessons

16. Evaluation
STANDARDS
Justify Utility
Describe the
Conclusions Feasilibily Program
• All health programs should be mandatorily Propriety
evaluated once in 3 to 5 years at the district Accuracy
level by the State Department by engaging
with academic partners and public health
experts for returns on inputs, process,
outcome and impact. Gather Focus Evaluation
Credible Design
• The DoHFW should engage with Karnataka Evidence
State Health resource Center and
Karnataka Evaluation Authority to
undertake periodic evaluation of health
programmes at periodical intervals to
bring changes in programme 17. Technology Enabled
implementation
Health Care
Evaluation is a systematic process to determine
objectively the relevance, effectiveness, efficacy
and impact of activities in line with their original 1 Formulate a health IT policy for Karnataka
objectives (Figure 13) (52).Evaluation is to ensure that includes all aspects of software
that the program meets the objectives, document solutions, choice of technology and
the changes in system performance, provide an frameworks, adherence to standards, design
evidence base for modifying the program and considerations, interoperability, security and
strategies, enable resource allocation as per privacy circles, hosting and deployment as
requirements, ensure that programs are sustained well as maintaining maintenance and IP and
and provide specific answers for achievements and licensing needs to be developed.
failures to make further corrections. Despite 2 Establish a state-level task force for digital
continuous monitoring, it is essential to have health to oversee architecture, technology,
periodic evaluation of all programs. solutions, and roadmaps to drive research
The evaluation activities undertaken by the National and implementation.
Health Systems Resource Centre (53, 54), 3 Set up a dedicated health IT sell in the
Karnataka Evaluation Authority(55) and DoHFW to manage level II and level III
independent agencies; academic institutions with support systems with empanelled architect
strong expertise in evaluation are few and in select teams, scale up capability. manage
areas; not all programs have been evaluated in the equipment and infrastructure to ensure
state. There is need to integrate evaluation into the support for users
original program implementation strategies so that

45
 4 Develop a dedicated district health IT cell with 8 Undertake a pilot project for digital health
health IT professionals and analysts to plan cards by integrating health systems,
and manage IT solutions and especially in the NDHM ecosystem to improve
analysis/reporting of data online access to patient medical history by
5 Implement a common format for guaranteeing data availability for care
e-prescriptions as the first step towards providers.
digital interoperability and health data 9 Foster a digital health innovation hub and
exchange by operationalizing the relevant regulatory sandbox in the state by creating a
modules of the NIC e-hospital solutions corpus fund with industry and academic
which is already deployed in the state but partners to support innovative solutions
requires strengthening. using cutting-edge technology. An initial grant
6 Operationalize NDHM integration through a of INR 20 crores over a three-year period
unique health ID for collating all digital should be allocated to set up this innovative
registries of establishments and professionals. start-up for accelerating programs for
Karnataka should be the first state to join the healthcare technology solutions
piloting of NDHM by identifying two districts 10 Strengthen tele-education, tele-training and
for the pilot rollout at the earliest. Two to evaluation in the state based on the lessons
three hospitals in each of the districts across learnt from Covid 19 pandemic in the coming
public and private systems should be the years. Apart from obvious need in pandemic
initial participants in this integrated program like situations, leveraging technology in
which can further be replicated to other teaching and training methods should be
districts established on a very firm footing as an
7 Facilitate real-time data analysis for program integral part of tele-education and
monitoring and evaluation by moving away tele-training. Towards this, a coordination
from periodic weekly reporting to real-time unit should be set up in Karnataka for
data availability generated under various compiling medical content in association with
programs by a dedicated analytics wing in the the state universities.
IT division of the DoHFW. This should also 11 Support an annual digital health submit in
enable creating relevant dashboards for Bangalore that brings together experts in
different (to be piloted for prioritise conditions healthcare, technology consultants,
to begin with) programmes. This HMIS should academicians and industry to provide a
also facilitate SAST for treatment categorisation platform for catalysing collaboration and for
procedures and settlement of claims. showcasing advances in digital health.

The appropriate leveraging of technology for importance of technology in healthcare scenario

empowering and enabling healthcare in a has been highlighted in the National Health
comprehensive manner and to establish the state Policy(18). The National Digital Health blueprint and
as a leader in the country's road map is vision of the the consequent National Digital Health Mission
group. This is based on the values of ensuring promise to provide a consistent, secure, national
patient centric and quality healthcare for everyone, framework and architecture for interconnecting
adopting a combination of physical and digital disparate systems(45). The standards for storage
Information systems for reimagining health and exchange of health records are evolving as
services, leveraging technology to integrate electronic health record standards for India. In
services in the existing systems, adopting a user addition, the vision 2035 for public health surveillance
driven digital transformation process to manage in India is a welcome opportunity for driving
change and to ensure commitment and ownership technology driven health systems(46). Furthermore,
at all levels and across stakeholders in public, the recent development of telemedicine in all
private and NGO sectors. This has become a need branches of healthcare has proven to be a clear
as the expansion and exponential growth of technology pointer for its adoption on a larger scale.
in healthcare has revolutionised healthcare delivery
practices and healthcare services. The digital health scenario in Karnataka is
fragmented with minimal integration and data
The Covid 19 pandemic truly showcased the exchange, poor adherence to standards and
potential of technology to influence healthcare independently designed and managed software
delivery in Karnataka and India, with its own unique solutions typically driven by needs of a particular
challenges. Nevertheless, technology continues to programme / department / hospital. With some
be the key driver for improvements, innovations developments noticed in NRHM - HMIS, there is a
and advances in healthcare delivery. The move to quality individual reports and reporting of
summary statistics in facilities at periodical intervals
46
due to progressive digitisation of activities. However,
majority of the health programmes have their 18. Health Financing
individual versions of software and different formats
usually developed by third-party vendors and
operating in silos. Inadequate fund allocation and lack
• Increase state spending on health in a
of a systems perspective continues to plague effective
phased manner from existing 4.7% to 8% by
implementation. The appointment of a Deputy
2025 in line with the recommendations of
Director and an Assistant Deputy Director in recent
the 15th finance commission.
times is a welcome development. In order to
accomplish the desired objectives, it is important to • Financing and pooling of resources from
reorganise the existing IT system support with different departments and from different
clearly defined roles and responsibilities. schemes towards a centralised scheme
In Karnataka, there are nearly 35 distinct that is more convenient, easy and people
web-based applications in the DoHFW services friendly should be implemented for
with minimal interaction of flow of information convergence.
amongst them, often managed and enhanced • Consolidated measures to reduce Out of
independently as per program needs. Every PHC, Pocket Expenditure (OoPE) for users
district hospital and ASHA worker continue to through a decentralised state-level tender
maintain a number of manual registers. Some process will be helpful.
efforts are in progress to integrate a few of the
schemes within the department and at times with • Expanding the coverage and scope of Jan
other departments. Apart from the highly critical L1 Aushadi centres in all districts and talukas
support for program activities, dedicated L2 and L3 will reduce expenditure on drugs and
support is lacking in different programs. In this consumables for families.
context development of an inclusive ecosystem for
digitally enabled healthcare is the need of the hour. • Increasing the participation of the private
The 10 strategies and the recommendations for sector under the CSR programmes is
leveraging technology use in healthcare programs worth exploring in select areas.
and moving in a systematic direction to address • Strengthening administrative processes to
these issues are urgently required. The recommended ensure transparency and to avoid
strategies are duplication is urgently required.
1. Universalise digital personal health records
2. Align and adopt the NDHM federated architecture
Ensuring equitable access for all regardless of
3. Re-imagine and design applications to be income, social status, gender, caste and religion to
user-centric rather than program-centric. affordable, accountable, appropriate health
services of an assured quality as well as public
4. Aggressively scale up Tele-services. health services requires appropriate health
5. Optimise resource management across private financing mechanisms as recommended by the
and public facilities High level Expert group for UHC(57). The greater
participation of private sector and the diminishing
6. Build capacity within health department for role of the public sector, more so in urban and
Health Information Technology capability transitioning areas is a matter of serious concern.
As per NSS 75th round, the costs of healthcare in
7. Define a coherent and comprehensive strategy private healthcare facilities are 4 to 10 times higher
for data management in urban areas, in private sector, depending on the
8. Comprehensively augment Health IT nature of ailment and service provider further
Infrastructure throughout the state. influenced by the duration of treatment or
hospitalisation and does not include indirect
9. Constitute a forum of experts from technology, expenditure( Table 9)(58) .
medicine, public health and health informatics
for ongoing assessment, evaluation and
incorporation of relevant emerging technologies.
10. Enable both advanced clinical research as well
as improved personalized patient care and
catalyse health-related data for Public Health
informatics.

47
Table 9 : Cost of health care and services in Karnataka and India

Sl no Category Details as per NSSO 75th Round 2017-18 Karnataka in Rs India in Rs

1 OOPE by type of care

Mean OOPE for Out patient care 708 721
Mean OOPE for hospitalisation 15546 18088
2 OOPE for hospitalisation
Mean OOP for hospitalisation excluding Child birth in PHI 3591 4600
Mean OOP (excluding child birth) in private hospitals 19888 31000
3 Mean OoPE on hospitalisation based on Place of living
Mean OOP in Urban Areas 21657
Mean OOP in Rural Areas 11930
4 OOPE by type illness
OOPE for Chronic Illness Outpatient care 647
OOPE for other Illness Outpatient care 771
5 Mean institutional birth medical expenditure
Government Hospital 2177 1438
Private Hospital 21852 22131
6 OOPE for hospitalisation in Government Hospitals
Medical Expenses 3624 20135
Other Expenditure 1303 2245
Total Expenditure 4927 22380
Total OOPE 3591 18088
7 OOPE for hospitalisation in Private Hospitals
Medical Expenses 23086 20135
Other Expenditure 2197 2245
Total Expenditure 25283 22380
Total OOPE 19888 18088

The national public health spending is only 1.2% of payment issues. The referral process is considered
GDP even though there have been several to be quite burdensome for both providers and
recommendations to increase spending to a beneficiaries especially for tertiary services due to
minimum of 2.5% of GDP with greater allocation for nonuniformity in the public sector. In addition,
primary and secondary healthcare activities(59). several schemes coexist in the state leading to
The GoK spent only 0.7% in 2018 – 19(60). With an double dipping into resources due to overlapping
annual allocated health budget 12,035 crores for beneficiaries and duplication of efforts. The
2021-22 covering all areas, the per capita coverage of population with health scheme / health
expenditure for health in Karnataka was Rs. 1 429 insurance has remained the same at 28% over
(60).The Ayushman Bharat scheme is implemented NFHS 4 and NFHS 5 rounds in Karnataka. The
by the GoK to cover all healthcare services, routine different package rates for different type of
public health services, preventive services and procedures and the payment to the facilities
health and wellness Centre component. appears to be a quite complicated procedures. The
OoPE for drugs and diagnostics are not covered
The UHC scheme provides partial financial risk under the UHC scheme with majority of the
protection even in public hospitals due to the outpatient costs for investigations borne by users
presence of user fees and accompanying including admission expenses in empanelled
expenditure on drugs, diagnostics and hospitals. Even in the public sector hospitals, the
consumables resulting in high year out-of-pocket lack of required drugs, human resources,
expenditure for consumers. The exclusion of equipment and consumables force the beneficiaries
outpatient primary care services, reauthorisation to spend in private sector leading to high OoPE.
procedures and poor utilisation of the scheme by
households even from BPL categories contributes The private health insurance coverage in the state
for poor usage of the scheme. Furthermore, the is also only 12% of all those insured which can be
private sector participation is limited to certain much lower in different geographical areas(16). The
geographical locations in the state and high cost of the premium, waiting period for the
non-existent in few of the districts. In addition, policy to become active, terms and conditions in
hospitals have empanelled themselves for small print, unfair practices that include claim
selective specialities due to low package and late rejections, partial payments and delayed grievance

48
redressal mechanisms contribute for the low subsidy to an extent of Rs. 1.5 lakh coverage per
enrolment in private health insurance schemes. family per year and also include expanded scope of
Data from the 71st and 75th round of NSS in 2014 services by including secondary care in its broader
and 2018 indicate that if public health facilities can ambit. SAST working on an assurance mode is the
be strengthened for outpatient, in patient and state health agency for implementing Ayushman
referral services it could lead to a dramatic fall in Bharat Arogya Karnataka Scheme and uses the
the overall financial burden on patients who visit ARS software for all public health institutions (62,
private healthcare services(58, 61). This calls for a 63).As on January 2021, 1.43 crore e-cards have
significant increase in public sector investment to been issued for 14 lakh beneficiaries treated and
make services more easily available for all sections 3413 hospitals have been empanelled under the
of the society that would help in shifting patients scheme. The empanelment process of hospitals and
from private providers to public facilities. doctors are done as per standard procedures. Private
sector services for emergency and tertiary care
Risk Protection supplement the public health system by bridging the
gap in the availability of health services.
• There is an urgent need for focused and However, the scheme provides only partial financial
targeted empanelment of healthcare risk protection for the covered population. So far,
facilities in all districts to be done on a the scheme has covered only 0.8% per year of the
priority basis. The package rates at present hospitalisations compared to the hospitalisation
needs a revision especially for certain rate as per the NSS data of 4.7% for Karnataka(62).
categories of geographical locations, Among the beneficiaries, nearly 98% are from the
nature of the institutions and the type of BPL category and only 1.7% from APL categories
services provided in these places. with differential utilisation of available packages.
Interesting to note that only a small proportion of
• Strengthening district diagnostic facilities the population is using the services considering the
and streamlining referral mechanisms
based on clear guidelines and protocols is Figure 14: District wise variation in
very much required along with timely pre-authorisation raised by type of provider
payment to healthcare providers.
Kodagu 13308 0
• The implementation of the Karnataka
Yadagiri 14306 0
private medical establishment act 2017 is
Ramanagara 19813 119
urgently required through a consensus
Chamarajanagara 26734 289
driven and a consultative approach.
Chikkaballapura 39941 590
• A common IT platform to avoid duplication Richuru 29185 953
and convergence of activities as well as Koppala 33443 971
expanding the scope of services in the Ballari 45117 1085
scheme with strict monitoring and auditing Chitradurga 40782 1213
Uttara Kannada 28784 1215
mechanisms are urgently required.
Bidar 24735 1221
Chikkamagaluru 22712 1445
With an exponential growth in private health care, Hassana 58505 2625
costs has increased exponentially resulting in huge Mandya 42963 2632
Haveri 30606 2807
OoPE and catastrophic expenditures for the poor.
Gadag 15754 4028
Drugs, vaccines, diagnostics, specialised care,
Tumakuru 48730 4929
tertiary services are at the forefront today, while
Kolara 31444 5503
basic essential healthcare has been relegated to
Bengaluru Rural 11552 9765
the periphery. This change has resulted in change in Vijayapura 26653 10882
quality of services, costs of healthcare, greater Kalaburagi 46460 11171
inequalities, as well as limited access to affordable Shivamogga 41872 14274
healthcare for people. Davanagere 29775 14869
Bagalakote 21451 15145
Karnataka launched the Arogya Karnataka scheme
Udupi 14344 15185
in March 2018 even before the Central scheme was
Belagavi 45396 18535
launched in September 2018 by integration of the
Dharawada 38153 19222
earlier schemes along with enhancing the coverage Bengaluru 111355 20512
to Rs. 5 lakhs per family, now covering about 115 Mysuru 64761 27858
lakh families falling under the BPL category(62). Dakshina Kannada 26153 37286
The 19 lakh APL families are entitled to a 30%
Government Private

49
catastrophic expenditure for some ailments. Figure 15: Proportion of health care providers in
Delayed payment to the empanelled hospitals, rural and urban areas of India.
administrative barriers in empanelment, limited
capacity of the financial software, burdensome
Rural
reference procedures complicate the matter to a
great extent. The public hospitals contributed for Informal Health
care provider
77% of reauthorisation as against 23% from the 4% Govt./ Public
private hospitals(62). Hospital
33%
The developed districts of the state contributed for a
high end utilisation with more private facilities in Tier 1
cities and majority the population in uncovered
districts are still exposed to financial hardships in
accessing healthcare (Figure 14). The scheme has
several limitations by its non-comprehensive nature.
For example, exclusion of Ayush packages, limitation Charitable/ trust/
of palliative care packages, incomplete coverage of NGO-run hospital
NCD's, the co-payment strategy for APL in making 1%
Private doctor/
use of the scheme. Despite the coverage for certain Pricate clinic
conditions, many services like transport costs, 41%
Private Hospital
ambulance services, payment towards laboratory 21%
services are excluded along with limited number of
Arogya Mithra’s in many public and private Urban
empanelled hospitals.
Informal Health Govt./ Public
care provider Hospital

19. Private Sector

1% 26%

Engagement

Strong administrative and regulatory frameworks

(as seen during Covid times) is a fundamental
prerequisite for continuous engagement with the
Charitable/ trust/
private sector to see that people are not exposed to Private doctor/ NGO-run hospital
Pricate clinic
greater risk and higher losses based on consensus 44%
1%
Private Hospital
and a consultative process. The GoK developed the 28%
Karnataka Private Medical Establishments
(amendments) Act 2017 that aimed at bringing
certain regulatory measures within the existing Figure 16 : Current health expenditures
administrative framework(42).However this is still (2016-2017) by various health care financing
been an unresolved issue in establishing clear schemes in India.
standards and guidelines. The quality of care needs
to be standardised as per evidence (accreditation Union Government (Non-Employee)
7%
processes) and established regulations for Others Union Government (Employee)
different activities. The existing governmental 10% 3%
schemes should be more people centric and help in State Government (Non-Employee)
10%
availability of services to control the rising costs of
State Government (Employee)
healthcare. It is equally important that the 1%
government focuses on increasing the health Urban Local Bodies 1%
budget and strengthening the public health system Rural Local Bodies 1%
which would in turn help in greater utilisation of Social health insurance
schemes 3%
public facilities and services bringing in a healthy Government Financial
competition between public and private sector. Health Insurance
1%
Privatisation of healthcare is a noticeable
phenomenon in India and in Karnataka. Today,
healthcare delivery system is often a combination All Household Out-
of public and private sector resources used jointly Of- Pocket Payment
63%
for providing healthcare to people. Recognising the

50
fact that public sector alone cannot cater to huge
population needs, private healthcare services is 20. Public-Private
delivered by a wide range of qualified and
semi-qualified service providers with a
Partnerships
predominant focus in curative services. Both in
urban and rural areas such services are provided
by general practitioners and specialist clinics,
• The government should establish an
nursing homes, corporate hospitals, private
independent and autonomous PPP cell in
medical colleges in addition to a host of private
the state to develop clear policy guidelines
laboratory services, radiology services, supply
for PPP in health sector and to examine the
chain management and other areas. The resource
benefits / threats to avoid conflicts of
crunch in the government has necessitated giving
interest.
greater autonomy and invitation for private
partners to increase - expand – augment – • All new PPPs should be carefully examined
consolidate public health services. Both pharma at the highest level for its benefits and
industry and medical consumable industry are risks and should be reviewed/ evaluated at
highly visible from the private sector. Overtime, the periodical intervals for its public health
private sector participation has evolved from a benefits.
service model to a business model
• Strong administrative and regulatory
As per data from NFHS – 4 and NFHS – 5, nearly frameworks should be established for
80% of ailments in urban areas and 70% in rural implementation of PPP models after
areas received care from private healthcare defining the scope of services and
providers and contributed equally to the rate of investment patterns for maximum health
hospitalisations in both the areas (Figures 15-16) returns.
(58). Due to the unregulated and the for-profit
nature of the sector, the medical expenditure has
increased significantly in the past few years. The Public-Private partnership ( PPP) has emerged in a
cost of hospitalisation in a private healthcare significant way as a cooperative arrangement
facility is estimated to be INR 17085 in rural areas between the government and private organisations
and INR 31 462 in urban areas,. while the same in a for providing services by sharing/supporting public
public healthcare facility was INR 3445 and INR infrastructure, facilities, services through mutual
4195, respectively (64). An assessment of human agreements on an agreed-upon framework. A PPP
resources in Kolar district for mental health care model is an approach to address public health and
and trauma care respectively revealed that 60% of social development issues amidst resource
human resources was in the private sector and cost constraints through the combined efforts of
was significantly higher resulting in many families public-private organisations. It is characterised by
to face the catastrophic health expenditure(30). the sharing of investment, risk, resources,
Advantages that come in hand with the health responsibility and rewards between all partners to
sector privatisation are its availability, proximity to best meet the required public needs. While there
communities, increasing reach, greater range of are few advantages of a PPP model in terms of
speciality services and others, while providing the extending the reach, enhancing program credibility,
choice of choosing a method for people. However, enabling governments to develop public assets,
the major disadvantage of this engagement has ensuring quality and client satisfaction, providing
been the increasing costs leading to greater iniquity opportunity for equal and responsible engagement,
and lesser accountability. At times, it has even led PPP models also pose some major threats and
to unhealthy competition as well as exploitation and challenges.
misconduct towards patients. Several PPP models exist in Karnataka in areas of
The engagement of the private sector extends health care, infrastructure development,
beyond simple healthcare to the larger commercial technology applications, primary healthcare
determinants of health as the industry can delivery, telemedicine, Thayi Bhagya scheme( to
influence / nudge the government in formulating address infant mortality and maternal mortality),
policies and programmes. Many industry players Yashaswini health scheme by extending financial
from tobacco, alcohol, motor cars, food industry, support to farmers, helpdesk teams, emergency
packaged foods and others engage with ambulance services, running of hospitals and in
governments in indirect ways to develop a other areas(66).
favourable climate for their continued presence and
participation(65).

51
PPP models also present several challenges in its The goal of a health logistics system is much larger
implementation due to deficiencies / absence of - a than simply making sure a product gets where it
PPP policy for health at national or state level, needs to go. Ultimately, the goal of every public
output and outcome indicators, clearly defined health logistics system is to help ensure that every
institutional frameworks, grievance redressal customer has commodity security. Commodity
mechanisms, accreditation standards, a clear security exists when every person is able to obtain
understanding on the economics of health services and use quality essential health supplies whenever
and most significantly nonavailability of he or she needs them. A properly functioning
well-designed evaluation studies. The sustainability supply chain is a critical part of ensuring
of these models over time is a major challenge and commodity security. Effective supply chains not
many PPPs can damage the credibility of public only help ensure commodity security, they also help
health institutions, when collaboration confirms determine the success or failure of any public
legitimacy and credibility on programs that health program. Well-functioning supply chains
increase healthcare costs and affect quality of benefit public health programs in important ways
services. by increasing program impact, enhancing quality of
care and improving cost effectiveness and
21. Drugs and Logistics efficiency. The Six Rights of Logistics are: The RIGHT
goods in the RIGHT quantities in the RIGHT condition
delivered to the RIGHT place at the RIGHT time for
the RIGHT cost(67).The policies, framework,
• Ensure transparency in procurement, structure, administration and process of drug
procurement performance should be logistics system should be developed by
monitored regularly to ensure that considering the above rights.
tenders for supply of drugs are finalised The Karnataka State Drugs Logistics and
timely and drugs are available as and Warehousing Society (KSDLWS) had been
when these are needed; established during the year 2003 with the main
• Strengthen quality assurance objective of establishing an efficient, cost effective
mechanism of the drugs procured and and decentralized Drug Logistics and Warehousing
supplied through standard guidelines to System in the State, adhering to modern
health facilities for ensuring efficient warehousing and rigid quality control practices and
drug storage/maintenance of storehouse providing information technology enabled services.
and adherence to rational prescription The Society had been procuring drugs, vaccines,
practice, display essential drug list in all chemicals, equipment’s and miscellaneous items
health facilities, for use in the hospitals in the State under the State
Sector, District Sector, and Directorate of Medical
• enhance funding for the corporation, Education. The Society had also been meeting the
generate annual reports to document the drug requirements of various programmes like
procurement, distribution, consumption National Rural Health Mission, Akshara Dasoha of
pattern, Education Department and those of the Karnataka
State Aid Prevention Society(68, 69.
• conduct prescription audit of public
health facilities and survey of facilities Recently (2019), KSDLWS was transformed into a
once a year to examine the availability corporation called- Karnataka State Medical
and stock-out position of essential Supplies Corporation. Corporatization is expected
medicines at all levels. to provide clear autonomy, transparency and
management control in the decision-making
• Pharmacovigilance should be mandatory process and help in providing better governance for
in all hospitals with more than 300 beds effective buying and supply chain operations. Also,
to closely examine antibiotic resistance, multidisciplinary professionals and healthcare
drug adverse reactions, drug monitoring professionals would be deployed in developing
as well as developing a hospital formulary system optimization solutions for the procurement
be employing Pharma D graduates. of medicines, chemicals, equipment and other
medical supplies. Currently KSDLWS has 27
warehouses and 2,940 institutes (primary health
centers, community health centers, taluk hospitals,
and district hospitals) that they supply to. KSDLWS
has automated supply chain management system
called Aushada software and through which all the
health facilities including PHCs would submit their

52
annual drug indent plan and indent the drugs. This
software also facilitates monitoring of stock 22. Health Legislations
position in all the 2940 health institutes and enables
issue of only standard drugs and freeze that are not
of standard(68, 69). • Large scale capacity building activities
Despite such progressive improvements in the should be undertaken in health, law, police,
overall drug logistic management system, several welfare and related sectors to develop
challenges exist within the system that are barrier sustainable mechanisms for
in providing free drugs to the needy individuals. implementation of public health and
Studies have reported stocks-outs and related legislations.
non-availability of drugs in the health centers and • All legislations and regulatory acts that
only little more than half of the essential medicines were framed before the year 2000 should
are available in the health facilities. Non-existent or be reviewed by a joint expert committee for
poor stock control including poor forecasting are its scope – reach – coverage – procedures
the major causes of stock-outs and shortages and recommendations of this committee to
reported at the health facility level when stock is be used for amendments.
available at the central or depot level. It is also
important to note that drug stock outs are observed • The implementation of existing legislations
at the central drug store or in the warehouses in health. Safety and wellness in all
which reflects poor management practices at the settings should be scaled up uniformly
central level. The Karnataka Accountant General’s across the state in a uniform and visible
(General & Social Sector Audit), audit report in 2018 manner along with provision of resources
recorded poor quality assurance by the Karnataka at different levels.
State Drugs Logistics and Warehousing Society
while procurement and distribution of drugs, • The impact of public health legislations
inordinate delay in communication of Non-Standard should be measured at periodical intervals
Quality drugs to warehouses/ hospitals resulting in by health and safety experts and academic
distribution of non-standard quality drugs to health institutions in collaboration with legal and
facilities across Karnataka(70). enforcement officials at regular intervals.

A performance audit of the procurement and

distribution of drugs by the Society undertaken by Public health legislations are an important tool to
the Karnataka Accountant General’s during 2007-12 improve service delivery mechanisms, create
revealed the following: a) flaw in tender evaluation, health promoting environments, promote safe
b) Drugs procurement lacked planning, resulting in behaviours and to safeguard societal interests(73).
chronic delay in finalizing the rate contracts for The public health acts are related to “legal powers
supply of drugs resulting in non-availability of and duties of the state to assure conditions for
sources for procurement of drugs during certain people to be healthy and also to constrain the
calendar time, c) certain drugs are purchased at autonomy, privacy, liberty, propriety or other legally
higher rates when compared to other states, d) protected interests of the individual for protection
procurement of drugs, especially IV fluids, had not and promotion of community health”(74). The
been based on estimates of actual need and drugs health-related legislations broadly include health
had been procured far in excess of requirement, and social care, regulatory acts, acts that minimise
creating storage problems in the warehouses and health-related risks and those applied during
health institutions. These excessively procured disaster epidemic situations.
drugs had been stored in garages, toilets, corridors
etc in health institutions, e) Drugs are procured with It is commonly observed that despite the presence
lower shelf life and f) the quality assurance system of good knowledge and service availability, health
was not effective(71). behaviours are not widely adopted by individuals
and organisations as they are subject to a wide
According to 7th common review mission of NRHM variety of internal and external influences. It's well
in Karnataka following were the issues with respect proven that educating people alone or providing
to drug management and storage at the health information or formulating guidelines or mere
facility level- a) drug storage was found poor (lack advocacy activities may not effectively result in
of space, racks, shelves, ventilation at the store behavioural change necessitating the need for
houses, no systematic arrangement of drug storage legislative and regulatory interventions. Regulatory
e.g. alphabetical ordering, labeling etc), b) record mechanisms are also important to safeguard
keeping was found weak and c) had poor update of societal interests. Effective implementation of
stock registers(72). legislations and acts is based on the spirit of

53
implementation, probability of being penalised and Joint action(s) taken by departments of health with
the deterrence of punishment. Visible enforcement other government departments, and at times with
of laws, randomness in its coverage, stiff penalties private, voluntary and non-profit groups to improve
for violators and uniform application to all, brings in the health of population is commonly referred to as
larger public health benefits. intersectoral collaboration. In simple terms, it
means working together across sectors to improve
Number of public health legislations has been health and influence its determinants to achieve
enacted by the Government of Karnataka or at health, economic and social improvements(76). As
times, judiciary has provided directives. The health is multicausal in nature, the response should
intervention of the judiciary during the recent Covid be multisectoral.
pandemic is an example to show that legislations
are a powerful tool to direct governments and Intersectoral action on health provides a solution
control institutions by forcing the government to when governments have to implement
act. There is also need to revisit legislations for its programmes or formulate policies that overlap to
role and use overtime as some may become achieve a common goal of health benefits and
outdated and at times even pose danger. Recently beyond, but that are administered across a number
many regulations have been either amended or of departments. Implementing intersectoral
modified to bring in changes as per current policies and action plans include self-assessment,
requirements, like the Indian Motor Vehicles assessment and engagement of other sectors,
Act(75). Implementation of legislations is the key to stakeholder and sector analysis followed by
success but is fraught with several challenges like analysis of the area of concern, use data in all
lack of intersectoral coordination, nonuniformity of engagements, select an engagement approach,
guidelines, misinterpretation of the regulations by develop an engagement strategy, identify a common
the public and the media, institutionalisation of framework and Monitoring and evaluating(77).
implementation, minimum use of technology
Securing high-level political commitment to an
applications and others.
inter-sectoral initiative is a major requirement and
can pose a primary challenge. However, the major
23. Intersectoral problem associated with ISC in Karnataka lies with
the scantiness of documented systematic
Coordination programmatic experiences thus making the
processes and outcomes of intersectoral work
more challenging. For example, Road safety is a
shared responsibility of several departments in the
• In the state, health sector policies, state. The earlier state Road Safety Council (all
programmes and action plans should be departments included) was more of an advisory
agreed upon and supported by a high level body and implementation was slow. The
intersectoral committee from the early constitution of a state road safety authority with
stages, duly represented by all concerned representation of police, transport, health, law and
departments at the highest level, from the infrastructure departments is a step towards ISC
planning to implementation levels for for developing programmes for implementation(78).
consensus building, resource allocation However, equipping this agency with knowledge and
and coordinated execution. skills, resources, action plans and tools for
implementation still remains a challenge.
• The Head of the state should review all Constitution of district level road safety agency can
health programmes once a year to greatly facilitate implementation at district levels.
facilitate ISC at all levels for effective Examples are in plenty like suicide prevention,
monitoring and resource allocation. tobacco and alcohol control, violence prevention,
disability care and welfare, etc., requiring
• A District Health Implementation and intersectoral coordination across departments
Monitoring Committee, chaired by the from planning to implementation stages.
District Commissioner and coordinated by
Zilla Parishad officer, that also includes In practice, this is a very challenging area as both
senior officials of all departments should horizontal (within ministry or department) and
oversee implementation of all vertical (across ministries/departments) are
programmes to measure progress, required for joint activities. To overcome such
efficiency, effectiveness and resource challenges, it is important that the state leadership
utilisation based on a set of agreed upon (like Chief Minister) or the senior most officer (like
indicators. Chief Secretary) takes control of overseeing
implementation (ex., road safety, several health
determinants, environment health etc.,). This is also
54
a common practice followed in many High Income Community Engagement
Countries. The success of this approach has also
been evident in Covid – 19 pandemic in the state In
India and Karnataka, the judiciary has directed the The state government should facilitate capacity
governments to enhance coordination for smooth building of community engagement process by
delivery of services or implementation of activities strengthening all panchayats and other
as seen during recent Covid pandemic. existing local committees in district - taluka
Implementing policy frameworks is another method levels and in urban areas in health care
for ISC. Health sector being responsive to delivery process. NGOs can also be actively
initiatives led by other sectors and inviting other engaged in such capacity building programs.
sectors to participate in health sector activities
provide opportunities for improving health, enhance
cooperation and coordination that is often more Bringing public health to people involves bringing
effective, efficient and sustainable, than could be public to public health. The collective involvement of
achieved by the health sector acting alone. local people in assessing their needs and planning
strategies to meet those needs is a fundamental
requirement for the success of public health
24. Advocacy, Community programs. This has been adequately emphasised

engagement and IEC since 1978, through the Alma – Ata declaration
which emphasised the role of primary health care
approaches and community participation(3).It
emphasises the involvement of individuals, families
Advocacy for Health and community members in promotion of their own
health by participating in planning, organisation,
An active engagement of all stakeholders in cooperation and control of healthcare activities
public health advocacy should be strongly making fullest use of all available resources.
supported by the state to benefit health and Based on the initial success of a pilot project on
safety of people and should not be restricted to ‘Community Action for Health’ in 1620 villages
selected days in a year, but should be an across 36 districts of nine states in 2009, the
on-going and continuous process. implementation of our ASHA schemes and
formation of Village Health Sanitation and Nutrition
Committees (VHSNCs) and Rogi Kalyan committees
Public health advocacy is a process of educating
were implemented under the NRHM program which
and encouraging elected officials, organisations or
has become a key strategy for engaging the public
influential members of community to support,
(80). These agencies along with citizens charters,
formulate, enact and/or adopt policies that will
community-based planning and monitoring and
inform the community, protect health and promote
untied funds for the Arogya Raksha Samitis, have
safety(78). Public health advocacy ensures access
formed important components of the
to care, generate resources and campaigns to
communitization process under NHM with
eliminate existing inequalities to get new measures
engagement of local agencies and functionaries
like legislations and other mechanisms in place.
drawn from the villages(81). People are empowered
Advocacy is undertaken by large number of NGOs,
to take leadership in health matters to strengthen
advocacy groups, coalition groups, students
health care at local levels. Many successful
associations, workers unions, media houses and
examples (GRAAM) and during Covid times adopted
several others and these grass root efforts help in
this process for effective actions(82).
achieving several requirements required for
healthcare. Community engagement and participation is
well-known to result in dissemination of information,
Karnataka has been a leader in advocacy
improved organisation of services, delivering more
campaigns because of the active participation of
acceptable and relevant services, increasing
many health interested groups. Many successful
community satisfaction, use of resources and
examples are available in HIV AIDS, disability,
increased community responsibility for their own
mental health, child labour and several others.
health(82) . However the process includes mobilising
Advocacy campaigns related to alcohol control,
communities, formation of committees through a
tobacco and road safety and others have ensured
democratic process, capacity building and community
the government to implement several programs.
action. During the process of community engagement
Several groups are actively engaged in advocating
several lessons have been learnt that needs to be
for the rights and health of vulnerable populations
adopted in different places. Several challenges
without adequate health care. Stronger advocacy
have been identified in engaging with communities
efforts are required to bring change.
for a number of reasons.
55
IEC Activities
Box 5: Campaign for helmet use and no-drunk
driving
The state IEC cell/partners in the health/other
organisations should run systematic The Helmet wearing and No-Drink and drive
campaigns in a scientific manner based on campaigns run by Bangalore city police , NGOs,
data and evidence in prioritised health areas citizens group and coordinated by NIMHANS
and on focused topics in the district and taluka during 2006 – 09 is a well acknowledged
levels at the beginning of a program or before programme(83). Started in Bangalore city, the
targeted interventions or prior to introduction campaigns were extended to several districts
of new schemes for maximum impact. Most in the state following the notification of helmet
importantly effectiveness of such campaigns legislation on Nov 6, 2006. Starting with data
should be evaluated on defined para meters. collection from city police and 8 hospitals on
road crashes, information was analysed and
key points of communication were identified.
Information, education and communication ( IEC) Various health education messages were
and Behavioural change communications ( BCCS) finalised based on the analysis and
are very powerful tools to change/ reinforce implemented through print and visual media.
health-related behaviours in populations regarding Feedback was obtained from public and
a specific problem using a wide variety of contents modified based on suggestions.
communication channels. It aims to instil positive Helmet use and drink driving rates were
knowledge for appropriate health and safety measured in hospitals, in road accident
behaviour and a variety of methods are employed to records and through field observational
undertake IEC activities. IEC activities inform surveys up to year 2013 under the Bangalore
people about the benefits of various Road safety programme (6). In effect, helmet
schemes/programs, strengthen health seeking use rates increased from 5 – 10 % before
behaviour and increases utilisation of services. legislation to 60 – 70 % after legislation. Drink
Experience in the recent Covid 19 pandemic has driving reduced following enforcement by
demonstrated that public education on a continuous police authorities. The introduction of Motor
basis along with availability of vaccines helped in Vehicle Act in 2019 has further increased safe
decreasing the vaccine hesitancy and encouraged behaviours in these areas through increased
people to get vaccinated whenever it was available penalties and higher enforcement in recent
and demand when not available . It also empowers times.
people to make right choices for bringing social
change and development as well as exercise their
rights. Social media platforms are a powerful media
for education, but should be employed judiciously.

Lessons learnt included – campaign’s need to

be sustained, scientifically designed, right
communication channels to be chosen,
technology to be used and measured for its
impact.

56
 25. Public Health Research

• The state government should give importance

for public health research which requires –
identifying priority areas, developing a
state research agenda, dedicated funding
(core funding from state, corpus funding,
pooled funding, CSR funds, industry
investments, etc.,), networking of institutions in
different areas for developing research outputs.
• A state agency needs to be constituted in
RGUHS to strengthen research in medical
colleges and other healthcare educational
institutions. Health universities, medical
colleges and NGOs should collaborate with
various state departments to develop
improved mechanisms for undertaking
research in their districts for all activities.
• Health impact assessments should be
focussed in DoHFW by creating a small
dedicated unit to undertake research.
• Future research should focus on NCD's and
health determinants and strengthening health
systems by developing a systematic research
agenda and also undertake state NCD and
this factor survey at periodical intervals.

Health research reflects to the fact that improving

health outcomes requires a continuous
understanding of factors that influence health and
disease and generating new knowledge to bring about
improved outcomes (84). Research aims to
understand the impact of policies, programs,
processes, actions and help in developing
However, it needs to be recognised that an
interventions. Public health research should be
individual's behaviour is shaped by social, cultural,
interdisciplinary moving beyond a particular discipline
economic and political influences along with a and can use mixed method approaches as only
combination of many intrinsic and extrinsic factors. quantitative or qualitative research will not be an
While a one-time behavioural change as in the case appropriate mechanism. Translational research,
of vaccination is easy to achieve through IEC interventions research, implementation research,
methods, many changes required in the health systems research, operations research and health
promotion practices towards control of chronic impact assessments are gaining prominence to
diseases requires building/creating health increase research applications in improving health
promoting environments along with education of systems and to strengthen healthcare delivery.
people. IEC programmes should be participatory Technology applications are enabling more systematic
and include feedback which is a vital component of research to be undertaken in areas where it was
the entire process. not possible earlier.
Many successful campaigns in number of health In the state, there is no dedicated research wing to
areas have been undertaken in the state of prioritise and coordinate research activities.
Karnataka by the department and individual District level initiatives and capacity to undertake
organisations. Major limitations has been the public health research are minimum. Many
isolated nature of activities, vague message challenges exist for undertaking public health
deliveries, timing of the campaigns, lack of research including its neglect, absence of focus,
lack of institutions and researchers, funding issues
feedback from the public and at times
and utilisation of research findings. However there
non-imaginative methods of campaigns. Using data
are few institutions in the state that are actively
to formulate campaigns is a major requirement. engaged in research over a period of time.

57
 Life Course Perspective
• The state should shift focus and priorities from For example, children with early childhood
vertical and silo programmes to integrated traumatic experiences are more likely to
systems and programmes based on a life have mental health problems in later stages
course perspective. Consolidating activities, of their life. On the contrary, children
convergence across programmes and growing in more stable and protective
coordination across partners are obvious environments are more likely to be happy
advantages and saves resources. The vertical and healthy at later stages of life.
nature of some programmes should be retained
at the top in select areas under national and This understanding of a life course
perspective helps in identifying various
Section 3: Life Course Perspective

state programmes.
influences, enablers, facilitators and
• In this direction, the state should establish 5 barriers to good health or to disease at key
centres of excellence in the areas of – health stages of an individual's life. Recognition of
determinants, child health, youth and these factors is important to make changes
adolescent health, middle aged and elderly in health policies and programmes and for
health. This institutional mechanism should empowering people to promote health and
provide guidance and support to the prevent disease. The advantages of a life
government for policy support, capacity building course approach are that it - (i) helps in
and training, developing common platforms, recognition of specific factors that operate
funding mechanisms, implementation tool kits, at different stages of life, (ii) facilitates
monitoring, evaluation and research inputs. developing appropriate policies and
programmes as applicable to particular age
Health in a life course perspective recognises that groups, (iii) promotes integration of different
both past and present experiences are shaped by programs based on commonalities and (iv)
the larger social, economic and cultural context in developing implementation mechanisms in
which the person lives. Understanding the influence different settings- schools, colleges, work
of these factors that operate across the lifespan at places, youth centres, etc., (v) can be
different phases of pregnancy, childhood, monitored and evaluated using common
adolescence, young adulthood, midlife and elderly indicators and (vi) saving resources by
is of extreme importance to improve people’s avoiding duplication of efforts.
health. A life course approach recognises the
importance of several factors that shape an
individual’s health in that phase of life or into the
later stages of life because of the interaction and
interconnectivity of these factors, thus helping in
development of appropriate health policies(85).

Health in a life course perspective

58
26. Health Determinants
As per WHO, the determinants of health include the
• Health department should play a strong social environment, physical environment and
role in advocating for addressing health persons with individual characteristics and
determinants across sectors on a continuous behaviour(86).The context of where people live,
basis and should generate the requisite data work, play and engage in other activities
for policies and programmes. determines their health and, individuals on their
own are unlikely to be able to control the influence
• The Karnataka Health Steering Committee of some of these determinants. In Karnataka
headed by the leadership at the highest majority of the resource allocation to health is
level should be constituted by including all towards secondary and tertiary care with little
concerned departments for effective emphasis on addressing the determinants. Several
collaboration and coordination to review determinants of health lie outside the health sector
action plans, provide funding and monitor and strategies to address the need should be
progress by providing leadership and multidisciplinary and intersectoral in nature(85).
governance.
Many factors that influence health like nutrition,
• Existing institutional mechanisms should urban planning, environmental pollutants, socio
be strengthened and new agencies to be demographic determinants, tobacco, physical
established in select areas for continuous inactivity and several others needs to be addressed
work in a much stronger way to promote health and
• The district health teams capacity should prevent disease. The subcommittee on the
be strengthened with training and determinants of health using the Dahlgren and
resources to undertake mapping of Whitehead model informs that factors that have a
determinants and to develop vulnerability direct impact on health or at close proximity to the
index for populations along with prioritising individual can be addressed by people, while those
interventions. with progressively indirect effects need societal /
governmental interventions (Figure 17).

Figure 17: Determinants of health (adopted from Dahlgren and Whitehead model)

Ge
y Eq nder
i lit ua
E qu e
Resourc f
Transport, lity
on o walking paths &
allocati alth Bicycle lanes Gre
ion on he Spa en
rat budget
Mig ce
d
e an Education
ultur ion Urb
a
Agric product Slumn
food
y

al
rt

ogic Hea
chol
ve

Phys tress liter lth

Ho
So
Po

acy
en

cia

us

S
m

in
lv
oy

g
ul
pl

ne
em

Physical
ra
ca l

Alcohol
th tfu
Un

activity
bi
re

Tri alth
al ec

lit
He

y
he esp

ba
e ce

l
R

Us inan

He curi
Se
alt ty
a
st

Age
h
Su

Water and
Sanitation
ess

Gender
Nutritio lthy food

climate ch n &
Air pollutio
n & Acc
Healthcare

Support
services

Social

Peer-

Location
to he a

Caste
Groups
ange

env Work
iron
men
t

59
Application of this model resulted in identification of
24 determinants with specific reference to 27. Health Promotion
Karnataka that are critical and should be addressed
for improving health of the population. Most of
these determinants influence health of people on • Develop a strong framework for
their own and by their interaction with other health implementing health promotion activities
determinants. For example, while alcohol use is under NHM
prevalent among 16% of males, driving a motorcycle
under the influence of alcohol results in about a • Build data driven strategies along with
fifth of emergency registrations(87).Similar monitoring, evaluation and feedback to all
associations exist between depression and obesity, partners to strengthen such activities
poverty and violence, low-income and use of
tobacco, lack of access to safe water and • Health promotion activities in facility based
communicable diseases and several others. The settings like all educational instritutions,
extent, nature, pattern and impact of these work places, family settings , health care
determinants are different across geographical institutions should be systematically
regions and in districts across Karnataka, calling planned, implemented and monitored by
for state-level policies and strong local actions. DoH.

Data is extremely limited in the area of health • Adopt an approach of one health in all
determinants. Essential to note that, mere data on policies rather than just the health policy
the prevalence of these determinants is helpful to a
limited extent and information is required on the
interactions, policy frameworks, action programs, Health promotion, often used interchangeably with
advocacy, health promotion strategies and several health education is different from health education.
others. Global and national evidence indicates that It is a combination of health education and healthy
a substantial health impact and disease burden can public policy(88).Health promotion ideology
be reduced by addressing health determinants. recognises that only informing / educating people in
Significantly, policies and programmes from the absence of support systems and environments
outside health sector do not keep health in the has limited impact, as health is not only an
centre of their policy works, while health sector has individual issue, but also a social responsibility to
not evaluated the impact of various policies / change the underlying socio economic and other
programmes on health of people. These determinants to achieve equity in healthcare(89).
determinants can be addressed through a variety of This approach moves from ‘victim blaming’ to
cost-effective policy and programme interventions. ‘people’s empowerment’.
Addressing each of these determinants requires a Health promotion includes building public health
set of integrated actions, implemented at policies, creating supportive environment,
population levels with an agreed-upon goal and strengthening community for action, developing
measurable indicators(86, 87). Actions in the area personal skills for change and reorienting health
of tobacco and alcohol control, road safety, violence services. Many high-income countries have been
prevention, mental health, air pollution and several able to reduce the burden of NCDs and injuries
others is the joint responsibility of several through strong health promotion strategies that
ministries/departments and requires a strong have addressed the root causes rather than merely
policy framework, state action plan, data touching the surface. Implementing health
information, advocacy and awareness, strong promotion strategies require strong intersectoral
legislation, building safe environments, taxation coordination mechanisms in collaboration and with
measures, public and school education, the active participation of sectors outside health.
enforcement, technology use, health sector Since the health sector faces a huge burden of
mobilisation, monitoring and several others. health conditions, health department has to
Establishing a strong intersectoral coordination advocate for strong integrated policies and
mechanism to address the challenge of programmes that can reduce this burden and work
multisectoral determinants is urgently required in towards achieving health goals.
the state. Strengthening institutional mechanisms
with adequate authority, funding and responsibility Developing joint action plans and overseeing
can greatly enable strategies to address health implementation by concerned sectors is a very
determinants. Developing a health Charter in useful mechanism. This process requires capacity
addition to advocacy awareness and education building of all sectors, including health to develop
plays a significant role in many of these activities. such mechanisms. Similarly, developing
institutional mechanisms (e.g., Karnataka Road

60
safety authority with health, police, transport, IT and healthcare is another major problem to be tackled.
education; Setting up Yuva Spandana Kendras Political action needed for health promotion is
(Youth guidance centres for health promotion under central for social development, public health and for
Yuva Spandana program through the Department of health promotion for improving people’s health.
Youth Empowerment and Sports) in select areas of
high public health importance can facilitate this
process. Few good examples exist in the state as in Settings for Health promotion
the case of tobacco control, but is lacking in many
other areas. The state has poor health promotion
frameworks for implementing activities under NHM • Schools and colleges
and needs strengthening. Building strategies based
on data and evidence along with monitoring,
• Workplaces
evaluation and feedback to all partners can • Health and wellness centres
strengthen such mechanisms.
• Family settings
Several challenges need to be overcome in health
promotion activities starting from behaviour • Health care facilities
modification of people in the society. Inequity in

28. Women's Health

• Based on the available data and death audits, • Establish Level 3 referral ICU in all medical
identify districts and talukas within districts colleges in all districts with Dialysis unit and
performing poorly on MMR with concomitant specialist services (obstetric medicine).
mapping for complete RCH resources for
strengthening maternal health programs on • Continually upgrade the skills of health
priority. workers in providing emergency obstetric
care and life support and also in identifying
• Strengthen essential and emergency and managing high risk pregnancies.
obstetric care services across the state and
close the disparity gap between districts by • Strengthen monitoring mechanisms and
strengthening the public health care facilities undertake concurrent evaluation of the
with adequate resources (including human program and activities on a yearly basis to
resource, financial resources and others). delineate areas that require improvement.

• Upgrade maternal ICU, HDU with 1:1 staff • Focus on improving overall health of women
nurse/ANM facilities as per NHM by adopting life course approach and by
recommendations. Develop and implement addressing all health concerns of women like
SOP for Labour ward, Operation theatres, anaemia, cancer, domestic violence, gender
HDU and ICU in accordance with standard disparity etc. (Ex: Address anaemia among
protocols recommended by NHM/WHO. women through broad based approaches like
Establish State of art genetic center and fetal providing IFA supplementation across the
medicine unit with lab at 3-4 medical lifecourse, improving nutritional services
colleges in the state. under ICDS scheme, Kishori shakthi yojana
and SABLA scheme, ensuring food security,
improving literacy and by reducing poverty
among women).

Globally and in India, women are an important pillar

of our society and are the primary caretakers, but
still, they suffer more and have poorer health
outcomes - with repercussions not only for women,
but also for their families and society. Globally,
about 800 women die every day of preventable
causes related to pregnancy and childbirth, and 20
per cent of these women are from India (90). India’s
anaemia burden among women is widespread, with

61
53.1 per cent of non-pregnant women and 50.3 per levels, minimum availability of standard simulation
cent of pregnant women being anaemic as per the labs for acquirement of competency,
NFHS-4 in 2016, despite having various disproportionate demand-supply of beds and
programmes and policies for the past 50 years. non-uniform admission-discharge policy at public
Women also bear exclusive health concerns, such hospitals resulting in overcrowded public hospitals
as breast cancer, cervical cancer and menopause with reduced satisfaction among patients, difficulty
apart from higher rate of heart attack deaths, in sustaining programmes like LAQSHYA and NQAS,
depression and anxiety, suicides, urinary tract problems in use of digital technology, lesser focus
conditions, sexually transmitted diseases. Women’s on health education of public regarding safe sex,
health are influenced by various factors like role of contraception, family planning and emergency care
women in our society, gender disparities, poverty, life support, data management issues and
illiteracy, early marriage, dowry system, domestic nonuniformity in adaptation of strict protocols for
violence, sexual abuse, nutrition, access to quality referrals and others.
healthcare and affordability and several others.
While the primary answer to issues with women’s
Maternal health has been a priority public health health is the gender inequality, there are others
problem for decades in the state of Karnataka. which also include the poor healthcare systems.
Initiatives like Janani Suraksha Yojana, Janani Despite taking necessary action to improve health
Shishu Suraksha Karyakaram, LAQSHYA and NQAS indicators and providing healthcare for all, the
programmes involving upgradation of labour ward, government must also focus on the
operation Rooms and other wards, and several implementation, monitoring and evaluation of
other programs implemented in the state have programmes for coverage and quality of services.
overall resulted in considerable gains in terms of Apart from health sector, departments of women
improvements in maternal health. Karnataka’s and child development, rural development,
Maternal Mortality Ratio (MMR) declined to 92 per education, welfare and others need to establish
one lakh live births in 2016-18 from 97 per one lakh strong intersectoral mechanisms with a focus on
live births in 2015-17 (91). The total fertility rate is 1.7 health and social determinants to correct
children per women, which is below the inequalities for better health outcomes. There is
replacement level of fertility (91). also a need to work on bringing awareness in the
society about gender equality and equal opportunity
Despite certain improvement in women’s health in for education, health, and work for women.
the state, several other health concerns of women Achieving sustainable health through investment
remains far from being achieved or addressed. and priority-driven approach in strengthening and
Prevalence of anaemia among women in the age expanding healthcare services and creating
group of 15-19 years has increased to 49.4% during awareness on women’s rights will effectuate in
2019-20 from 45.5% during 2015-16. Utilisation of achieving Universal Health Coverage in Karnataka.
public health facilities for delivery has not improved Women’s empowerment, mobilisation and
over years. According to NFHS-5, only 64.8% of engagement in health care programmes is vital to
delivery in the state is taking place in public sector bridge the gaps. A life course approach with women
which was a marginal increment when compared to given importance at all stages as a child, as an
NFHS-4 (61.4%). Utilisation of public health facilities adolescent, working and family member and in later
for delivery in urban area is very low (56% years needs a focus, integration and an investment.
according to 91). Percentage of deliveries
undergoing caesarean section has increased in the
state, though the reasons for the same are largely
debatable. Between NFHS-4 and NFHS-5, SDG goal related to Women’s health(92)
percentage of caesarean section increased from
23.6% to 31.5% respectively. In addition, wide • By 2030, reduce the global maternal
disparities in women health indicators between mortality ratio to less than 70 per
regions and districts of Karnataka also remain 100,000 live births
unaddressed. • By 2030, ensure universal access to
Notwithstanding the major investments into RCH sexual and reproductive health-care
programmes, there are several major barriers and services, including for family planning,
challenges to be overcome in implementation of information and education, and the
programs and activities. Some of these include - integration of reproductive health into
acute shortage of trained and skilled human national strategies and programmes.
resources, regional disparities in infrastructure
and manpower, non uniformity in implementation of
programmes, poor maintenance of records at all

62
29. Child Health
The vision group envisions that every child in the state
• Constitute an independent task force to should have a healthy survival, optimal development and
examine the district level variations and reach their full potential as happy and productive adults
deficiencies to strengthen regionalisation through a responsive, assured, affordable, accountable
of child health care services to reduce and high-quality healthcare system. Karnataka is home to
inequities and variations for setting up 23 million children below 18 years of age (> 27 % of the
specific strategies for aspirational and low projected population in 2021) spread over 31 districts. With
performing districts. policy reforms, strengthening of infrastructure in
maternal and child health care services and programme
• Implement a decentralised action-oriented implementation, there has been a decline of child
approach at the district level for effective mortality and morbidity rates (Figure 17) overtime, but
data management under the district health challenges still exist due to regional disparities in
information system for early infrastructure, coverage and quality deficiencies. In order
decision-making at the district, sub district to move forward towards the state commitment to the
and community levels. global agenda to end preventable deaths of new-borns
• Further scale up new-born and child and to achieve a single digit neonatal mortality rate by
health care services through evidence- 2030, there is need to augment and innovate through
based interventions, improved intrapartum, intensified actions.
postpartum and follow-up services with a Child health programs are delivered under the
focus on early intervention through Reproductive, Maternal, Newborn, Child Health and
screening and effective referral linkages. Adolescent Health (RMNCH +A) strategy of the National
• Enhance quality and monitoring through Health Mission through integrated interventions. The
establishment of standard protocols, quality program supports improved child health, nutrition status
parameters, quality monitoring, nutrition and addresses several factors contributing to neonatal,
audits, mentoring programmes and infant, under five mortality and others. The state has
accreditation systems. implemented several initiatives through evidence-based
interventions like facility based new-born care,(
• Transform paediatric care units and bring new-born stabilisation units, new-born care Corner),
them to the same level of infrastructure, home based new-born care, Janani Shishu Suraksha
staffing and clinical standards or new-born yojana, child death reviews, Kangaroo care and lactation
care using standard facility based clinic, integrated management of neonatal and childhood
paediatric care packages. illnesses and intensified the area control fortnight
• Develop a model for reinforcement and programs. Further, under Rashtriya Bala Suraksha
reorientation training, soft skills Karyakrama ( RBSK) interventions to address birth
development and sharing of good defects, diseases, delays and deficiencies are delivered.
practices for improved childcare services. The basic vaccination coverage in the first year of life has
increased from 63% to 84% between NFHS 4 and NFHS 5
• Strengthen state level and district level surveys. Acute respiratory infections, childhood diarrhoea,
convergence committees and establish other childhood infections are being addressed through
institutional mechanisms for convergence several programs along with strengthening breast
of activities by the Departments of women and feeding practices, young child feeding practices and covering
Child development, education, social justice micronutrient deficiencies like anaemia and others.
and empowerment for early childhood
development and nutrition programs. Figure 18: Percent coverage of all basic vaccinations
• Develop and implement IT solutions for among children aged 12-23 months by district, NFHS-5
improved documentation and digitalisation
of registers to support various programs Ramanagara Kolara
100 86

Tumakuru 98 Koppala 85

and to link all related software under Mysuru 97 Karnataka 84

different activities. Hassana 97 Yadagiri 83

Shivamogga 96 Belagavi 81

• Promote a network of health promoting Haveri

Chitradurga
96
95
Raichur
Davanagere
80
79

schools through development of framework, Mandya 94 Bagalakote 79

standards and accreditation system. Uttara Kannada 94 Bengaluru Urban 78

Chamarajanagara 93 Chikkaballapura 77

• Life skills training and counselling Bengaluru Rural

Chikkamagaluru
93
91
Kalaburagi
Bidar
76
75

services should be mandatory in all Kodagu 91 Gadag 74

schools to promote social and emotional Udupi 90 Ballari 72

Dharawada 88 Vijayapura 71
skills as well as mental health of children. Dakshina Kannada 87

63
However, variations across districts are recorded
varying from 100 % immunizations for less than 1 Box 6: Health promoting schools
year old in Ramanagaram to 71% in Bijapur with also
a higher coverage in the rural areas as compared to Schools are important spaces for promoting
urban areas (Figure 18)(28).Regional variations in child and adolescent health. More children
child nutrition, child immunisation, coverage under than ever are now attending school and the
different programs have been documented as school has become a natural entry point for
revealed by NFHS-4 and 5 surveys (57, 91, 93). As a reaching children and adolescents with health
decline in infectious, communicable and nutrition education, health promotion and health
disorders are registered, there is also a growing services. Schools present the ideal ecosystem
burden of emerging conditions like anaemia, over for students to learn, adapt and practice. Thus,
nutrition, gender-based violence, injuries, developing a positive school climate through
disabilities, autism and delayed development the health promoting Schools approach
disorders, onset of NCD factors, technology creates conditions that are conducive to better
addiction, early marriage and pregnancy, lack of health and educational outcomes and
nutrition awareness, poor healthy behaviours, influences health behaviours to the benefit of
academic stress, poor health seeking behaviour children and adolescents, school personnel
and poor compliance to Iron and folic acid and also to the broader community.
supplementation in the 10 to 19 years age group. The Health promoting Schools model uses six
school health program though existing far more strategies to promote good health:
than a decade, needs greater focus and scale of school-level policies, the physical
implementation to achieve maximum benefits. environment, the social environment, the
Several field level challenges exist for improving health curriculum, and linkages to community
child health in the existing programs of Karnataka. and health services. School health services
Despite significant effort and progress, the child under Health-Promoting Schools ensures that
health outcomes in Karnataka still lag behind all students have access to comprehensive
neighbouring States like Kerala and Tamil Nadu. school-based or school-linked health services
The state needs to expand and strengthen the focus through a range a preventive, promotive,
from survival to intact survival and thrive agenda curative and rehabilitative services along with
(early child development, early intervention) by regular health appraisal of school children.
strengthening child health services for equity and School-based interventions for promoting
quality through systems and life-course approach, adolescent health programme (SEHER) in
augmenting infrastructure and motivated human Bihar were first of its kind in India to
resources at all levels for better service delivery, demonstrate the effectiveness of
and setting up multisectoral coordination and school-based intervention to improve
collaboration for implementation of programmes. adolescent health outcomes. Activities of
Health sector reforms and strengthening programs SEHER included establishment of a School
are urgently required to scale up activities, improve Health Promotion Committee comprising
healthcare services to bring further reforms for students, teachers, parents and school
improving child health in Karnataka. It is most management; awareness-raising activities; a
important to focus on districts that are poorly suggestion and complaints box; a wall
performing to strengthen activities in this area. A magazine; competitions; and the adaptation
district wise mapping would be helpful to identify and adoption of policies on bullying and
specific pockets for providing in-depth inputs. substance use. The success of SEHER
Peer Educator programme under RKSK provides an immense scope for improving
children and adolescent health though
The Peer Educator programme aims to ensure that intensification of school health activities under
adolescents or young people between the ages of Ayushman Bharat in the state of Karnataka.
10-19 years benefit from regular and sustained peer
education covering nutrition, sexual and In Karnataka, school health services are
reproductive health, conditions for NCDs, implemented by a team concept , with each
substance misuse, injuries and violence (including team having doctors and nurses visiting
Gender based violence) and mental health. This is schools on a regular basis. Implemented
eventually expected to improve life skills, under RBSK, and even upto taluka levels,
knowledge and aptitude of adolescents. Four peer opportunities are in plenty to promote healthy
educators per village (1 male and 1 female for schools. Can this programme be scaled up
schools and 1 males and 1 female to cover out of with a clear focus and programme outline with
schools) selected based on the recommendation/ monitoring and evaluation ?
nomination of ASHA and the school teacher are
expected to perform a range of activities like
sensitization, education and referral activities.
64
30. Adolescent Health
The vision group envisions that every adolescent
• A landscape analysis of the current status and youth ( 10 – 30 years) should achieve positive
of adolescent and youth health and health, a healthy lifestyle and well-being with the
well-being should be performed to clearly potential to live without any disease or disability in
understand the current status of programs, Karnataka. Adolescents and youth in the age group
services and schemes to develop a of 10 to 30 years is a transitioning period in
baseline district level youth line and everyone’s life and is associated with significant
adolescent development index for a physical, mental, social and emotional changes
long-term perspective during this phase. Many NCD risk factors take their
• Adolescent and youth health and origin during this time. This is also the phase when
well-being programs should clearly focus many life changing events such as education,
on the identified seven areas of nutrition, marriage, childbearing and childcare occur. The
mental health, gender and sexuality, injury growth spurt and hormonal changes including
and violence, leadership and communication, development of secondary sexual characteristics
physical health and well-being as well as creat demand for better and adequate health.
education and life skills. Despite the significant progress made in reducing
• Create enabling environment that the prevalence of Iron deficiency among
promotes health and well-being of adolescents in Karnataka, about 30 micronutrient
adolescents and youth in educational deficiencies have been observed in this group. The
institutions, health and wellness centres, double burden of over nutrition and under nutrition
youth guidance centres adolescent health is prevalent among 31% of adolescents in India and
clinics, yoga and meditation centres, Karnataka may not be an exception(93). The
community amenities like playgrounds, prevalence of mental morbidity among 13 to 17
stadiums, parks and other green spaces. years and 18 to 29 years was 7.3% and 7.5%,
respectively, with depression, anxiety and suicidal
• Establish and enhance robust inter-and ideations(94). Nearly 42% of the total 11288 suicides
intra-department collaboration were in less than 30 years age group, more among
mechanisms between the departments of women(95, 96).The national NCD monitoring survey
health and family welfare and other showed that physical inactivity, tobacco use, raised
departments for promotion of schemes for blood pressure, and alcohol use was common in
vulnerable adolescents and youth this age group; likely to be similar in Karnataka with
• Develop technology-based and technology minor variations(93). Among the 10958 road
enabled programmes for youth that can accident deaths in the year 2019, 4.1% and 19.1% was
integrate solutions in the age group of 0 - 17 years and 18 to 24 years,
with one out of four road deaths among individuals
• Enhance social protection programmes/ less than 25 years(96). Unintentional injuries and
schemes for vulnerable populations violence is also more in this particular age group.
including the urban poor, migrant Data from the Yuvaspandana program reveals that
communities, homeless adolescents, tribal a large number of young people have low
and backward area members and for self-awareness, emotional issues and low
children living with widowed/single mother/ self-esteem and were in need of services for
gender sexual minorities and others specific health concerns(97).
• Enhance skill development, empowerment
Seven select areas have been identified in the
and leadership opportunities by engaging
overall health, well-being and development of
with different organisations and state-level
adolescents and youth in Karnataka. These are (1)
youth Federation through the departments
nutrition, (2) physical health, (3) psychological
of health and other relevant agencies
well-being, (4) education- life skills and
• Establish strong monitoring and surveillance employability, (5) gender- sexuality and
systems for health seeking, morbidity and gender-based violence, (6) injury and violence and
mortality among adolescents and youth by (7) leadership and communication. Data is scant
creating family linked and facility based from Karnataka in these areas as there are no
records in all ongoing programs and large-scale population-based youth health surveys
services under the National Digital Health in the state; when included in larger surveys
Mission and Ayushman Bharat schemes. disaggregated data is not available.

65
The seven areas identified above for preserving and Many policies and programmes of both GoI and GoK
promoting health are important and needs to be have a focus on health of young people. In the state,
addressed and previous efforts through RKSK has there are nearly 400 schemes and programmes
had limited success for variety of reasons. There across all government departments catering to the
are evidence-based and cost-effective sustainable needs of youth. Huge variations are seen with
interventions (Table 10). A review of the ongoing regard to the implementation of these programs in
programs in the state clearly indicate that different departments in different districts with
programmes specific to youth are either absent or different goals and objectives as well as financial
limited to pregnant and lactating mothers, along arrangements..
with lack of awareness about health and youth
issues, stigma associated with help seeking,
dependence on others for providing help apart from
absence of data in the specific areas.

Table 10: Cost effective programmes, strategies and solutions for health and
related problems among youth.

1) Nutrition ICDS, Mid-day meal program, village health nutrition and

sanitation committees, WIFS, Annual deworming program,
National Iodine Deficiency initiative, Anemia control during
pregnancy through Iron and Folic acid supplementation program
2) Physical Health and Stronger focus on health promotion aspects of National Program
Well-being; for control of NPCDCS, promotion of physical education in
education systems, effective implementation of anti-smoking
laws, prevention of alcohol use, and anti-substance use laws
along with networking and standardization of existing
de-addiction centers for early rehabilitation.

3) Mental health and Implementing and promoting School mental health program,
psychological well-being; Yuva Spandana program, online tele-counselling and support
services, Youth helpline, Sneha clinics (adolescent health and
wellness clinics) throughout Karnataka.

4) Education, life skills & Promotion of National Service Scheme, National Cadet Corps,
employment Bharat Scouts and Guides, life skills and counselling services
program.

5) Gender, Sexuality and RMNCH-A+ program, RKSK, Adolescent reproductive and sexual
Gender based violence; health clinics, urban wellness centers , gender sensitization and
gender equality programs, Spoorthi program

6) Injury and violence Use of helmets, seat belts, no-drink drive, less speeding, ban on
cell phone use, good pedestrian behaviors and implementation of
these laws ; mental health promotion – building resilience-
control of substance use – mental health services ; ensuring
women’s safety – one stop centres-other violence prevention
measures – school safety programmes

7) Leadership and Promoting GoI’s Skill India and Atma Nirbhar Bharat initiatives,
Communication Youth empowerment programs, empowering youth clubs within
the state for sustained economic and social stability

66
31. Health of The Middle-aged
Ensuring that the population in middle aged groups
• Karnataka should establish an are provided basic health services in organised and
autonomous Occupational Health Authority unorganised work sectors to achieve optimum level
as an umbrella autonomous organisation of physical, mental and social health is the vision for
to plan, supervise, implement, monitor and the state. Nearly 45% of the 62 million population of
enforce occupational health services Karnataka (27.9 million) are classified as working
across multiple sectors population and their health status is likely to impact
the overall health, economy and productivity of the
• A state-level task force should be state. Most significantly, children, women and
constituted to review existing health and elderly in their families are dependent on this
related programs, services and productive section.
legislations to recommend changes to
address changing health priorities in
workplaces Figure 19: Evolving work environments

• A state Institute of occupational health is

necessary to advise the government and
Corporate
coordinate activities of capacity building, culture
research, diagnostics, surveillance and Newer
Occupations
Privatisation
Traval for
policy analysis in occupational health Work

• A robust and reliable occupational health

Increased Technology
information system which collects data women at driven
from different sectors on a regular basis is work Workplace

required for reporting, notification,

monitoring and surveillance of health of Evolving Work
Rotating Environment
workers shift work
Artificial
Intelligence and
(Work in odd
Automation
• Pilot demonstration models for integrating hours)

basic occupation health services into

primary healthcare in three different High Job
demans Physical
districts in the state should be facilitated by Effort reward Inactivity
the government. imbalance
Competative
Low Job
• Sustainable capacity building programs to Security
target driven
work styles
bridge the deficiencies in qualified
occupational health professionals should
be started in different areas of
occupational health including training for Nearly 92 % of the workers are employed in the
primary healthcare staff at taluka and unorganised sector with minimal and health
district levels welfare benefits : several factories and industries
• Workplaces provide an excellent employ significant numbers. With most of the
opportunity to strengthen health promotion industries concentrated in places like Bangalore
and screening activities for control of Rural, Bellary, Mysore, Kolara and Tumkur ( 75% of
NCDs, NCD risk factors, mental disorders, all industries), people in this age group work in the
injury prevention, safety promotion and unorganised sector(11). In cities like Bangalore and
should be implemented in all workplaces. few other places, a large population works in IT and
BT sectors with significant numbers from outside
• Most importantly, it is crucial to recognise the city.
and implement basic occupational health
services for those in the unorganised
sector which include screening, health
protection, guidelines and linkages with
existing national and health and welfare
programs.

67
The work environment, pattern, nature of work and People working in unorganised sectors are not
life styles have changed significantly over time. healthy either, apart from their lesser exposure to
Health priorities of working populations are rapidly environmental toxins and formal work
evolving but occupational health ecosystems has environments. The fragmented and scattered
not evolved at the same pace to address the fast nature of this sector makes it challenging to track
changing health risks among workers (Figure 19). their health issues in the absence of well conducted
Workers today face a quadruple burden of population-based health surveys. In addition to
occupational diseases, communicable diseases, several health problems, people in this age group
noncommunicable diseases and injuries. In this age also face number of family, social and economic
group, apart from the major occupational disorders problems. The recent Covid 19 pandemic is a living
like silicosis, pneumoconiosis, musculoskeletal testimony revealing a combination of health, social,
injuries, pesticide poisoning and noise induced economic and psychological problems amidst
hearing loss, emerging health problems like NCDs situations of uncertainty and increased stress. In
and their risk factors are highly prevalent. the absence of proper social protection
Substance use and mental disorders are a major mechanisms this population is highly vulnerable to
problem in and outside work places ( Table 11). many influences including health. There are several
Injuries account for a major share of morbidity, programs and schemes for safeguarding health of
mortality and disability. Most significantly, NCDs are the workers which is implemented in Karnataka.
not covered by existing legislations in occupational Some of them like Rashtriya Swasthya Bima Yojana
health services and programs. , ESI scheme for wide range of workers, Karnataka
Labour welfare board schemes, construction
workers welfare board benefits, and individual
Table 11: Occupational diseases, NCDs,
schemes operated by departments covering
Psychological problems in workplaces(97)
maternity benefits, disability benefits, accidental
death benefits and even funeral assistance for
NCDs, Psychological Prevalence individuals and families and others.
problems in workplaces
Diabetes 8.1% A review of the current occupational health
services indicates their presence outside the health
Obesity 30.9%(men), 32.8%(women)
sector and primarily in the Department of labour.
Overweight 33% Even within the Department of labour they are
Hypertension 11% - 31% mainly for the organised sector workplaces
Tobacco, Alcohol use 31% , 27.7% covered by specific health legislations or by the
Psychological distress 23% respective global health policies. The Indian
Factories Act is applicable to all registered
Work stress 10 - 11%
factories and, occupational health services are
provided by occupational health units, established
Among women, health problems related to in the premises based on number of employees and
reproductive child health are still prominent in rural the nature of the industry. The act prescribes the
areas despite the progress made in our MCH need for occupational health clinic in all hazardous
programs. Specific problems of women include industries with 50+ workers governed by
noncommunicable diseases and substance use state-level inspectorate. ESI scheme provides both
disorders, especially consumption of tobacco and curative services and other benefits to enrolled
its products in rural areas. Anaemia (46 %)(91), workforce. Mines, plantations, cinemas, tobacco
depression and anxiety (3 - 4 %)(99), diabetes workers and several others have health
(2.5%)(100), hypertension (11.5%), obesity (11.2%)(100) systems-based separate acts for their group of
and others placing a significant burden on women workers. In 2020, 13 such labour laws were
and their families. In Karnataka, nearly 20.8% of replaced by the occupational safety, health and
deaths among women aged 15 to 49 years was due working code to integrate several of the schemes
to self-harm followed by deaths due to ischaemic under one umbrella(102).Consequent to such
heart disease(11.7%), maternal causes (4.37%), diversified range of activities, many other
tuberculosis (4.1%) in 15 to 49 years(91, 101).Women components of integrated healthcare like training,
living in underprivileged areas, urban slums, technology use, service delivery are also split
marginalised communities, tribal areas, migrant across different sectors with no uniformity in
populations have a disproportionate health burden services. Hence, policy and legislative reforms are
and also cannot afford proper healthcare due to urgently required along with changes in health
several reasons. systems and services for working populations
along with strong advocacy measures.

68
32. Health of the elderly
The subcommittee of the vision group for care and
• Delivery of wide range of preventive, support of elderly envisions an independent,
promotive and welfare services for elderly healthy and secure living for all senior citizens in
with adequate protection mechanisms by the state to live a life with dignity till the end. The
developing an ecosystem for geriatric goal is to promote healthy ageing for all people to
health and care in the decade of healthy lead a healthy and happy life.
ageing 2021 – 2030 and beyond
The phenomenon of population ageing considered
• Training personnel for elderly healthcare as unprecedented global demographic
activities with the development and transformation is a major concern all over the
adaptation of eight modules for different world. The requirements of the elderly are complex
categories of health personnel as and belong to multiple domains of physical, mental,
suggested by the subcommittee on elderly social and economic spheres. The determinants of
health. elderly health pervade beyond the confines of
• Enhance clinical and related care through health and are reflected in the SDGs in 10 different
effective implementation of NPHCE, areas. Protecting and promoting positive health
strengthening of activities in health and among elderly should be an area of highest priority.
wellness centres, geriatric care clinics in Elderly suffer from multiple and chronic diseases
all medical colleges at the district level, and need long-term and constant care. Their health
including packages under the ABArK problems also need general and specialist care
schemes . from various disciplines in the medical field. The
immobile and disabled elderly need care closer to
• A comprehensive plan for elderly care in their homes and all these not just in the range of
the state needs a task force to be services but also in terms of quality.
constituted with experts drawn from health
and all related sectors to examine issues
beyond medical care, including areas of Figure 20. Health status of elderly, LASI study
assistive living, adult day care, long-term
care, residential care, hospice care and Percent
home care to develop integrated models of 80.0
68.4
comprehensive geriatric care in both urban 70.0
59.9
61.3
and rural areas and for both the rich and 60.0 53.8 51.7
50.0 51.5
poor people through a hub and spoke 40.0 36.6 39.6
35.6
model, juxtaposed with primary health 30.0
30.0 29.8 33.4
20.0
care centres as a add-on service 20.0
10.9 24.5
30.3
24.6
component. 10.0 4.9 12.7 8.0 11.9
17.7
11.2
0.0 2.0
• set up a state geriatric Institute to provide <45 45 49 50 54 55 59 60 64 65 69 70 74 75+

standardised academic and research Any ADL Limitation Any IADL Limitation Any Aid Support
activities in every medical College with a
central monitoring and evaluation
framework. Elderly account for 8.6% of the total population in
2011 and is projected to be 20% by 2050 in India
• Community-based services which are well (12).The number of elderly in Karnataka is nearly
designed, and monitored with stringent 6,000,000 (9.1 %)(11, 103) and greater than the
regulations and legislations as required for national average. The NSSO 2019 report indicates
elderly and this requires innovation for that 27.7% of the elderly reported ailing in the 15
providing assistive devices for the disabled days reference period with an equal proportion
population among the elderly. among males and females(91).The vulnerability of
elderly increases across economic levels and in
other dimensions such as place of residence,
gender, caste, marital status, living arrangements,
children and economic dependence.

69
As per the recent Longitudinal Ageing Study of
Indians study, more than two thirds had sought
outpatient care in the past year and from a private
facility. Expenses of the private facility were double
then what was usually in a public facility. Less than
half were reporting satisfaction with their own life
and 1/10 reported poorly on self-rated health. Ten
percent of the elderly reported any experience of
ill-treatment in the last one year. Limitation in
activities of daily living was reported by 18.7 % and
nearly half required assistance for day-to-day
activities with the trend increasing with age(103)
(Figure 20).
The National Programme for Health Care of the
Elderly (NPHCE) is the single most comprehensive
and dedicated program for elderly in India. In
addition, National Programme for Palliative Care,
NPCDCS, National Programme for control of
blindness, National Programme for Preventing
Deafness also address issues and concerns of the
elderly. Karnataka government is implementing the
NPCHE programmes across all districts in the state
since 2019 and infrastructure strengthening has
been a key focus. Apart from conducting geriatric
clinics and providing facilities at times of need the
program is essentially supply side driven and does
not answer the demand related questions. In a
recent review of the NPHCE programme in Kolar
district many challenges with regard to
implementation of the programme has been
observed(104).
The existing services in the state addresses select
health conditions as per funding and manpower
availability. There are several challenges like
accessibility and availability of services,
fragmented family structure, costs for additional
support, health economic dependence of the
elderly, integrated rehabilitation services, absence
of continued support, patient given education is only
cursory and end of life care is scant in both
qualitative and quantitative terms. Support
programs for elderly are unmonitored in its true
sense at the district and sub district levels. In
addition to all these, the inadequately trained staff
at all levels and failure of convergence and linkages
between silo programs remains a major challenge.
The principles of elderly care are – recognise them
young for effective preventive care, plan for a
comprehensive range of services for every elderly
person, incentivise service delivery at all possible
levels, support collaborative care and involve family
members, and arrange services for 60 + and for
those below 60.

70
33. Health Status And Burden

Section 4: Implementing national and state programmes

Policy reforms by successive governments, Success has also been documented in the
moderate investments in infrastructure and fight against a few of the communicable and
manpower and strengthening programme infectious diseases. The state has
implementation have brought positive changes in implemented all national programmes over
the state amidst sociodemographic and time jointly with the central government
epidemiological transition. In the year 2017, along with its own resources, programmes
Karnataka became first among all states in India to and efforts. Consequently, the burden due to
set forth a comprehensive plan for UHC in line with some infectious diseases like Tuberculosis,
achieving SDGs by 2030(1). Malaria, HIV/AIDS (Figure 21 & 22), and
others are on the decline due to rigorous
As per NITI Aayog health index ranking, the state implementation of disease control
has moved from 9th to 6th position in terms of programmes, while Leprosy is on the verge
overall rank as well as in incremental rank between of eradication as per official data
the base year (2015-16) and reference year sources(28). The burden of few localised
(2017-18)(3). Karnataka state was ‘one among the diseases like encephalitis, AFS, KFD and
top ten performer Front-runner Larger States’, with others have been controlled and mortality
a progress in performance score in health has been reduced.
outcomes domain (incremental change= 2.75) while
there was a decline in performance score in key Few childhood infectious diseases like polio,
inputs/processes domain (incremental change= measles and others are also on the decline
-2.81) between the base year and reference year(13) and continued efforts are required for
further success. The coverage of
The National Family Health Survey (NFHS) data of immunization increased from 63 % to 84 %
2015 - 16 indicates that Karnataka has performed between NFHS –4 and NFHS – 5(91). The
relatively well in the area of maternal and child coverage of immunisation varied from as
health. The fertility level , the birth rate (per 1000 high as 100% in Ramanagara to as low as 71%
population), the death rate (per 1000 population) in Bijapur (Figure 18). Urban areas had poor
also decreased from 7.4 in 2008 to 6.3 in 2018 along coverage when compared to rural areas.
with increase in number of child immunization, NFHS-5, also highlighted the poor
number of mothers receiving antenatal care and help-seeking behaviour and poor practices
number of institutional deliveries are documented related to ARI (acute respiratory infection)
over the past decade. The Infant Mortality Rate and childhood diarrhoea.
(IMR) and Under Five Mortality Rate has declined
over the past decade(91) as well as maternal
mortality (Figure 22). Life expectancy has also
increased in the last 2 decades (18, 54, 91, 105)
(Figure 19)

Figure 21: HIV Prevalence levels among ANC clinic attendees in Karnataka

Amidst this changing scenario, it is to be

realised that progress made in some of the
areas highlighted earlier is not uniform
across the state. Disparities and variations
0.89 0.69 0.53 0.36 0.38 exist between regions, between urban and
rural areas, across various districts and
2008-09 2010-11 2012-13 2014-15 2016-17 even within districts.

71
 Figure 22: Trends of early neonatal, neonatal, infant and under 5 mortality rates since 2008.

Early neonatal mortality rate Neonatal mortality rate Infant mortality rate
25 22.5 45
41
per 1000 live births

22

per 1000 live births

per 1000 live births

22.5 25 25
25 24 40 38
20 20
20 19 23
35
18 22.5 22 35
17 21 32 32
17.5 31
15 20 19 30 28
15
13 13 18 18
25
12 17.5 25 24
12.5 16 23

10 15 20
2009 2011 2013 2015 2017 2009 2014 2009 2011 2013 2015 2017

Under 5 mortality rate MMR TFR

55 250 2.2
2.1
per 1000 live births
225
per 1000 live births

50 48 213 2.1
45 200
45 2
178
40 175
40 1.9
37 144
35 150
34 133 1.8
35 1.8
31 125
108 1.7
30 29
28 28 100 92 1.7

25 75 1.6
2009 2013 2004-06 2007-09 2010-12 2013-15 2016-18 2019-20 2005 2015 2019

25 Birth Rate and Death rate Malaria 52 Anaemic

in Karnataka (2008-2018)
20 50
51.2

percentage
70000 48
15 47.8
60000
50000 46
10 40000 44.8
44
30000
5 20000 42
10000
0 0 40
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2005-2006 2015-2016 2019-2020
2011

2017
2012

2016

2019
2013
2010

2015

2018
2014

2014
2007
2006

2009

2020
2008

Atleast 4 antenatal care visits Institutional delivery Child Immunization

85 100 90
94 94
80 84
percentage

percentage

percentage

80 80 80
64.7
75 60 70
70 62.6
68
70 40 60
55
65 20 50

60 0 40
2005-2006 2015-2016 2019-2020 2005-2006 2015-2016 2019-2020 2005-2006 2015-2016 2019-2020

• According to the Epidemiological Transition • Mental and substance use disorders account for
Level grouping by India State-Level Disease about 10 % of total morbidity in the state
Burden Initiative, Karnataka comes under population(99).
higher-middle category. In the year 2016, the
• Neurological disorders in the state account for
proportion of total disease burden in the state
2.52% of all deaths and 3.4% of total DALYs(101,
was highest from Non communicable Diseases
106) with stroke being the leading contributor of
(62.0%), followed by communicable, maternal,
mortality as well. About 41564(106) and 700,000
neonatal, and nutritional diseases (25.1%) and
(107) deaths were due to stroke in Karnataka
injuries (12.9%)(11). NCDs, particularly
and India respectively in the year 2019.
cardiovascular diseases are leading cause of
deaths in those aged above 40 years along with • In 2019, about 10,000 persons, majority in young
respiratory disorders and cancers(15) (Figures and productive age groups and often men, died
20 – 25). in road crashes(96). With increasing urbanisation
and unsafe environment in homes, schools and
• The leading causes of DALYs in the state in 2016
work places, fall injuries has become a major
were Ischemic heart disease (11%), followed by
cause of deaths and hospitalisations. Burns,
COPD (4.9%) and self-harm (4.3%). The
drowning, mechanical injuries, and agricultural
contribution of Diabetes towards DALYS
injuries have increased in last decade contributing
increased significantly from 1.1% in 1990 to 3.4%
for a greater share of hospital admissions and
in 2016(101).
disabilities. Suicide (often cutting across mental
72
 health and social issues) and violence among
children, women and elderly are becoming
major health and social concerns.
• Among all the risk factors, high blood pressure
(10.5%) contributed highest towards DALYS in
the state in 2016, followed by dietary risks (9.6%),
high fasting plasma glucose (8.3%), tobacco use
(5.5%), high total cholesterol (5.4%) and alcohol
and drug use (4.1%)(101). Among the risk factors
for NCDs and RTIs, unhealthy diet, high blood
pressure, high blood sugar, high cholesterol,
and overweight together contribute for about a
quarter of the total disease burden in India.
Karnataka was one among the states with high
proportion of these risk factors leading to that are at the central stage today. Health sector
cardiovascular disease, diabetes, stroke and needs to respond to these challenges and be
cancers ( Figures 26 and 27). responsive for all existing and emerging health
conditions in both rural and urban areas.
• Amidst these existing and established
problems, many emerging health conditions and • The various innovative efforts undertaken by the
concerns present greater challenges for the State Government has resulted in reduced
coming years. An elderly population with morbidity and mortality in some areas
multiple physical, mental, neurological accounting for partial success. Both NRHM and
conditions ; dementia and Alzheimer’s among NUHM and various activities in both schemes
elderly: suicide in multiple segments of society, have made progress in implementation across
especially among women and younger age the state. Expansion of water and sanitation to
groups ; poisoning with a variety of products ; village level has shown remarkable success.
depression – anxiety and other disorders; The Yeshasvini Co-operative Farmers
substance use problems with drugs – alcohol – Healthcare Scheme is a largest self-funded
tobacco – other addictive substances ; child healthcare plan in Karnataka and also in India,
obesity and coexistence of malnutrition; COPD – completing 15 years of successful
asthma – allergic conditions due to air pollution; implementation(15). Establishment of Suvarna
technology addictions among youth ; stress and Arogya Suraksha Trust(SAST) to deliver the
its consequent effects ranging from sleep Vajpayee Arogyashree Health Assurance
disorders to cardiac events; sports injuries; Scheme to BPL families in the state and its
disasters of varying nature; localised epidemics expansion to tertiary and secondary care is
and moving pandemics as in Covid-19 ; new another novel programme in the state (16). More
suspected zoonotic infections; and others are a such examples in individual areas are provided
few examples of emerging health conditions in later sections of this report.

Figure 23: Life expectancy at birth in Karnataka Figure 24: Trends of DALYs due to various diseases
in different age groups

Communicable, maternal,
70 neonatal, and nutritional
69.5 diseases

69 Non-communicable
diseases
68.5
10
68 Injuries
67.5
Percent of total DALYs

67
66.5 5

66
65.5
65 0
2004-08

2007-11
2008-12
2005-09
2006-10

2009-13
2010-14
2011-15
2012-16
2013-17
2014-18

Under 5
5-9
10-14
15-19
20-24

30-34

70-74

80-84
25-29

35-39
40-44
45-49
50-54

60-64
55-59

65-69

75-79

85+

73
 • The changes in disease burden over time are • In this complex and changing scenario and
influenced by a wide range of health, social, because of these emerging challenges and
economic and environmental determinants that issues, the state has a long way to go in
influence the origin, burden, progress and achieving standard health outcomes. The health
outcomes of these conditions. Factors linked to department has to understand the nature and
access, availability, and utilisation of health care size of problems, have the resources to address
services broadly influence the outcomes and problems, design and implement solutions
financial impact of all health problems. uniformly across the state in an equitable and
Understanding the overall disease burden and sustainable manner, ensure well-functioning
its determinants is a necessary step towards health service delivery system and monitor and
bringing for working towards improving health evaluate programmes.
outcome.

Figure 25: Major disease burdens across age groups in Karnataka.

0-14 years (7% of total deaths) 15-39 years (11.4% of total deaths)

1.2%
HIV/AIDS & tuberculosis
4.6% 1.4%
5.7% 9.9% 9.8%
Diarrhoea/LRI*/other

23.7% 7.4% NTD’s† & Malaria

2.3%
12.3% Maternal disorders
22.9%
1.3% 6.5% Neonatal disorders
2.2% 1.2%
1.3% Nutritional deficiencies
13.9% Other communicable diseases
8.2%
44.9%
Cancers
10.1%

4.3%
Cardiovscular diseases
4.5%
Chronic respiratory diseases

Cirrhosis

Digestive diseases
40-69 years (41.6% of total deaths) 70+ years (40% of total deaths)
Neurological disorders
1.7% 2.3%
3.4% Diabetes/urog‡/blood/endo�
3.5%
4.8% 4.8% 3.9%
2.5% Other non-communicable
6.7%
16.1% 11.9%
Trasport injuries
8.8%
13.7%
3.9% Unintentional injuries
7% 1.3%
4% 1.1% Suicide & Violence

13.9% Other causes of death

10.6%

36.8%
37.2%
*LRI is lower respiratoey infections
†NTDs are neglected tropical diseases
‡Urog is urogenital diseases
�
Endo is endocrine diseases

74
Figure 26: Leading causes of DALYS in Karnataka in 1990 and 2016.

Leading causes of DALYs 1990 Leading causes of DALYs 2016

Diarrhoeal diseases 1 1 Ischaemic heart disease

Preterm birth complications 2 2 COPD*

Lower respiratory infections 3 3 Self-harm*

Ischaemic heart disease 4 4 Stroke

Other neonatal disorder 5 5 Diarrhoeal diseases

Tuberculosis 6 6 Preterm birth complications

Measles 7 7 Diabetes

Neonatal encephlopathy 8 8 Sence organ diseasee

COPD* 9 9 Iron deficiency anaemia

Congental birth defects 10 10 Road injuries

Self-harm* 11 11 Low back &neck pain

Stroke 12 12 Migraine

Iron deficiency anaemia 13 13 Lower respiratory infections

Sence organ diseasee 14 14 Tuberculosis

Asthama 15 15 Congental birth defects

Low back &neck pain 17 21 Neonatal encephlopathy

Road injuries 18 23 Other neonatal disorder

Migraine 21 24 Asthama

Diabetes 23 74 Measles

Communicable, maternal, neonatal, and nutritional diseases

Non-communicable diseases
Injuries

Figure 27: Trends of risk factors from 1990 -2016.

Risk factors 1990 Risk factors 2016

Malnutrition* (34.3%) 1 1 Malnutrition* (10.7%)

WaSH* (11.7%) 2 2 High blood pressure (10.5%)

Air pollution (9.1%) 3 3 Dietary risks (9.6%)

Dietary risks (5.2%) 4 4 High fasting plasma glucose (8.3%)

High blood pressure (4.7%) 5 5 Air pollution (8.2%)

Tobacco use (4.1%) 6 6 Tobacco use (5.5%)

High fasting plasma glucose (3.2%) 7 7 High total cholesterol (5.4%)

Occupational risks (2.3%) 8 8 Alcohol & drug use (4.1%)

High total cholesterol (2.2%) 9 9 Occupational risks (3.3%)

Alcohol & drug use (1.8%) 10 10 Impaired kidney function (3.3%)

Impaired kidney function (1.6%) 11 11 WaSH* (3.3%)

Behavioural
Envioronmental/Occupational
Metabolic

75
34. Infectious and Communicable Diseases
Karnataka has made significant progress in the
Ten strategic action areas to address the last control and prevention of major communicable and
mile journey of Communicable and infectious infectious diseases with an impressive decline in
diseases. the incidence and prevalence during the last
• The last mile journey in prevention / decade. State is committed to the implementation of
elimination has to be driven by good quality national programs and to achieve the goals set out
data using GIS software to focus on high under the National Health Policy 2017(18).The
geographic locations for area specific landmark programs of the state like the “state
control measures for individual diseases. Framework for Malaria Elimination” and “Kshaya
Mukta Karnataka” (Tuberculosis free Karnataka)
• Capacity strengthening of state and district are major programs along with Leprosy and
officers along with engagement of Junior HIV/AIDS. Expansion of programmes and
Health Assistant (Male MPW) with decentralisation of diagnostic laboratories, from
supervision and monitoring of his work at the times of H1N1 outbreak to recent Covid
village level is crucial. pandemic, and the excellent work done by ASHAs
• High incidence /prevalence report should are well appreciated(108).
be developed / shared on a periodical basis A steady decline in the incidence of Malaria has
with the nodal officers of various districts been observed throughout the state by interrupting
for monitoring control measures. the indigenous transmission of cases (Figure 28).
• IDSP should share the surveillance data Digitised smart surveillance and
with all the programme officers with the micromanagement has resulted in a decline in
creation of . User id and password cases along with the enhanced private sector
credentials for taking timely action. participation. Similarly, the incidence of Japanese
encephalitis is steadily decreasing primarily due to
• Epidemiological investigation of all scaled up immunisation programme undertaken in
individual disease cases is a must at 10 endemic districts which include Bellary, Kolar,
district / taluka levels with action reports to chickaballapur, Mandya, Raichur, Koppal,
state programme officer. Chitradurga, Davanagere, Vijayapura. Some
• Screening of migrant people is a priority progress has been achieved in management and
action area to check import of new cases of control of Dengue, chikungunya and Lymphatic
relevant communicable diseases like Filariasis, despite the presence of local outbreaks.
malaria, filariasis, etc.in select districts on
Tuberculosis is a major public health problem in
a regular basis
Karnataka and the state has achieved impressive
• As the state moves steadily towards achievements in prevention care and control. The
elimination of diseases like malaria, National Tuberculosis Elimination Programme has
filariasis, leprosy etc. the last mile efforts taken major steps like decentralised TB diagnosis,
require high quality surveillance. Peer testing of HIV for tuberculosis and active case
review or expert group review is required detection. Every year, the state TB programme tests
in those districts which are to be certified more than 10 lakh people and treats approximately
for elimination. 64,000 patients and the total TB case notification
has increased steadily during 2015 to 2019 (Figure
• Accreditation of health care institutions
29).
and laboratories has to be done regularly
along with Quality assurance of diagnostic
tests at sentinel laboratories.
• Greater coordination and collaboration
“Education is the most
between health department and medical
education department institutions has to be
powerful weapon which you can
ensured.
use to change the world”
- Nelson Mandela

76
Figure 28: Trends in Malaria and PF Cases, 2006-20

70000 Malaria Cases

62842

60000 Pf Cases

49355
50000 47344
44319

36830
40000

30000
24237

20000 16459 16466

13302 14794 12548
11295 10630
9864
10000 5685
7936 7381
5289 3499 1773
2648 1278 967 1329 1506 1693 1170 846 562 249
0
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

The state has been a pioneer in active case finding operational and nearly 10 lakh patients have been
in the last four years. By linking the program to tested using microscopy and active case detection.
Arogya Karnataka, treatment costs are significantly Six medical colleges are fully functional. Drug
reduced.. The engagement of the private sector in resistant TB centres are providing DRTB services to
active case detection and management is a positive patients and few of them have culture and DST
step. The state has decentralised the diagnosis of facilities certified under the NTEP(109).
tuberculosis and 1893 diagnostic Centres are

Figure 29: Trends of total TB Patients notified for treatment, 2010-19

1 00000

91 7 03

90000

8264 1
Numbers Notified

80000

7 0595
68655 691 99
70000 67 57 5

61 4 4 6 61 328
59932 597 24
60000

50000
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Leprosy is seeing a downward trend in the last 10 and treatment protocol are in place. Sustained
years. The annual new case detection rate is at 3.88 efforts for continued care with social support,
per thousand and the deformity rate is 2.96 per enhanced supervision and monitoring along with
thousand population(110).Special surveillance increased funding have been recommended
activities for intensified active case detection, towards the last mile efforts for elimination of
improved leprosy care through advanced diagnosis leprosy in the state.

77
HIV work in Karnataka is well recognised with the The success achieved in control of many
state recording a 46% decline in new infections as communicable and infectious diseases as well as
compared to the national average of 26%. As per the progress towards elimination of certain
NACO, prevalence rate of HIV adults in Karnataka is diseases are in line with the national goals and now
0.47% as against the national average of 0.22%(110) require the last my efforts for elimination of
(Figure 30). The observed HIV prevalence among conditions like malaria, TB, leprosy and HIV.
ANC clinic attendees has shown a declining trend Regional and inter – intra district variations are
and close to 98% of positive pregnant woman are present in different programmes. At the same time,
placed on ART treatment. The state has been a emerging infections are a matter of concern as
leader in conceptualising convergence of NHM with seen during COVID – 19 pandemic. Undoubtedly,
NACP along with universal screening for HIV in all challenges exist with regard to skilled manpower,
health care facilities including 2433 PHCs. lack of preparedness, delayed investigation of
Counselling services and testing is strongly outbreaks, decreasing community involvement,
established all over the state. poor reporting practices, delays in screening and
diagnosis, inequalities in accessing services,
Figure 30: Trends of Observed HIV Prevalence resurgence due to recent ecosystem changes,
among ANC clinics greater engagement of laboratories in new
activities and other factors.

The success achieved and progress made in

Communicable disease control should be
sustained and strengthened to complete the
last mile journey for achieving desired goals.
The vision group recommends building
strong decentralised programs at the
district and taluka levels, strengthening
health infrastructure for service delivery,
continuing research in communicable disease
control and establishing multisectoral
Many of the Vaccine Preventable Diseases (VPDs) coordination and collaboration along with
has shown a decline with increasing immunisation monitoring and surveillance as the pillars
coverage for children. The state has a goal to for effective control of communicable
maintain its polio free status and to achieve diseases in the coming days. In addition,
measles elimination and rubella control by the year specific activities listed under the national
2023. A high rate of immunisation and active programmatic guidelines need to be
surveillance contribute in a significant way. In implemented for effective control. The focus
addition to community case detection, laboratory should be on effective prevention, screening,
linked VPD surveillance is in progress for polio, diagnosis, case finding, notification and
measles, diphtheria, pertussis and neonatal tetanus early management especially in districts
along with AFP surveillance. Integrated Disease and talukas which are considered as difficult
Surveillance Programme is a major activity and hard to reach and with poor
undertaken for communicable disease surveillance performance. In the long run, genotypic
in the state. The Integrated Health Information research needs to be strengthened along
Platform has been implemented that provides real with norms and standards for regular
opportunity for reporting all individual case-based monitoring of the program. The IHIP needs
information. A strong infrastructure for to be scaled up in its capacity for effective
implementing IDSP with augmented human data monitoring. The district level
resources, training, technology and field committees should be actively involved in
supervision has been created in the state. planning several activities required for
effective disease prevention and control. More
detailed recommendations for individual
programmes are available in the
accompanying main report.

78
35. Noncommunicable Diseases

• The state leadership has to give highest • As ASHAs and peripheral health workers are
importance to NPCDCS programme overburdened due to their engagement in
implementation with multipronged approaches multiple programmes, segregating a section
and integrated coordination mechanisms. The of frontline workers exclusively for NPCDCS
state NCD team in DoHWF should be program would be advantageous. In addition
strengthened with the addition of trained a dedicated nurse and a counsellor should be
professionals and district implementation available in all district and taluka hospitals.
mechanisms.
• All existing legislations for control of tobacco,
• A comprehensive state action plan that alcohol, food security should be implemented
includes prevention, screening, diagnosis, along with creating new mechanisms for
referral and rehabilitation should be promoting physical activity at district and
developed with clearly outlined implementation taluka levels.
processes at district, taluka and village levels.
• Standard protocols for screening of risk
• All 31 districts of the state should have an factors and diseases among 30+ individuals,
integrated NCD programme with facility level counselling and regular follow-up services
activities delivered through competent teams should be followed in all educational
starting from health and wellness centres to institutions, workplaces, community settings
district hospital levels. and in healthcare institutions at district and
taluka levels. Education and counselling
• Four regional NCD Centres of excellence
services should be made available in all
should be established in the next 1 year for
public health facilities and Ayush doctors
implementing coordinated activities in
should be actively engaged in health
multiple areas. All medical colleges and apex
promotion activities for behavioural change,
institution should fully participate in program
counselling and towards developing healthy
development and implementation in the areas
lifestyles.
of capacity building, training, screening,
service delivery, referral, monitoring, • Secondary and tertiary care services under
evaluation and research. the NPCDCS program should be strengthened
with availability of defined clinical services,
• The state should make strong investments in
laboratory and referral services.
addressing health determinants and risk
factors through a robust intersectoral • Opportunities should be explored for
mechanism between different departments integration between NPCDCS and NPHCE for
with a focus on health promotion activities. A early recognition and management of NCDs.
district level intersectoral committee should Record maintenance, surveillance,
ensure and implement activities with better monitoring should be given importance at the
coordination and implementation adequately district and taluka levels to establish
facilitated by the state. systematic linkages and for uniform
record-keeping.
• A set of 30 measurable indicators should be
developed by the state to ensure systematic • The role of technology needs to be explored to
monitoring of the programme in view of the develop sustainable surveillance activities
increasing burden of NCDs under NPCDCS especially for surveillance,
monitoring indicators and evaluation at the
• Capacity building of policy makers,
district levels.
administrators and professionals at different
levels and training of all categories of health • Research should be strengthened in the area
staff through the higher academic of NPCDCS in all required areas and 4 – 5
institutions, state training centre and district medical colleges should be given
training institutes should be undertaken with responsibility for continued research in all
active engagement of medical colleges. areas from epidemiology to evaluation in
collaboration with state level academic
• All health and wellness centres should
institutions.
become fully operational in the next 2 years
and focus on increasing awareness in the
community, promotion of healthy lifestyles,
screening, referral and follow-up activities.

79
Since 2015, the state is on its way to address the reduction activities: For NCDs there is no cure, but
growing burden of Noncommunicable Diseases only care. With epidemiological and demographic
(NCDs) with the targeted reduction of 50% by 2030 transition, the burden of NCDs is increasing in the
to reduce the burden of mortality, morbidity, state. Many of the risk factors and the NCD
disability and socio economic losses from NCDs conditions have moved up the ranks contributing for
through combined and integrated preventive, a significant proportion of deaths and DALYs as per
promotive, curative services. NCDs are due to a India GBD study(15) (Figures 23 – 27 earlier). In
complex interaction of genetic, physiological, 2016, NCDs contributed for 62%, communicable
environmental, social and behavioural factors and diseases for 25.1% and injuries for 12.9% of the total
require multi-pronged approaches to address the disease burden in Karnataka. The NCD burden
problem. NCDs are characterised by some common continues to increase from the age groups of 30
risk factors, complex aetiology, slow onset in years, both genders are equally affected, primarily
progress, non-reversible pathological alteration, affect lower and middle income sections of society
greater morbidity, residual disabilities, prolonged and in both urban and rural areas. The economic
course of illness, high mortality along with impact of NCDs is phenomenal due to the
significant OoPE and poor quality of life(111). increasing costs of care as well as the need for
continuity in care(112).With only 28% of the
NCDs include a number of conditions and CVDs, population covered under any health scheme, the
Cancer, Diabetes Mellitus and Stroke top the list costs towards consultation, diagnostics, drugs
along with mental disorders and injuries; the first procedures and long-term care is significant, more
four are included under the NPCDCS programme. in urban areas and in the private healthcare
State-level data with regard to each of the NCDs is facilities, in the state with 20% of the population
not available. Valid, reliable, representative and living below the poverty line(113).
real-time data with regard to NCDs is extremely
limited due to absence of good quality research, Cardiovascular diseases (CVDs) are a leading
NCD surveillance, population-based surveys and cause of death in the age group of 40 years and
disease specific registries. Population data of above. The prevalence of Diabetes Mellitus ( DM) in
hospital based information required in terms of Karnataka is reported to be 7.7%, while the
prevalence, incidence, risk factors, care pattern, prevalence of prediabetes is 11.7% as per the
referral pathways and course of illness at the state findings of India Diabetes study(115).The prevalence
and district levels are not available. In addition, data of Stroke in the population is reported to be 150 /
from the private sector and from the non-health 100,000 in urban and rural Bangalore(114). Cancer
sector departments is not routinely available. contributes for 8.1% of total deaths with a rate of 126
Extrapolating from smaller research studies can be per million populations(116).Cancer cervix, breast
misleading. The program implementation is in the cancer and oral cancer are the leading cancer
early stages and efforts are now initiated to collect conditions in the state. The National Cancer
good quality data. Registry data indicate that nearly 36% of all cancers
among males will be due to lung, oral cavity,
Many risk factors operate in the causation of NCDs prostate, and stomach cancers, while cancer of the
and some of them like elevated blood pressure, breast, cervix, ovary, corpus uteri will predominate
increased blood glucose levels and cholesterol, among females for 53% of all cancers(116)( Figure
obesity, physical inactivity, unhealthy diet, tobacco 31). Despite these alarming numbers, the number of
use, alcohol use, stress and others are eminently persons requiring NCD care in a district is not
amenable for prevention programs and risk available.
Figure 31: Top ten leading sites of cancers in Karnataka state,2020

40 40
(35.0, 40.5)

27 .9
(15.0, 17.7)
(9.8, 13.0)
(6.2, 8.7)

(6.7, 8.6)

12
(8.0, 9.4)
(5.2, 7.0)

1 0.1
(4.1, 4.8)

(4.1, 4.9)

(4.1, 5.6)
(3.7, 4.4)
(3.7, 4.3)

(4.8, 6.0)
(4.8, 5.9)

(4.7, 5.8)

(4.7, 4.6)

(4.1, 4.9)
(4.1, 5.2)
(3.3, 4.2)

(2.8, 3.4)

6.4 6.9 6.4

5.4
4 .2 4 .2 4 .3 3.8 3.8 3.8 3.7
3.4 3.6 3.6 3.3 3.3
2.3

0 0
Colon Brain, NS NHL Mouth Tongue Liver Oesophagus Prostate Stomach Lung Breast Cervix Uteri Ovary Corpus Uteri Mouth Lung T hyroid Oesophagus Stomach Colon

Relative Proportion (%)

80
The state has to take a stronger and proactive role evidence-based interventions focusing on health
in the prevention, surveillance, care delivery and promotion and early identification, early referral,
other aspects of NCD prevention and care by cost-effective care, availability of drugs and
building on the principles of universal coverage, diagnostics delivered through public owned or
equitable distribution, affordable healthcare and a regulated health system is very much essential.
strong intersectoral collaboration. The actions for Setting-based health promotion activities in
NCD control should focus on interventions to workplaces, educational institutions, community
reduce NCD risk factors and key metabolic risks by organisations should be implemented. The 10 Best
creating a larger ecosystem on a framework of buys for intervention for prevention and control of
political, policy, administrative and legislative NCDs are given in box 1 and the global targets to be
mechanisms. Several proven to work achieved are also given in box 2.

Box 7: Best buy interventions for prevention and control of noncommunicable diseases

Intervention Number Intervention

domain
Tobacco use 1 Increase excise taxes and prices on tobacco products
2 Implement plain/standardized packaging and/or large graphic health
warnings on all tobacco packages
3 Enact and enforce comprehensive bans on tobacoo advertising, promotion,
and sponsorships
4 Eliminate exposure to second-hand tobacco smoke in all indoor
workplaces, public places, public transport
5 Implement effective mass media campaigns that educate the public about
the harms if smoking tobacco use and second-hand smoke
Harmful use 6 Increase excise taxes on alcoholic beverages
of alcohol 7 Enact and enforce bans of comprehensive restrictions on exposure to
alcohol advertising (across multiple types of media)
8 Enact and enforce restrictions on the physiclal availability of retailed
alcohol (through reduced hours of sale)
Unhealthy diet 9 Reduce salt intake through the reformation of food products to contain less
salt and the setting of target levels for the amount of salt in foods and
meals
10 Reduce salt intake through the establishment of a supportive environment
in public institutions such as hospitals, schools, workplaces, and nursing
homes, to enable lower sodium options to be provided
11 Reduce salt intake through a behavior change communication and mass
media campaign
12 Reduce salt intake through the implementation of front-of-pack labeling

Physical 13 Implement community-wide public education and awareness campaign for

inactivity physical activity which includes a mass mesia campaign combined with
other community-based education, motivational, and environmental
programs aimed at supporting behavioral change of physical activity levels
Cardiovascular 14 Drug therapy (including glycemic control for diabetes mellitus and control
disease and of hypertension using a total risk approach) and counseling to individuals
diabetes who have had a heart attack or stroke and to persons with moderate
(>20%) and high risk (>30%) of a fatal and nonfatal cardiovascular event in
the next 10 years
Cancer 15 Vaccination against human papillomavirus (2 doses) of 9-13-year-old girls
16 Prevention of cervical cancer by scanning women aged 30-49 years, either
through Visual inspection with aceetic acid linked with timely treatment of
precancerous lesions Pap smear (cervical cytology) every 3-5 years linked
with timely treatment of precancerous lesions Human papillomavirus test
every 5 years linked with timely treatment of precancerous lesions

Source: https://www.who.int/ncds/management/WHO_Appendix_BestBuys.pdfsource

81
 Box 8: Voluntary global targets under global action plan for the prevention and control
of noncommunicable diseases 2013-2020
• A 25% reduction in risk of premature mortality from cardiovascular diseases, cancer,
diabetes, or chronic respiratory diseases
• At least 10% reduction in the harmful use of alcohol
• A 10% reduction in prevalence of insufficient physical activity
• A 30% reduction in mean population intake of salt/sodium
• A 30% reduction in prevalence of current tobacco use in persons aged 15+ years
• A 25% reduction in the prevalence of raised blood pressure
• Halt the rise in diabetes and obesity
• At least 50% of eligible people receive drug therapy and counseling (including glycemic
control) to prevent heart attacks and strokes
• An 80% availability of the affordable basic technologies and essential medicines, including
generics, required to treat major NCDs in both public and private facilities

Source: https://www.who.int/publications/i/item/9789241506236

Karnataka is implementing four major NCD national for NCD prevention control, working with the
programmes, namely, NPCDCS, NPHCE, National private sector, poor regulatory measures, lack of
Palliative Care Programme and National Fluorosis dedicated staff for NCD activities, isolated IEC
Control Programme along with National Mental activities, poor community mobilisation, high costs
Health Programme. The NPCDCS program is the and difficulties in care continuity - referral and
flagship program for Karnataka from 2015 onwards absence of systematic monitoring and evaluation
and implemented across 14 districts with expansion are a few of the major limitations.
in recent times. A major focus of the program is on
screening all individuals above 30 years for
Hypertension and Diabetes in the NCD clinics of
The state should establish Centres of
district and talukas, and recently through
Excellence to develop new knowledge,
develop and strengthen human resources,
population screening by ASHA workers. The 2319
undertake research, support policies,
centres along with 347 NCD clinics have been develop standards - guidelines - protocols,
operational at district and taluka levels. Under the identify package of interventions, monitor
programme, capacity building, training, health implementation status, conduct evaluation
education, opportunistic and population screening and demonsrate cost effectiveness.
for hypertension and diabetes for 30+ population,
early detection, NCD surveillance and
cost-effective treatments are being provided. The • Centre for health determinants
state is also making efforts to provide advanced • Centre for work safety
care in specialised centres across the state and,
new regional centres are under the consideration of • Centre for Human resource quality
the government to provide care for CVDs, DM and development
cancer. In addition, all private hospitals and medical • Centre for health technology
colleges provide basic and advanced care for
• Centre for urban health
different NCDs in the state.
• Centre for road safety and injury
Despite its commitment and a renewed focus for prevention
implementation of NPCDCS, there are several
implementation challenges in the area of NCDs. The • Centre for rehabilitation medicine
absence of clearly defined action plans and • Centre for poison prevention
program implementation strategies, lesser
importance given by other sectors for health and
• Centre for AYUSH services
• Centre for elderly health

82
Cardiac Care • The protocols of management of heart attack at
taluka and district levels have to be developed –
Management of Acute Myocardial validated - circulated and all these doctors have
to be trained. Training can be provided to
Infarction (heart attack) and strengthening doctors and all supportive staff through digital
critical care in semi-urban and rural platform and wherever possible by organising
areas through HUB AND SPOKE MODEL workshops.
Approximately 8-10% of the population suffer from • In this context, it is essential and imperative to
Cardiovascular Diseases, particularly Ischemic have 5 bedded cardiac ICU in Taluka hospitals
Heart Disease. Around 1-2% suffers from Congenital and 20 bedded ICCUs in District hospitals. The
Heart Disease and Rheumatic Heart Disease. Acute Taluka hospitals have to be mapped to tertiary
Myocardial Infarction accounts for most of the care hospitals in every district at the vicinity for
cardiovascular deaths. Since Tertiary care centres this Spoke and Hub model.
are located mainly in one and two tier cities,
management of heart attack and heart failure in • The equipment’s and manpower for setting up
Taluka hospitals has to be strengthened to reduce an ICCU at a district level have to be procured –
mortality, hospitalisations, complications and installed – maintained and operated through
consequences. In addition, greater emphasis has to skilled resources.
be placed on heart health by addressing risk factors • The training, monitoring, supervision and
like tobacco use, alcohol, unhealthy diet, physical transfer responsibilities of patients from Spoke
inactivity along with control of hypertension, to Hub Hospital have to be evidence based and
diabetes mellitus and dyslipidaemia. protocol driven.
HEART ATTACK MANAGEMENT IN RURAL AREAS • Simple data management protocols have to be
• For every 30 minutes of delay in initiating developed and analysed regularly to assess
treatment for heart attack, the risk of death effectiveness of the hub and spoke model.
increases by 7%. Hence there is a need to • Emergency 108 Ambulance services are to be
provide treatment at the earliest by establishing functioning and integrated into this system for
heart attack management programme at Taluka timely transfer of patients.
hospitals as well as in District hospitals.
• Jayadeva Hospital has branches in Kalaburgi
• Thrombolysis therapy or giving clot dissolving and Mysore apart from Bangalore Centre.
medicines is effective if implemented within Demonstration projects can be initiated in the
first 6 hours of onset of symptoms of heart next 12 months in these 3 sub-divisions.
attack and should be made available in all taluka
hospitals( spokes)
• Doctors in rural hospitals (MD qualified
physicians are already trained to treat heart
attack patients by thrombolysis) with an MBBS
qualification can be trained to treat heart attack
patients. Necessary training packages have to
be developed centrally at the state level.
• Heart Attack management kits have to be
provided to Spoke Hospitals and can be taken
up using either Telemedicine network or on
Digital Platform, where an ECG taken at the
Spoke hospital is automatically transferred to
specialists in the tertiary care hospital through
Network heart attack management. Once the
diagnosis is confirmed, treatment is initiated in
peripheral hospitals to avoid unnecessary delays.
• After initial stabilisation of the patient, he /she
can be shifted to tertiary care hospitals in
Districts, either Government or Private hospital,
for Coronary Angiogram and Angioplasty
Stenting procedures at the earliest within 24 –
48 hours (hubs).

83
36. Injury and Violence
36.1 Road Traffic Injuries
• The Karnataka Road Safety Authority
established in 2017 should be strengthened Road Traffic Injuries (RTIs) and deaths have been
with adequate manpower, technology, funding increasing at an alarming pace in Karnataka
and should develop defined action plans for since accelerated motorisation occupied centre
district level activities to achieve the 50% stage amidst poor safety environment (Figure 32
reduction of deaths as per the SDGs and & 33). The state ranks 4th in the country for the
global road safety targets. The state agency number of fatal road crashes(94). RTIs occur
should undertake intersectoral arrangements, predominantly in the age group of 15 to 45 years,
coordination, funding, implementation, males, in economically productive populations
monitoring, evaluation required for implementing and in the poor and middle-income sections of
road safety policies and programmes as road the society. with increasing industrialisation,
safety is a multisectoral problem. motorisation, urbanisation, and economic growth,
• A multisectoral state action plan for reducing the exposure of people to complex and
road crashes with a focus on strengthening unregulated traffic environments has
monitoring and evaluation systems should be drawn significantly increased, resulting in increasing
up and implemented at state and district levels. number of road deaths, injuries and related
disabilities.
• A district level road safety program anchored
by the district road safety councils should be
Figure 32: Trend of RTIs in Karnataka, 1989 – 2019
piloted in four districts of the State in a
scientific and systematic basis in next 2 years.
12500
• Implementation of all legislations under the
Indian motor vehicles act towards the use of 10000 10904
helmets – seat belts – child restraints – 9770
pedestrian safety- drink-driving – speeding – 7500 8056
mobile phone use should be enforced in a
uniform – random – visible manner to achieve 5000
a minimum 80% compliance among road 5239

users at the district level and in urban areas.

2500
• Data collection mechanisms by using digital
and innovative techniques should be put in 0
1990 2000 2010 2019
place (on similar lines of Tamil nadu) along
with developing a district injury and road
safety surveillance program in at least four After adjusting for underreporting for the State
districts before state-wide replication. Crime Records Bureau ( SCRB) data, it is
• Systematic training of all police, transport, estimated that nearly 13,000 deaths, 400,000
health and road development officials to adopt severe RTIs and nearly 10,000,000 mild injuries
and integrate modern principles of road safety occurred in the state in 2019(96, 117) . RTIs place a
should be facilitated by the Karnataka road huge burden on the health systems for care and
safety authority. rehabilitation services for the affected persons.
Nearly 65% of road deaths in Karnataka occurred
• Scientific design of roads as per IRC guidelines
in the age group of 18 to 44 years and among the
and ensuring mandatory audit of roads soon
younger and productive sections of the
after completion and at periodical intervals for
safety parameters should be implemented. population(95). Nearly 80% of crashes and 88% of
deaths occur in the rural parts of the state
• Post-crash care should be scaled up in a indicating the need for strengthening road safety
scientific and systematic manner at district mechanisms at district and taluka levels (Figure
and taluka levels for managing trauma 33). Studies undertaken by the WHO collaborating
patients (for more details see the section on Centre at the NIMHANS clearly indicate that 3 out
trauma care services). of 4 deaths and injuries are among pedestrians,
• In the long run, investing and strengthening two wheeler riders and pillions and
mass public transport systems across the state bicyclists(118).
will reduce the exposure of people that would
also reduce the use of personal modes of transport.

84
Figure 33: RTIs in Karnataka The five pillars of road safety focusing on road
safety management, safe road infrastructure, safe
vehicles and improving road user behaviour along
Bidar
281 with post-crash care are to be implemented in all
seriousness to achieve success in road safety in the
Kalaburgi state (Figure 34).
407

Vijayapura
378 Yadagiri Figure 34: Five pillars of road safety.
163

Bagalkote
Belagavi 358 Raichur
868 274

Safer Road Infrastructure

Road Safety Management
Koppala
Dharwada 217
281 Gadaga Above 500

Road User Behaviour

148
Ballary
345
300 to Below 500
Uttara Kannada

Post Crash Care

236 Haveri
213 300 to Below 100

Safe Vehicles
Davanagere
289
Chitradurga
Shivamogga 392
365

Udupi Chikkamagalur Tumakuru Chikkaballapura

264 786 280
210
Bengaluru Rural
389 Kolara
Hassana Bengaluru Urban 274
Dakshina Kannada 464 768
300
Ramanagara
Mandya
542
389 International Coordanation Strengthening Global
Kodagu
87 Mysuru Architecture for Road Safety
571
Chamarajanagara

36.2 Unintentional Injuries

154

The Karnataka Road Safety Authority was

established in 2017(78) and the Karnataka Road • A state task force should be constituted to
Safety Policy was notified in 2015(119) with a vision formulate comprehensive injury prevention
to achieve a safe road environment for reducing policy and an action plan with defined
road crashes by 25% and fatalities by 30% by the programmes and intervention - implementation
year 2030 ; goal is yet to be realised. Under the road strategies through convergent mechanisms.
safety policy, establishing a multi-road safety lead • Formulate and implement a pilot district
agency at the state and district levels, action plan and a program in four districts
strengthening road crash database system, of the state covering major causes of
developing a safe road infrastructure, regular road injuries in the next 2 years.
safety audits, increasing road safety awareness, • Plan and implement innovative technology
enhancing enforcement levels, timely medical driven enforcement to increase awareness and
services and increased financial protection for compliance to existing rules and regulations
survivors have been proposed. However several under various provisions and legislations.
implementation delays have halted the progress.
• All known and proven interventions for
The condition of roads are still at a very high risk prevention of falls, burns, poisoning and
level with most of the roads not even achieving a drowning should be enlisted, reviewed by a
three star rating and hazard mapping is still in state technical committee and implemented
continuation. Nine districts of the state have at required places.
identified 80 accident prone areas. The safety of the • Develop a comprehensive and integrated
vehicles that is available in the state are to be injury surveillance system to provide
assessed even though the national ratings indicate reliable data regarding injury distribution,
a poor performance. The prevalence of helmet use, risk factors, high-risk areas and trends
seat belt use, child restraint use remain at overtime with a focus on risk factors.
moderate levels ( higher in urban central areas) • All implementing officers in health, police
while drunk-driving, speeding, use of mobile phone in law, transport, urban development and
and poor pedestrian road safety behaviours are on several others should be systematically
the increase. The post-crash care is a fragmented trained through institutional mechanisms for
and a fractured system with deficiencies in early implementing injury prevention programs.
care, referral of patients, availability of definite care • Safety audits in all schools, workplaces,
services at district and taluka hospitals and poor high rise buildings and commercial places
rehabilitation services(117, 119). should be mandated on a regular basis

85
One out of every 10 deaths in the state is due to an 36.3 Suicide
injury in Karnataka. In 2019, nearly 30,000 persons
died, 1 million people were seriously injured and
hospitalised, and 2 million people received care for • Establish a state suicide prevention
minor injuries due to all unintentional injuries in registry in three districts of the state to
Karnataka as per estimates by the WHO CC at develop data driven programmes.
NIMHANS (Figure 35)(117). • Building up strong public health approach
and advocacy through development and
Figure 35: Burden of injuries in Karnataka, 2020 implementation of state-specific suicide
prevention policy and action plan
• Developing and implementing timely and
effective evidence-based interventions
through establishment of robust
30,541
surveillance and monitoring system for
Deaths suicidality and suicide,
• Regulate the easy availability of pesticides
9,16,236 and related products ( ban those with high
levels of toxicity) and over the counter
severe injuries
drugs through regulatory mechanisms.
• Strengthen health infrastructure and other
2, 137, 884 resources by establishing a state poison
prevention centre to provide preventive,
Mild to moderate injuries promotive, curative, rehabilitative training
for doctors and nurses for better
management of poisoning at all levels and
These injuries include falls, burns, drowning, research activities related to suicide
mechanical injuries, poisoning, injuries in disaster prevention (Box ).
situations and several others. Systematic and good
quality data to quantify the burden of deaths and • Supporting individuals and families with
hospitalisations due to unintentional injuries is not timely help and intervention for early
recognition and care through organised
available for the state of Karnataka as injury
mental health services in districts, talukas
surveillance programs are not in place and the
and primary health centre levels along with
official reports are an underestimate of the real services in community-based settings
burden of injuries(117). Among all other causes of
deaths, apart from RTIs, 8.4% of deaths were due to • Bringing a life-course perspective in
drowning, 6.1% due to poisoning, 3% due to falls, suicide prevention by integrating suicide
3.3% due to burns and 1.9% due to electrical and fire prevention interventions with the on-going
injuries as per data from SCRB(95).Most deaths and national programmes to target multiple
injuries occurred in the younger age groups, among settings (schools, colleges, workplaces,
males, in rural areas and in poorer sections of the etc)
society. • Establish a mental health help-line or
The global advancements in the field of injury liaison with existing helplines ( e.g., SAHAI )
for early help seeking for needy
prevention and care inform that many evidence –
populations
based and cost effective interventions can reduce
the burden of injuries. However, these are not • Increasing public awareness about suicide
implemented in India or in Karnataka. The key gaps prevention, about early recognition at
in injury prevention are lack of a specific injury family and facility level and also educating
prevention policy, dedicated injury prevention media about sensitive reporting on suicides
centres, safety nodal officers, poor budget for
prevention, limited intersectoral coordination,
absence of safety assessments, lack of monitoring While there is a common notion in the society that
systems and others. Poor enforcement practices by suicide cannot be prevented, there is ample
all concerned departments are a cause for concern. evidence across the globe to indicate that majority
Low safety awareness, lack of safety of the suicides are eminently preventable.
consciousness and community capacity to deliver Neighbouring countries like Sri Lanka and Thailand
effective first aid are some of the major gaps. Safety have achieved significant reductions in deaths and
audits and lack of a social ecosystem to product hospitalisations due to suicide with implementation
safety is key to prevention. of scientific, integrated and coordinated programs.

86
 Suicide is a serious public health problem in
Karnataka (Figure 36). Suicide occurs throughout Figure 37: Distribution of Suicide
the lifespan and is the second leading cause of in Karnataka, 2019
death among 15 to 29 year olds globally (120, 121). In
India 150,000 persons die in a suicidal act and Bidar
Karnataka state accounts for nearly 10 % of 193

suicides(96, 122). The state reported 11,088 suicides

in the year 2019 accounting for 8.1% of all suicidal Kalaburgi
273
deaths in India in 2019(96). Nearly 75% of the suicide
was among males, 73% among married and 62% in Vijayapura
283 Yadagiri
poor and low-income households. About 42% of 108

suicides were in persons less than 30 years and Bagalkote

32% in those aged between 30 to 45 years(91, Belagavi
835
216 Raichur
186
96).Suicides are more in Bangalore urban, Shimoga,
Dakshina Kannada, Mysore and Bangalore rural Dharwada
Koppala
129
500 to 2000
districts (Figure 37). Due to absence of good quality 405 Gadaga
174
research and surveillance, the precise number of Ballary
212
300 to 500
suicidal deaths and hospitalisations are not clearly Uttara Kannada
269 Haveri
327 100 to 300
known in the state and the official police figures are
an underreporting of the real situation. Davanagere
332
Chitradurga
Shivamogga 285
513
Figure 36: Suicide rate per lakh population,
India and Karnataka. Udupi
368
Chikkamagalur
330
Tumakuru Chikkaballapura
356 164
Bengaluru Rural
419 Kolara
25
Hassana Bengaluru Urban 159
Dakshina Kannada 301 2079
462
Ramanagara
22.5
21 .5 Mandya 184
21 .2
20.6
256
Kodagu
20
174 Mysuru
Suicide rate per lakh population

1 8.5
1 7 .8 18 488
1 7 .7
1 7 .4 1 7 .1 1 7 .1
Chamarajanagara
1 7.5
100

15

The most common mode of suicide in Karnataka are

1 2.5
1 1 .4 1 1 .2 1 1 .2 11
1 0.6 1 0.6

hanging, poisoning and drowning. Poisoning due to

1 0.3 1 0.2 1 0.4
10 9.2

pesticides, herbicides, rodenticides and

over-the-counter drugs are responsible for
7.5
201 0 201 1 201 2 201 3 201 4 201 5 201 6 201 7 201 8 201 9

India Karnataka hospitalisation. The causes of suicide as provided in

the NCRB and SCRB reports are vague and do not
point to any specific mechanisms that can be used
to develop prevention programmes. Studies
undertaken by Nimhans indicate that history of
alcohol and use of drugs, domestic violence,
presence of a mental illness, history of suicide
attempts in the past and absence of protective
factors such as social support, lack of skills for
crisis management and others are some of the
important risk factors for suicide(123).
Despite the availability of knowledge, efforts
towards prevention of suicide are scant and limited
in Karnataka. Suicide prevention programmes are
limited in the state due to absence of a specific
suicide prevention strategy and an action plan, poor
health system response and resources, lack of
robust data and surveillance systems, unlimited
use of pesticides, and the wide array of risk factors
that exists in the society that are least understood
along with poor health system response.

87
36.4 Violence Prevention. Violence is one among the leading causes of death
for people aged 15 to 44 years(124).Violence has
existed in society in different forms across the
The state should seriously address violence lifespan in various forms like child abuse and
prevention by neglect, youth violence, intimate partner violence,
spousal violence, domestic violence, sexual
• strengthening the role of health systems
violence, elder abuse and self-inflicted violence.
within the multisectoral response by
Health of people is seriously compromised in the
developing and monitoring a state action
plan in this area, presence of violence. Apart from deaths, majority of
the violent acts result in injuries, mental health and
• fostering advocacy to integrate and reproductive health problems, sexually transmitted
strengthen violence prevention in social diseases and other problems for which health
and educational policies thereby promoting sector provides care for all these affected
gender and social equality, individuals; however, focus on violence prevention
• strengthening health information systems is missing in the society.
and the workforce to provide Availability of good quality data remains a major
community-based support for reducing challenge for violence prevention. The official
violence, figures are highly underreported as many people do
• establishing strong network of not report violence because of stigma and several
organisations and integrating programs other factors. Violence against children is a serious
with a focus on violence prevention, public health problem and Karnataka recorded a
• strengthening violence prevention high rate of children under the Protection of
interventions within the on-going national Children from Sexual Offences Act
programs like RKSK, NMHP, NPHCE and (POCSO).Violence in children increases the risks of
others to target multiple settings, injury, HIV and other sexually transmitted
infections, mental health problems, delayed
• increase the capacity of the health sector cognitive development, poor school performance
to develop better quality data as well as and dropouts, early pregnancy, reproductive health
support research to monitor the burden, problems and a host of communicable and
identify changing patterns and to develop noncommunicable diseases. Youth violence in the
and evaluate culturally appropriate
age group of 10 to 29 years includes a wide range of
strategies, and
violent acts from bullying to physical fighting to
• investing in addressing determinants of more serious forms of assault and suicide. Girls
health across the life span. and women are more likely to experience violence
in this age group. According to NFHS-5, nearly half
of ever married women and 6% of ever married
pregnant woman aged 18 to 49 years in Karnataka
experienced physical or sexual violence with an
increase between the two rounds of surveys(91).
Abuse and violence against the elderly includes
physical, sexual, and psychological abuse as well as
neglect; these incidents are on the increase. One
out of every 10 older men and women reported
some type of violence from within or outside their
family circles(124). The impact of violence on elderly
is much more significant due to failing social
support and fragile economic systems. In the state,
risk factors for violence is least understood as it
differs within population and settings and are
closely linked to health determinants.

88
37. Disability and Rehabilitation
Available data indicate that there are
• Karnataka State Council for integrated
rehabilitation and inclusion of disabled
1.3 million persons with disabilities
persons should be established for policy, in Karnataka.
planning, implementation, funding, coordination,
monitoring and evaluation purposes. Disabilities are a huge challenge in the state of
Karnataka. Rehabilitation programmes and
• District disability rehabilitation centres should services require multisectoral coordination for
be elevated to district community-based effective inclusion of people with disabilities in
rehabilitation centres with strong coordination the societal mainstream. The field requires very
mechanisms up to village level with effective strong implementation of programmes,
use of VRWs, MRWs teachers, and Panchayat interventions at different levels across the life
raj institutions. span, within and outside the health department,
• State Centre for Disability studies should be integration of programs in health, welfare and
established in the next 2 years to develop other sectors, innovations for delivery of
academic, research and training programs for comprehensive services to disabled population,
various categories of medical, non-medical increase in investments both in financial and
and nonhealth professionals by linking RGUHS, human resources, as well as the development
SIHFW and other academic partners with the of indicators to systematically monitor the
NGO sector. progress made in disability programs in the state.
• Multidisciplinary rehabilitation team In Karnataka, data regarding the 21 type of
comprising of a physiotherapist, speech expert, disabilities is not clearly available. The Ministry
occupational therapist, psychologist and a of Statistics and Programme implementation,
social worker, who should in turn collaborate
Government of India, reports that nearly 5 to 6%
with medical professionals in the district and
of the population are Persons with Disabilities
the medical College hospitals for both
institution-based and community-based (PWDs)(125-127). The 76th round of NSS in India
outreach activities should be promoted in reported that the proportion of persons with
district hospitals. disabilities in Karnataka was 2.4%, higher than
the national average of 2.2%(127). Locomotor
• Early childcare and developmental Centre in disability prevalence was 1.9% and mental
all district medical colleges should be retardation/ mental illness were 0.2%. The
facilitated for early screening of new-borns National Mental Health Survey 2015 – 16
and for children with disabilities to institute reported that nearly a third of persons with all
interventions and follow-up activities illness have moderate to severe
• Pilot demonstration projects for integrated disabilities(128).The Brain injury registry at
rehabilitation services for PWDS in the three NIMHANS informed that 20% of injured had
districts of Koppal, Ramanagaram and Udupi in varying types of multiple disabilities(129) As
the next three years should be facilitated for disabilities occur due to a wide variety of causes
supportive, therapeutic, managerial, training ranging from many congenital conditions to
and other activities. injury and trauma,PWDs have multiple needs in
• Access to assistive devices and assistive health, education, social, employment and
technologies for PWDs as per available require support from professionals and family in
guidance needs to be promoted through a single all these areas along with timely interventions.
window facility at the state and district level
• A pilot district level registry of PWDs in at least
two districts of the State, in Chickaballapur and
Yadgiri districts, within the next two years
should be initiated in the state.
• Increase awareness and empower the
community on disability issues for inclusion of
PWDs at different levels as per provisions of
RPD act 2016 along with promoting self-help
and mutual support groups by training for home
care by utilising ASHAs and Anganwadi workers.

89
Figure 38: Proportion of different types of education resource teachers appointed by the
disabilities in Karnataka. n=1324205 education Department at the cluster level help in
identifying children with disabilities in the school.
The overall responsibility of rehabilitation services
in a district lies with the District Disability Welfare
Vision Officer along with the support of village
7% rehabilitation workers and multipurpose
20% Hearing
rehabilitation workers.
19% Speech
No comprehensive evaluation of programs in terms
Movement
of coverage, quality, reach and utilisation of
2% 18% Mental retardation services has been undertaken in Karnataka. As in
other program implementation areas, several
Mental illness
7% challenges exist at the state, district and taluka
20% 7% Others levels and even in urban areas. These include lack
of good quality robust data for evidence-based
Multiple Disability
programming, greater reliance on institution based
rehabilitation, limited understanding of all
disabilities, lack of trained manpower, absence of a
Percentage of population with different disbailities in single window facility to get assistive devices and
Karnataka (NSS, 76th round, 2018) assistive technology and absence of accessibility
audits. Limited technology applications in
1.4 rehabilitation programmes are visible and glaring.
A major challenge in the field of rehabilitation is the
lack of intersectoral coordination in implementation
of programmes at state, district and taluka levels
highlighting the need for a strong integrated
platform for delivery of services. Even within health
sector, childhood programs, deafness prevention
0.4 0.4 program, mental health program, rehabilitation
programs, NPCDCS and others work independently
0.2 0.2
without any defined coordination mechanisms.
Overall, the absence of a State Council for
Integrated Rehabilitation has been a major
Locomotor Visual Hearing Speech and Mental deficiency for program implementation.
language retardation/
Intellectual
disability

The Rights of Persons with Disabilities Act 2016

replaced the earlier Disability Act of 1995(130). The
Department of Rural Development and Panchayat
Raj issued an order for spending 5% of development
budget for inclusion of people with disabilities and
data is not available in the public domain to examine
its full utilisation. Similarly, the National Education
Policy 2020 has included disability issues to provide
greater opportunities for this population. In
Karnataka, the District Disability Rehabilitation
Centres were started in the year 2000 with support
from state and national government to implement
disability related activities. In almost every village, a
village rehabilitation worker is present under each
gram Panchayat along with multipurpose
rehabilitation workers at the block level. The
primary services to be provided include meeting the
needs of the persons with disability, counselling
services, referral services and support to access
for available schemes and provisions. The inclusive

90
Speech Language and Hearing Disorders
Speech Language Disorders: For a plethora of by quacks. Many medical colleges do not have
speech and language disorders (developmental, departments of Speech Language and Hearing
neurological insults like stroke, trauma, disorders and people are unable to afford and
neurodegenerative and psychiatric conditions) maintain continuity of services in private sector
in children as well as adults and in late facilities in urban areas.
adulthood there are facilities for assessment
and intervention in metropolitan cities, medical Schemes and Provisions: The Rights of Persons
college hospitals and speciality institutions. with Disabilities (RPWD) Act 2016 promulgated
Although some facilities have been created in by Government of India encompasses all
district hospitals (under NPCDCS programs to disabilities including communication
deal with hearing disability), not much attention impairments associated with many of the
has been given to various other types of conditions. Several national level schemes are
communication disabilities except for issuing in vogue in this area like; i) National Program for
disability certificates for availing government prevention and control of deafness
social and economic benefits. [NPPCD-(2007) 228 districts of 27 States /Union
Territories]. The NPPCD scheme needs
Hearing Disorders: Multiple conditions like personnel at taluk hospital for hearing
Congenital hearing loss secondary to birth assessment and monitoring; Accelerated
trauma, heredity, Rubella, meningitis, neonatal facilities for repair of instruments and their
jaundice, ototoxicity and idiopathic etiology, maintenance ii) schemes to provide hearing
acquired hearing impairment secondary to aids and Cochlear implants (ADIP Scheme), iii)
traumatic brain injuries, brain lesions, ear RBSK scheme for identification, follow up and
infections, noise induced and aging (some Cochlear Implantation surgery. However, these
medical conditions are treatable/preventable) schemes require trained professionals,
are seen in all age groups and needs personnel at grass root level, screening,
interventions to improve quality of life among effective implementation and monitoring at
those affected. taluka and district levels.

At a district level in Karnataka, there is paucity Universal new-born hearing screening for early
of human resources and diagnostic identification, monitoring and rehabilitation
requirements. Many mild to moderate should be initiated in Karnataka for early
individuals often do not seek care and also identification with the help of ASHA workers and
resort to traditional therapies and interventions other health personnel. Learning disability
secondary to hearing/listening disorders
(auditory processing disorders) should be made
a part of school health programs. Other
neurological hearing disorders are treated at
specialized set-ups for both medical and
non-medical eventualities. Other national
schemes that can be extended to the area of
communication disorders are a) National
Programme for Prevention and Control of
Cancer, Diabetes, Cardiovascular diseases and
Stroke (NPCDCS) b) The National Programme
for the Health Care for the Elderly (NPHCE) c)
Ayushman Bharat (2018) d) Mission
Indradhanush- IMI 2.0(2019).There is a need for
implementing interventions, integration of
different schemes, strong monitoring and
hand-holding by an expert team at state level to
develop cost effective and sustainable
programmes for district level implementation
along with engaging with family members,
teachers and health professionals.

91
38. Mental Health
The subcommittee of the vision group on mental
• Strengthen human resources at health envisions that every citizen of in the state
administrative level in the DOHFW - district should receive quality and comprehensive mental
and taluka levels. health services including promotive, preventive,
curative and rehabilitative services at affordable
• Constitute a separate committee or a task levels based on their needs across the entire
force for developing an action plan to lifespan. Karnataka will have about 200,000 people
monitor the essential mental health suffering from either mental illness or substance
services at primary, secondary and tertiary use problems. As per data from the National Mental
levels including outpatient services, Health Survey of India 2015 – 16, the prevalence of
availability of drugs and outreach activities any mental morbidity was 10.6%(98, 127).Data from
at the primary level, inpatient and the state program department indicate that persons
rehabilitation services at the secondary with common mental disorders ( depression,
level and mental health promotion services anxiety, phobias and others: 34%), severe mental
at the community level. disorders( 18.4%), substance use disorders (11.2%)
• Expand the Taluka mental health program along with nearly 30,000 people with suicidal
to 100 talukas across the state in the next thoughts received help in the year 2018 – 19.
five years, Significant variations in the burden and pattern of
mental disorders have been observed across the
• Extend the scope, coverage and state.
completeness of services with adequate
resource supplies. Karnataka is one of the leading states with a
full-fledged District Mental Health Programme
• Include and implement all social security implemented across all 31 districts in all the urban
welfare schemes for persons with mental agglomeration divisions. Recently, the state has
illness and their families and facilitate started the Taluka Mental Health Programme in ten
implementation of rights of persons with talukas with one psychiatrist and one psychiatric
mental illness. social worker with plans to extend for all taluka
over the next few years. Mental health is also
• Foster multisectoral collaboration among
related to several national and state driven
all stakeholders like primary healthcare
legislations, policies and programmes like, Mental
providers, ASHA workers, government
Health Care Act 2017, Rights of Persons with
agencies and different departments in the
Disabilities Act 2016, National Mental Health Policy
state for smooth provision of services.
2014, National Health Policy 2017 and the Karnataka
State Integrated Health Policy of 2014. Karnataka
has also been a pioneer in implementing various
innovative programs through Telemedicine
Monitoring and Mentoring Programme, care at the
doorstep, Manochaitanya program, Mansadhara
programme, Manasa kendras, e - Manas and
e-monitoring of DMHP by adopting technology in
mental health care.
Despite the progress and expansion of the
programme, several challenges still exist in
implementation of the programme including the low
funding for mental health activities. Others include
fragmentation in advocacy, lack of clear and simple
indicators to monitor progress of implementation,
problems in integrating mental health into primary
healthcare, absence of action plan, insufficient
resources, poor mental health literacy in the
population and associated stigma.

92
39. Neurological Services
others are placing a huge burden on health
• The stroke prevention, care and systems, families and society due to limited
rehabilitation components under NPCDCS services and high costs of care. Among these
should be scaled up for delivery of services conditions, stroke has higher mortality and
at district and taluka levels morbidity and many others are associated with
significant morbidity and disabilities. Persons with
• The state should undertake sensitisation of neurological disorders also lead poor quality of life
healthcare workers, ASHA workers about due to multiple disabilities with conditions like
recognising neurological disorders at early epilepsy associated with huge stigma and social
stages which are already covered under the problems. Many neurological disorders affect the
three national programs mentioned above. middle-aged and elderly population ( above 50
• Training of primary and taluka level health years) and are associated with significant
care physicians in recognition and economic burden on the family and society.
management of common neurological Despite its huge burden, neurological services have
conditions like migraine, epilepsy and stroke remained out of reach for a common man with total
should be undertaken along with establishing lack of services at village, taluka are district levels.
referral protocols with higher centres. Management of these conditions and the need for
• Neurology units with dedicated beds, CT quick decision making in conditions like stroke need
scan facility, required drugs and supplies systematic planning at different levels of healthcare
should be made available in every district system. A crude calculation of the number of people
hospital to manage patients within a district. requiring neurological services in a district reveals
that in an average 2 million population of a district,
• DNB programs in neurology can be started there are likely to be 4000 persons with stroke,
in select institutions with the help of 14,000 persons with epilepsy, 4,00,000 individuals
regional and apex centres wherever with headache disorders with 25% of them suffering
neurologists or a neurology Department is from migraine, 50,000 persons with dementia and
existing about 1000 people with Parkinson's disease (see
main report for details)(115); most of these are not
• Regional neurology services in the form of routinely picked up in basic healthcare services.
regional centres in 5 to 6 districts of
Karnataka should be established with Neurological services are mainly available in urban
required infrastructure, manpower and areas and commonly delivered by neurologists or
laboratory support services . by trained physicians / paediatricians; of course by
large number of quacks. In Karnataka, there are
• The available protocols for diagnosis, around 250 neurologists (2500 neurologists in India,
management, and referral should be with 40 to 50% of them concentrated in large cities),
employed in training of doctors and nurses most of them in private sector, with majority of
for managing neurological disorders them in Bangalore and other cities; very few district
through short-term training programs hospitals have neurological services. There are
• Telemedicine and tele-teaching should be very few stroke ready hospitals and rehabilitation
employed for training and management of centres in bigger cities. Organised neurological
neurological disorders at districts levels. services are not available in rural areas; many
affected individuals receive late care. Care in
private sector leads also results in heavy OoPE to
the affected individuals and families. In addition, as
An estimated 7,00,000 persons require neurological
neurological diseases are chronic diseases, neuro
services in the state. With ‘Brain Health’ occupying
rehabilitation or even general rehabilitation
centre stage in recent times, promotion of brain
services are scant and limited.
health and preserving - protecting its functions
along with care for neurological disorders is of Even though national programmes like NPCDCS,
utmost importance as people are living longer. NPHCE and RMNCH have included few neurological
Many neurological disorders are recognised as disorders, its extent and reach is hardly noticed.
public health problems due to their high morbidity, Fundamentally, the absence of trained manpower at
mortality and disabilities. Epilepsy, Migraine, different levels of healthcare system is a major
Dementia, Parkinson's disease, Brain damage due barrier with no training for physicians, medical
to injury and birth trauma, Neuroinfections and

93
officers and healthcare workers along with lack of prehospital care, acute management, having a
support services. However, it is well proven that post discharge plan and monitoring the
majority of the neurological disorders, if detected progress of the patients in terms of recovery
early, can be managed at peripheral levels and (details with regard to the same are given in
within the existing healthcare systems. An table 1 below).
organised network of service providers and health
care facilities is required to manage these • Many preventive programs are well known to
conditions. reduce the incidence of neurological disorders
like addressing risk factors for stroke, helmet
• As stroke is already included under the NPCDCS and seatbelt wearing for head injuries,
program and because of its preventable / improved antenatal practices for childhood
treatable nature, a stroke unit should be neurological disorders and epilepsy. Health
established in every district in collaboration education and promotion programmes should
with the local medical colleges. In order to include these aspects as well.
examine the feasibility of this approach a pilot
stroke prevention/ management/ rehabilitation • The NCD wing of the DoHFW should take
program should be established in four districts leadership role to develop pilot programmes in
of the state in two years. The management of stroke prevention / management / rehabilitation
stroke involves building specific components of

Management of Stroke in peripheral areas

• The acute management of ischemic stroke • It is essential and imperative to have 5
in window period of 4.5 hours requires bedded ICU in Taluka hospitals and 20
organization of stroke services in the health bedded ICCUs in District hospitals. The
delivery system of the state Taluka hospitals have to be mapped to
tertiary care hospitals in every district at
• At village, PHC, Taluka level recognition of the vicinity for this Spoke and Hub model.
stroke and shifting the patient to nearest
primary or regional stroke centre should be • The equipment’s and manpower for setting
the priority. up an ICCU at a district level have to be
procured – installed – maintained and
• Doctors (MD qualified physicians are operated through skilled resources.
already trained to treat stroke patients by
thrombolysis) with an MBBS qualification • The training, monitoring, supervision and
can be trained to treat stroke patients. transfer responsibilities of patients from
Necessary training packages have to be Spoke to Hub Hospital have to be evidence
developed centrally at the state level. based and protocol driven.
• The protocols of management of stroke at • Simple data management protocols have to
taluka and district levels have to be be developed and analysed regularly to
developed – validated - circulated and all assess effectiveness of the hub and spoke
the doctors have to be trained. Training can model.
be provided to doctors and all supportive
staff through digital platform and wherever • Emergency 108 Ambulance services are to
possible by organising workshops. be functioning and integrated into this
system for timely transfer of patients.
• At district hospital primary stroke center
should be established, with availability of • Telemedicine should be used to link all the
stroke physician, 24 hour CT scan with centre and an apex centre who has
Stroke ICU and with facilities for experience in the stroke management
intravenous thrombolysis. should coordinate with adequate manpower
with regional centre which in turn
• Primary Stroke centers in a region of 3-4 coordinates the primary stroke centers.
districts should be connected to a regional
centre where in addition to intravenous • NIMHANS can provide support to establish
thrombolysis; cath lab with facilities for this Hub and Spoke model and
endovascular therapy for the stroke should Demonstration projects can be initiated in
be made available. the next 12 months in 3 – 4 districts

94
40. COPD and Respiratory Health
Chronic Obstructive Pulmonary Disease (COPD) is
Prevention, promotion, early diagnosis and defined as ‘ a common, preventable and treatable
management and, continued care of COPD disease characterised by persistent respiratory
persons should be strengthened by developing symptoms and airflow limitation due to airway
abnormalities caused by significant exposure to
• An expert committee to establish policies noxious particles or gases and influenced by a wide
and norms to be followed at different variety of host factors including abnormal lung
levels of healthcare system for screening development’ (131) . The damage to the lungs resulting
and management along with developing from COPD is irreversible and is therefore a serious
the requisite infrastructure support illness causing long-term disability and early death.
• Norms and guidelines for management, Individuals with COPD are also at an increased risk of
follow-up and review at primary, developing various comorbid conditions in their life. As
secondary and tertiary care levels along in other areas of public health, data to quantify the
with guidelines for home care burden of COPD in Karnataka is not available. However,
management for individuals suffering it is estimated that the prevalence varies from 2 to 22%
from COPD. in men and 1 to 19% in women as per various
studies(106, 15, 132) ; valid and reliable spirometry
• Mechanisms for linking COPD based prevalence data for COPD is unavailable even
management under the existing national though COPD ranked second in the top 15 causes of
programs for continued treatment of diseases and deaths in 2016 up from its nine position of
patients to control the post illness 1990(101). The prevalence and burden due to COPD is
sequelae. projected to increase over the coming decades due to
increasing risk factors due to genetics, exposure to
• Training and education of all categories noxious gases, tobacco smoke, outdoor pollution,
of health personnel including medical occupational exposure and indoor air pollutants,
undergraduates and postgraduates by airway hyper responsiveness and poor lung growth
having compulsory posting in pulmonary during childhood.
medicine departments .
The state of Karnataka implements a few programs for
• Pulmonary function test centres in all prevention and control of respiratory illnesses like the
PHCs, secondary health care facilities in National Tobacco Control Programme, National
district hospitals and in advanced Tuberculosis Elimination Programme and National
diagnostic and clinical workup centres in Programme for Control and Treatment of Occupational
medical colleges and district hospitals. diseases and Injuries. There is no programme for COPD
• Awareness in the population and to care and management as the importance given and
educate at risk individuals and groups. coverage of services for COPD is extremely limited.
Many other challenges for public health programs exist
• Research components in medical colleges for COPD as well, ranging from funding insufficiencies
for better understanding of COPD to the availability of basic drugs and diagnostics at PHC
levels with difficulties in implementation.

95
41. Oral Health
Optimal oral health is important for overall health
• Organise a state-level oral health survey to and well-being of individuals. As per the GBD study
estimate the burden of oral disorders and 2019, the prevalence of oral disorders in India was
to repeat the survey at periodical intervals 46.6%, with data being unavailable for the state of
to gather up-to-date information for Karnataka (Table 12) (106). Oral health is one of the
planning oral health services. most neglected public health problem at the policy
level due to lack of real-time data and absence of
• Constitute an oral health task force with qualified personnel. In addition, the absence of oral
experts drawn from government and healthcare services at primary and secondary
private sectors to develop the state-level levels has been a major impediment to develop
policy and programs as well as to oversee services. The dentist population ratio in the country
the implementation of oral health is 1: 200,000 despite the high concentration of dental
programs in the state professionals in urban areas and in private
• State specific oral healthcare delivery healthcare settings(133). Many oral health
models should be developed in select conditions like dental caries, periodontal diseases,
districts on a pilot basis to facilitate loss of attachment, oral mucosal conditions,
implementation and integration of different malocclusion, oral cancer, fluorosis and
programs eduntulousness are highly prevalent and
contributes for significant oral morbidity.
• Create positions of Dental Chair assistant
in all district and taluka hospitals to provide
effective services.
• Epidemiological surveys of oral health
conditions should be undertaken and
integrated with other surveillance
programmes along with establishing a
Karnataka state oral healthcare
information system.
• Establish a state Centre of Excellence in a
dental academic institution for coordinating
with government towards implementing
oral health programmes in the state

Table 12: Oral Health Status of Karnataka (Age-wise)

Conditions 5 Years 12 Years 15 Years 35-44 Years 65-74 Years

Dental caries 40.5 22.3 33.1 63.3 81.7

Periodontal disease 46.5 8.7 86.8 94.3 77.2

(Bleeding, Calculus & pockets)

Loss of attachment NA NA 4.8 33 47.9

Oral mucosal conditions 1.2 0.5 0.9 0.6 0.7

Malocclusion 0.3 19.4 18.5 26.2 NA

Oral cancer 1.2 0.4 0.9 0.3 0.7

Fluorosis 3 13.1 11 5.2 2.7

Edentulousness NA NA 0 2 122

96
The state has nearly 40,000 dentists registered
with the Karnataka State Dental Council of 42. Eye Care Services
which only a few have served in the public
sector. A large number of dental health officer
posts are lying vacant in the state and are to be
The subcommittee on strengthening ophthalmic
filled. The dentist density for one lakh population
care recommends an implementation framework
is 3.8 in the state, substantially lower as
for all state government schemes in consultation
compared to the WHO dentist population ratio
with expert committee to bring about integration
recommendation of 1 : 7500.
of private and public health care facilities under
The National Oral Health Programme(134) was the Ayushman Bharat scheme(62) with other
launched in the year 2016 in the state. The existing schemes. The committee recommends that
program aims to strengthen public health the government policy of 2017 should be
facilities for an accessible, affordable and implemented immediately for improving eye care
quality oral healthcare delivery. The National services in the state. The committee recommends
Oral Health Policy of 2021 is also under that
formulation. In addition, many other existing
programs also support oral health services. The • Mandatory refractive eye status examination at
notable scheme of the Karnataka state ' Danta school admission level and at annual
Bhagya scheme' supports patients from BPL promotion for subsequent classes should be
families and those above 60 years, RBSK for undertaken in coordination with the
oral health of children, National Programme for Department of Education and Women and Child
Prevention and Control of Fluorosis are also Development.
under implementation.. Many challenges as • A senior ophthalmologist should be appointed
applicable to other public health programs exist in all the districts for providing a wide range of
in oral healthcare delivery as well, ranging from clinical services who will also be responsible
human resource deficiencies to low awareness for training and capacity building activities at
levels in the community, maldistribution of the taluka levels.
oral health workforce, poor perception of oral
diseases in the community, miniscule budgetary • The licenses of all existing ophthalmic
allocation and lack of clarity on implementation institutions should be periodically reviewed to
of oral health programmes. ensure quality services. Eye banks should be
promoted in all cities and districts along with
information in all the medical death
certificates to support eye donation programs
• ASHAs and health workers should be
supported to update the village blind register
and to refer required cases to the medical
offices at the PHC levels
• All drivers above 50 years should be
encouraged to undergo periodical eye check-ups
especially those with comorbid conditions.
• Speciality care services in the area of eye
trauma, retinal detachment, paediatric
cataract, and other eye conditions should be
made available for all needy persons in
medical colleges, district hospitals and apex
institutions.
• Human resources in ophthalmic care should
be strengthen with training programs for
people working in government services
• Financial support to be extended to all needy
families and from poor income households to
receive eye care services by bringing some of
the existing schemes under the Ayushman
Bharat Arogya scheme

97
43. Trauma and Critical Care Services

• A state level multisectoral and • Introducing a triage system with a designated

multidisciplinary trauma critical task force to nurse coordinator should be made
be chaired by a senior official should be mandatory in all taluka and district level
constituted with the responsibilities of hospitals.
providing technical support to develop state • All designated trauma care facilities –
trauma and emergency care policy, trauma care, proposed and those in development should
action plan and for assisting the government in be fully functional by 2022 with total
implementing and monitoring the progress. availability of required manpower, functional
• The trauma care unit in the DOHFW should be CT scan and operational theatres in all district
supported with a fully trained and hospitals. In addition, all existing 30 district
professional team to coordinate all activities hospitals should be upgraded as integrated
at the state level. trauma and critical care centres.
• Sustainable, certified, need-based and • Telemedicine and Tele – teaching should be
effective training and capacity building scaled up and effectively used for critical care
programs has to be implemented in the state management and a comprehensive plan
by creating a pool of certified first care should be drawn up by the department.
responders from within the community; local • In every district, 20% of beds in district
medical colleges, district administration can hospitals and 10% in taluka hospitals should
train these people under the guidance of the be converted to fully functional ICU and
Karnataka road safety authority or any other critical care unit. All private hospitals should
implementation bodies. extend trauma care services, irrespective of
• The implementation of the Good Samaritan the injured person’s ability to pay.
law needs a greater push from the state • The state should establish six regional
government with the active engagement of trauma and critical care referral hospitals
NGOs, media, health Department and can be with each Centre covering neighbouring 4 to 5
done through larger CSR activities. districts for a population of ~ 10,000,000 to
• The existing ambulance network should be provide comprehensive trauma and critical
strengthened with a state owned, integrated, care services
geo-tagged and a single number with adequate • Monitoring and evaluation mechanisms
fleet management services, required should be established in all trauma care
technology and call centre operations for early facilities along with integrating HMIS systems
transport of injured and critical persons to the for trauma related information. Trauma audits
nearby definitive hospitals. should be part of trauma care in all hospitals
• An effective and functional district trauma along with quality control and accreditation
and emergency care program (PHCs as first mechanisms.
care centres, CHCs and taluka hospitals for • Departments of emergency medicine and
secondary care and district hospital / medical trauma care should be established in all
college hospitals as tertiary care centres) medical colleges and wherever facilities are
should be implemented on a pilot basis in four available super speciality programs like DM
districts of the state over the next two years critical care or DNB in critical care should be
with a designated nodal officer and a budget. started at the earliest.
• All doctors and nurses should be trained in • A fully operational cashless scheme and
emergency and trauma care through a 2 flexible financing solution should be
week training programme in designated established to ensure that all persons with
medical colleges of the state under RGUHS by emergencies are protected by insurance in
using modules already developed by the state. both public and private sector

Injuries and acute medical/ surgical conditions are hospital reporting and surveillance systems, data is
common reasons for hospital visits and admission lacking with regard to number of hospitalisations,
to emergency rooms, hospital wards and critical recoveries and deaths due to medical and surgical
care units. Due to lack of reliable state wide conditions in the ER and ICUs.

98
WHO and other international agencies indicate that Figure 39: Elements of effective Trauma Care system
efficient emergency, trauma and critical care
services can reduce deaths by 25 to 30%(117, 135,
136). Even in Karnataka, a demonstration project
Pre-hospital
undertaken in the districts of Mandya, Bagalkote
and Belgaum during 2013 – 16 informed that an • Call & control centre
integrated and interconnected facility based and • Ambulances
• Trained staff
resource applied program can reduce trauma • Sensitised & trained public
deaths(137). Based on available data and estimates,
about 3 million persons with injuries and an equal
Hospital
number or higher number of persons with medical
and surgical conditions need emergency and • Equipment
critical care services every year in Karnataka. The • Evidence-based guidelines
• Triage
data from the five years of Bangalore Road Safety • Trained staff
and Injury Prevention Programme revealed that • Audit
among deaths, 1/3 occur at the injury site, 10 to 15%
on the way to hospital, nearly 50% in the hospital
Refferal System
and a small percent post discharge(83). Many of
these can be averted with good trauma and critical • Transport
care services. Information on deaths due to other • Guidelines
causes and place of death is not readily available in • Training
• Specialised diagnose
the state. • Specialist care

The DoHFW is the lead state agency for

implementing trauma and critical care services in Rehabilitation system
Karnataka. Trauma care management in the state
• Appropriate appliances
suffers from lack of a clearly defined policy, • Occupational therapy
programmatic guidelines, organisation, skilled • Physio therapy
manpower, drugs, equipment’s and supplies and • Work & home support
poor coordination mechanisms at the state and
district levels, in both urban and rural areas, due to
slow-paced initiatives. An in-depth assessment of
trauma care systems in the district of Kolar in 2017 Trauma care management is an integrated set of
indicated that there was no trauma care policy, activities starting from management at the site till
SoPs, guidelines and trauma team concept. Only the discharge of the patient and subsequent
40% of the doctors and 17% of nurses were trained rehabilitation measures ( Figure 39)(139) .
in trauma care. The scoring of healthcare facilities
The Covid 19 pandemic necessitated the
and a comparison with WHO essential guidelines
government to act and make required
for trauma care revealed that none of the facilities
arrangements in view of the increasing cases,
from level 1 to level 3 had trauma care systems with
emergencies and deaths. The government acting
more than 75% of the WHO expected standards.
fast, scaled up manpower by recruiting doctors,
Only level 4 healthcare facilities had trauma care
nurses, specialists and all support staff, augmented
systems with more than 75% of the expected
critical care infrastructure by strengthening ICU
standards (30).
facilities with equipment and supplies, provided
In sharp contrast, the system assessment of training for all categories of health professionals,
emergency care services in Tamil Nadu indicated allocated greater funding for procuring drugs and
that an appropriate combination of Triage, Training other supplies, strengthened coordination
and Treatment (3 Ts) improved efficiency of trauma mechanisms through regular meetings, introduced
care services. Nearly 86% of the intervention telemedicine facilities and state-level coordination
hospitals had better treatment outcomes in spite of mechanisms definitely improved to a greater
receiving more polytrauma cases and head injuries, extent. The judiciary also played a major role by
as compared to hospitals without interventions. issuing directives and the media highlighted the
Nearly 85% of polytrauma patients improved in ground level realities. A combination of all these
intervention hospitals as against 60% in the control measures has helped in improving services in
hospitals. The most significant intervention in the trauma and critical care units across the state. A
facilities was the appointment and coordination by a real time evaluation is required to assess the
dedicated trauma care nurse coordinator who in sustainability and impact of these changes in due
turn was able to train many other nurses(138). course of time.

99
Regional Care Centres patients treatment centre - new multi-speciality
hospital in North Bengaluru area to provide modern
Emergency, critical care, acute care, speciality – and specialist medical services to the poor and
super speciality services will be required for an migrant workers – Operationalization of the
unknown (or even unestimated) proportion of Institute of Gastroenterology Sciences and Organ
persons from paediatric to geriatric age groups Transplant in Bengaluru - and other facilities with
with different health conditions who are in an upgradation being a continuous activity ( excerpts
advanced state of illness with co-morbidities and from the budget 2021 – 22 , Karnataka Government
complications. The precise number of such persons dated 8th march 2021) .
in a district ( ~ 2.5 million) is difficult to estimate in
the absence of good population based studies. A closer examination of management of such
Persons with diabetes, CVDs, stroke, cancer, renal persons reveals the need for a multidisciplinary
diseases, trauma, acute medical / surgical team approach (team of specialist doctors like
emergencies, burns, and several others fall into physicians, surgeons, orthopaedicians, cardiologists,
this category. Most patients (especially these above endocrinologists, anaesthetists, radiologists and
50 years) will have multiple comorbid conditions many others), advanced facilities (Operation
requiring inputs from multidisciplinary for theatres, ICUs, step down facilities, wards, etc.,) , a
management. In the current scenario, patients, large team of support staff like ( nurses,
families and hospitals make decisions of reaching technicians, skilled team of support professionals)
such patients to advanced facilities, mostly to urban along with many other support systems ( like blood
centres, based on access and affordability in the banks, CT / MRI facilities, etc.,).Needless to say, the
absence of specific protocol driven referral pathways. capital and recurrent expenditure of managing such
Referral from one hospital to another is a common centres on an year to year basis will be huge.
phenomenon also resulting in high costs of care. The state government should consider developing
While it is ideal that district hospitals and medical five such regional centres in different regions of the
college hospitals should provide advanced care state to provide speciality multidisciplinary services
(with dedicated 20 % and 10 % of beds in district and ( to manage many health conditions under one roof)
taluka hospitals, respectively along with systematic considering regional distribution, geography,
unpgradation of facilities and manpower), some development status of districts, access, possibility
may require care in apex tertiary care centres. At of getting specialists in different specialities,
present, standalone independent speciality and operational costs, and likely benefits to people.
super speciality centres, mostly in private sector Each centre can serve the needs of 5 – 6
and in urban areas are functioning in the state. The neighbouring districts. These centres can be
state government is considering establishing few exclusive speciality HCFs located in proximity of a
such centres in cardiology, trauma care, cancer medical college or a district hospital or can be up
care, burns management and others in the state. gradation of select medical colleges. The obvious
merits of this approach lies in – providing
To provide specialty services for state citizens, the multispecialty care, sharing resources and
Karnataka government is planning to establish reducing costs, and minimising patient
Intensive care units of 25 bed and 6 bed capacities inconvenience and multiple referrals. Apart from
in 19 district hospitals and 100 taluka hospitals, providing specialised care, these centres can also
respectively, – unpgradation of primary health serve as excellent centres for - human resource
centres to model primary health centres, stage by development centre for speciality areas - research
stage to provide additional services and modern – protocol driven and evidence based referral
facilities- emergency treatment departments in systems - promotion of specialities - and state of
Bengaluru, Mysuru, Ballari and Hubballi Medical the art facilities. Such centres can also have
Science Institutes - regional cancer treatment linkages with the district health systems with
centres on the model of Kidwai Institute at Mysuru provision of serving poor and vulnerable
and Shivamogga - three well equipped mobile communities. Telemedicine must be an integral part
laboratories for cancer detection among women – a of such centers.
sub-centre of Jayadeva Institute of Cardiac
Sciences of 50 bed capacity in Davanagere - a To help the government for identifying the need and
sub-centre of Jayadeva Institute of Cardiology at scope of such services, a scientific study should be
Bengaluru with 50 bed capacity and other facilities- commissioned by the health department in 2
a burn injuries treatment and plastic surgery districts of Karnataka (one in north and one in
division at Kalaburgi Medical Science Institute by south) to come up with a plan of implementation
Kalyana Karnataka Development Board – opening that is based on data and evidence.
up of a trauma care centre in Mysuru Medical
Science Institute – upgradation of DIMHANS at
Dharwad to a well-equipped mental and neuro
100
44. Environment and Health

Recommendations: II. Research and Technology

SHORT TERM Promoting research of environmentally
sound facilities for the treatment of
I. Compliance of Environmental Laws Bio-medical waste, Hazardous waste,
To address these challenges, the state has e-waste, construction waste, Solid waste,
established various departments and plastic waste, Air and water pollution for
agencies to coordinate the environmental innovations is required. Development and
protection and sustainability efforts. Strengthening of research centers and
Karnataka has a dedicated Department of build capacity of the health care providers/
Forest, Ecology and Environment. Various Pourakarmika/ vulnerable groups to
laws and regulations have been adopted identify Occupational hazards and monitor
which include - The Environment Protection the diseases that are attributed due to
Act, 1986,The Air (Prevention and Control of poor environmental conditions.

Section 4: Specific Topics

Pollution) Act, 1981,The Water (Prevention and III. Financial Instrument
Control of Pollution) Act, 1974,The Karnataka
Forest Act, 1963,The Wildlife (Protection) Act, Prioritizing environment sectors and
1972,The Forest Conservation Act, 1980,The getting required budgetary allocations by
National Green Tribunal Act, 2010.Strict considering various options like
implementation and compliance of these introducing environmental health cess in
Environmental legislations are necessary to taxation policy, tapping CSR fund for
address Environment and health issues. Environment and Health under CSR rule,
encouraging corporate companies to
II. Training and Capacity Building adopt villages, schools, anganwadis, and
Capacity building programs for all the public infrastructures like sports stadium,
stakeholders/user agencies and parks, and treatment plants and ensure
departments on environment and health health and hygiene should be considered.
through online and offline modes and Preventive taxation policy for eg: to ease
making it prerequisite for providing traffic congestion ; to control excessive
compliance certificates for agencies such as use of chemicals, pesticides, herbicides in
industries, slaughterhouses, blood banks, agricultural/ horticultural crops ;
transport and other user agencies using incentivizing eco-friendly material example:
policy guidelines to bridge the gaps and encourage cotton/jute bags ; elimination the
suggest required evaluation studies and single use plastic ;encouraging green
capacity building is required. infrastructure, smart city, and public
III. Monitoring transport through preventive taxation policy
needs examination.
Creation of Integrated Command and
Control Information System to address the IV. Education, Sensitization and Awareness
public grievances for all environmental creation.
and health concerned departments with a V. Policy Interventions & Evaluation and Social
unified 3 digits user friendly toll free Audit
helpline number with multiple options to
make voice calls, upload photographs with Creating sound environmental management
geographic location, send email etc., to system is a key for ensuring good public
register grievance along with a control health, therefore it is important to make
room monitored by a dedicated officer, Environment and Health everyone’s
preferably senior administrator is an business! For this public awareness needs
essential requirement. to be created to make it people’s
movement along with policy reforms.
LONG TERM
Covid-19 pandemic situations have made
I. Implementation of Environment us realize that it is important to prioritize
Management Plan (EMP) Health and Environment by enhancing
To create an environment management budgetary allocations and involving public
division at each Local body level participation to achieve required goals and
targets of good health and well-being.

101
Health of individuals is related to the environment • Total Hazardous waste generated in the state is
in which they live. Environment includes the 3,62,901 Mega Tones Per Annum (MTA) and
surroundings, conditions or influences that affect Plastic Waste generation is about 627 Tons Per
an organism (Davis, 1989). Clean air, water, Day (TPD). Total Bio-medical waste generated in
sanitation, green spaces and a healthy working the state is 66 TPD besides a significant amount
environment is important for a society to ensure of COVID waste during the pandemic.
equitable and quality life and for women, men and
children to be more productive and creative. The • The State Action Plan for Climate Change
dangerous levels of pollution of water, air and soil, (SAPCC) has identified the following concerns:
disturbances to the ecological balance of the Climate change affects the social and
biosphere and depletion of non-renewable environmental determinants of health – like
resources are a matter of increasing concern in clean air, safe drinking water, sufficient food and
today’s society. The improvement of public health secure shelter. Between 2030 and 2050, climate
also includes the protection and improvement of change is expected to cause approximately
the total environment without which public health 2,50,000 additional deaths per year, from
cannot be assured as shown in Figure 40. Malnutrition, Malaria, Diarrhea, heat stress and
related causes.
• In Karnataka the number of deaths attributable
to ambient particulate matter pollution (95% Existing/Ongoing Programs:
uncertainty interval) among females and males • National Clean Air Program (NCAP)
is 10,838 per annum (7,036 to 15,481) and 15,473
per annum (10,295 to 21,646) respectively. • National River Conservation Plan
Similarly the burden of mortality attributable to
household air pollution (95% uncertainty • Green India Mission - National Afforestation
interval) among females and males is 17,716 Program
(13,149 to 22,501) and 15,981 (11,552 to 20,778) • National Action Programme to Combat
respectively. Desertification
• At present existing treatment capacity of • Renewable Wind and Solar Grid energy, MNRG
Sewage Treatment Plant is 2289 MLD, but
capacity utilization is 1592 MLD in the state. • National Green Corps (NGC)
Inadequacy in sewage treatment plants and
• National Health Mission
underutilization of installed capacity lead to
contamination of surface and ground water due • National Vector Borne Disease Control
to discharge of untreated sewage into Programme (NVBDCP)
environment media.
• Family Welfare Sterilization Programme
• The solid waste generated from the urban
centers is about 11,085 TPD, and the amount of • Integrated Disease Surveillance Project (IDSP)
municipal solid waste collected is 10,198 TPD, the • Mission Indradhanush
quantity of the solid waste processed is about
5,838 TPD. • United Nations Sustainable Development Goals
(SDGs)

Figure 40: Levels of Environment

Total environment

Behavioural, social, natural

& physical environment
Social, natural
& physical environment
Natural & physical
environment

Physical
environment

102
45. Urban Health

• A state urban health authority should be • Health promotion activities should be

constituted for planning and coordination of strongly supported in all educational
all services across all sectors concerned institutions, offices, industries, workplaces,
with urban health as well as to regularly community agencies to encourage people to
monitor and evaluate activities. adopt healthy lifestyles.
• An urban health task force should be • An urban health demonstration project based
established with representation of diverse on the proposed urban health model should
stakeholders to support planning, designing be piloted in one or two zones of Bangalore
and implementation city to gather the learning’s and experiences
before scaling up activities.
• Within the DoHFW, an urban health division
should be established for undertaking all • Health impact assessment should be
coordination, funding and collaborative regularly undertaken for all health and
activities with concerned departments and nonhealth sector related projects and
urban local bodies programs including those falling under the
smart cities mission and in urban areas of
• Resources for urban health should be clearly
Karnataka
mapped and deficiencies in human resources
and facilities should be clearly delineated for • Evidence-based urban planning should be
strengthening along with an increase in undertaken to facilitate uniform and
budgetary allocation. sustainable urbanisation.
• Each zone in Bangalore and all cities with a • Engaging urban population and CSO’s is
population of more than three lakh should be critical for improving urban health with a
considered as separate units for implementing focus on vulnerable populations.
national health programmes with availability
of all services and a 24x7 programme.

Urbanisation has had a huge impact in Karnataka Undoubtedly, urbanisation has several advantages
with the proportion of urban population nearly in terms of education, economy, living, accessibility
doubling in the last five decades. It is estimated that to services and others. However, this urban
the state urban population will be closer to 50% by advantage may get jeopardised due to unplanned
2030 from the current estimate of 43.6%(11). Health growth and poor governing systems. The
of individuals is related to the environment in which determinants of urban health are several and
they live. Environment includes the surroundings, interact in many complex ways. Poverty, presence
conditions or influences that affect an organism of slums, low literacy levels, lack of basic amenities
(Davis, 1989. The noticeable feature of urbanisation in water – sanitation – housing, overcrowding, living
in the state's top-heavy nature lies with 70% of the habits, transportation, health care and costs,
urban population residing in class I towns and changing food habits, fast paced living, higher
cities. stress, increasing problems of substance and
technology use, and poor safety nets contribute for
the growing burden of a wide variety and nature of
health problems, specially affecting the urban
“Health care is vital to all of poor(140) ( Figure 41).

us some of the time, but

public health is vital to all of
us all of the time”

- C. Everett Koop

103
Figure 41: Connection between health outcomes and the urban environment (140)

Social cohesion Crime

Population
Heat & cold Chronic disease
Morphology and
land use Urban climate
Air quality

Service demand Physical activity Mental health

& supply Transport
(mode or distance)
Energy
Qualiy of urban Noise
Water environment
Buildings Injury & violence
Water quality
Sanitation

Solid waste Land contamination Infectious disease

Food
Infrastructure Disease vectors & pests

The health, social and economic problems in urban the laboratory services. However, many challenges
areas are also different as compared to rural exist in implementation of NUHM due to
issues. NCD's and injuries together contribute for governance, coordination and funding issues. Most
nearly 70% of mortality in urban Karnataka. Many significantly, healthcare in urban Karnataka is also
other communicable diseases also coexist in this through a wide network of private healthcare
scenario. One in eight individual suffer from mental providers. Utilisation of services from private care
and substance use disorder. While overweight and providers entail considerable OoPE and can be of
obesity is more prevalent in urban areas, child catastrophic nature. Poor urban planning and
malnourishment is common among the urban poor. adhoc-crisis oriented populist programs have failed
Mother and child related health problems are also to recognise the real burden of urban health issues.
higher among the urban poor in comparison to their
rural counterparts. Air quality in most of the cities, The subcommittee of the vision group after
the noise levels, waste disposal mechanisms, examining details, has suggested a hub and spoke
transportation crisis, safety concerns are all huge, model for healthcare through a mix of public and
leading to multiple health problems. Amidst the private sector health care facilities and providers.
basic struggles of job, income, housing, education The existing public urban health services in the
and survival, health is of concern and the place it gets state fall into three distinct patterns largely based
in individual hierarchy depends on the importance on population size. Thus, the nature and range of
given by governments, individuals and families. services in Bangalore city with an estimated 1.7
crore population is likely to be very different as
The National Urban Health Mission (NUHM) compared to other places in terms of the
launched in the year 2013 aims to improve the administrative arrangements. In cities with lesser
health and well-being of the urban poor by population, there are UPHCs providing clinical and
facilitating equitable access to quality healthcare preventive services functioning under the District
through an upgraded public health system with the Health Officer of the DoHFE. Secondary and tertiary
active participation of the urban local bodies(141). care services are provided through the district
The program also covers all the district hospital and all medical colleges. In smaller cities,
headquarters and other cities with population of the district health office and the district health
50,000 and above, while those below 50,000 are hospital are available for secondary health
covered under NRHM. A wide range of preventive, services. Based on the current understanding of the
promotive and curative services are covered under existing patterns the proposed urban health model
NUHM. One urban primary health centre is should be examined by the government for its
established for every 50,000 population and nearly implementation.
361 UPHCs are functioning in the state. Till date, no
formal evaluation on input, process, outcome and With the launch of the NUHM in 2013 and also the
impact of NUHM has been undertaken in Karnataka. smart city program implemented in select places
NUHM has certainly contributed to improving the focus of urban health has shifted to a more
resources for urban healthcare through increased integrated and inclusive model for healthcare
funding, establishing UPHCs, strengthening existing delivery. For improving health and life of people, a
health centres, recruiting more manpower, coordinated assessment and regulatory
improving community participation, constituting frameworks needs to be established in its
Mahila Arogya Samithis and also by strengthening implementation.

104
46. Disasters, Epidemics and Emergency Preparedness
In recent times - disasters, epidemics, pandemics Figure 42: Map of Karnataka with disaster
and other emergencies (eg., fire emergencies, proneness and occurrence
building collapse) has become common in today's
society. The health sector has a very significant role
in protecting the health and well-being of Bidar

populations, vulnerable populations in particular,

from the impact of varied hazards in the state. Apart Kalaburgi

from providing emergency services in crisis Vijayapura

situations, the health sector has a greater role in

Yadagiri

organising preventive and curative functions along Bagalkote

Raichur

with governance, guidance and regulatory roles.

Belagavi

Heavy rain fall

Disasters, pandemics and epidemics are known to Dharwada
Koppala

Low lying
widen the existing inequalities both within and
Gadaga

Landslides
between populations.
Ballary
Uttara Kannada
Haveri

Drought
Karnataka faces draught landslides, disturbed Davanagere

rainfall, cyclones, flooding and local epidemics on a

Chitradurga
Shivamogga

year-to-year basis, with Covid 19 pandemic added to Chikkaballapura

this list ; all aspects of people's lives are affected in

Udupi
Chikkamagalur Tumakuru
Bengaluru Rural

these situations. Most importantly, certain districts

Kolara
Hassana Bengaluru Urban
Mangaluru

of Karnataka are draught prone while few other Mandya Ramanagara

districts are disaster prone ( Figure 42) . The health Kodagu

effects and consequences vary from short to longer

Mysuru
Chamarajanagara

durations and has varying impact on health of people.

The current disaster management policies of disasters and epidemics require great
Karnataka outline an elaborate and comprehensive communication, coordination and convergence of
framework by covering wide range of services activities.
including emergency response. However, the • A district directory of institutions, manpower
importance given for mental health and and capacity along with referral pathways
psychosocial support services is only cursory in needs to be created as a ready reckoner or as a
nature. While the comprehensive coverage of work card for emergency purposes along with
medicines, nutrition, food safety, shelter, transport maintaining a directory of evidence-based good
and other areas exist, mental health has been the practices based on learning from other places
neglected part in disaster management situations. and lessons learnt from the past.
Though physical health is a fundamental dimension
of well-being, mental and social health is equally • The several sections of the disaster
important for creating the ability to lead a socially management act and state disaster
and economically productive life. management act have several provisions for
implementation during epidemics and
In line with the National Disaster Management Act pandemics. All these require developing
2005(142), the Karnataka State Disaster systems that can respond at early stages,
Management Authority has been established under maintain continuity of services, and ensure
the leadership of the Hon. Chief Minister of health and well-being of people as well as
Karnataka(143). The different administrative bodies delivering the required social and economic
are entrusted with specific responsibilities to support for the affected individuals. Both short
respond in disaster and crisis situations. The term and long term psychosocial care is
District Disaster Management Authority headed by important in disaster situations.
the Deputy Commissioner of the district is the nodal
unit for managing all activities at the district level • A greater investment has to be made in
along with development of the district plan. developing human resources of different types
through continuous and on-going training
The physical and psychosocial impact of disasters programmes at different levels along with and
differ significantly in terms of acuteness and capacity building of policymakers.
chronicity, nature of damage and hazard profiles,
and are invariably associated with loss of lives and • The role of technology does not require
damage to property. Both the primary and overemphasis as communication and
secondary stressors play a significant role in convergence of activities form the central
affecting the physical and mental health of pillars of relief operations in any disaster,
individuals. The district preparedness during epidemic, pandemic and other emergencies.

105
87
47. Tribal Health
The term “Scheduled Tribe” first appeared in the wasting and underweight in tribal children has
constitution of India. Article 366 of the Indian reduced but malnutrition is still higher than in all
Constitution defined Scheduled Tribe as “such population children. (144) (146)
tribes or tribal communities or parts of or groups
within such tribes or tribal communities as are Data with regard to specific burden of illness in
deemed under Article 342 to be Scheduled Tribes tribal population is limited. The tribal population in
for the purpose of this constitution. Currently, over the country faces triple burden of diseases. While
104 million tribal people live in India spread across malnutrition and communicable diseases like
705 tribes, and account for 8.6% of the country’s malaria and tuberculosis continue to be rampant,
population. (144) rapid urbanization, environmental distress and
changing lifestyles have resulted in a rise in the
In Karnataka, Schedule Tribes account for 6.55 prevalence of non-communicable diseases like
percent (3.46 million) of the total State population, cancer, hypertension and diabetes. To add to this
which comprises 4.11 percent of the total tribal the third burden that is the mental illness especially
population of the country. Concentrated tribal areas the addictions. (146) (147)
termed as Integrated Tribal Development Project
(ITDP) exist in 4 districts of Mysore, Chickmagalur, Communicable diseases - The tribal population
Kodagu, Dakshina Kannada and Udupi (South and bears a disproportionate burden of communicable
Coastal Karnataka). There are 50 major tribes with diseases. The estimated prevalence of pulmonary
109 sub-tribes in the State (as of March 2005), tuberculosis in tribal community is significantly
according to the notified Schedule under Article 342 higher than in the rest of population at 703 as
of the Constitution of India. From these, GoK has against 256 per 1,00,000 populations. In the year
identified (i) Jenu Kuruba; and (ii) Koraga tribes as 2016-2017 about 18.9% of the newly detected leprosy
primitive groups (PTGs). Jenu Kuruba tribes are cases were among scheduled tribes. Although
originally from Mysore, Chamarajanagar and tribal communities constitute only about 8% of the
Kodagu districts and Koraba tribes are from Udupi national population, they account for 30% of all the
and Dakshina Kannada districts. In Chamarajanagar cases of malaria and as much as 50% mortality.
district, only Kollegala Taluk has PTG areas. PTGs Non-Communicable diseases – The evidence of an
constitute the most vulnerable among the all notified early epidemiological transition in tribal areas and
tribes. Bellary district has the highest concentration associated increase in the incidence of
of Schedule Tribes (STs) in Karnataka. (145) non-communicable diseases is being observed.
Tribal people have remained marginal- geographically, One out of every four tribal adults suffer from
socio-economically, politically and therefore, health hypertension and only 5% men and 9% women
and healthcare in tribal areas remained unsolved suffering from hypertension knew their
problem. Large gaps in Human development hypertension status. Almost 72 percent of the tribal
indicators are observed between scheduled tribes men in 15-54 years age group use tobacco as
and all category group. (146, 147) The total fertility compared to 56 percent non-tribal men and about
rate of the tribal population is 2.48, while the 50 percent tribal men consume some form of
national average 1.92; the child sex ratio 957 in 2011 alcohol. The prevalence of genetic disorders like
higher than general population at 914 girls to 1000 sickle cell diseases, thalassemia and others varies
boys. The literacy rate stands at 59 percent in 2011, between one to fourteen percent. As tribal areas
as against 73 percent in general population. The life are surrounded by forests, animal bites from
expectancy at birth for ST population in India is 63.9 snakes, dogs and scorpions, the animal attacks and
years, as against 67 years for general population. also violence in conflict areas are common.
The high maternal mortality can be attributed to The National Health Mission (NHM) is a major
early marriage, early child birth, low body mass instrument of financing and support to the States to
index, and high incidence of anemia. Coverage of strengthen public health system and health care
postnatal care remains poor, only about 37 percent delivery and tribal health is given importance. The
woman receive the care. The estimated infant National Tuberculosis control program has started
mortality rate, neonatal mortality rate and under-5 newer interventions viz. Active Case Finding to
child mortality rate though declined over years has improve the case detection in hard to reach areas.
remained higher than the national average. The To improve access to tribal and other marginalized
immunization coverage, infants fully immunized groups, there is also provision for Additional TB
sands at 55.8 percent as against 62 percent of Units and Designated Microscopy Centre’s (DMC) in
general population. The percentage of stunting, tribal/difficult areas, compensation for

106
86
transportation of patient & attendant in tribal areas, professional isolation, weak human resource
higher rate of salary to contractual staff posted in policies, poor working conditions and environment
tribal areas, enhanced vehicle maintenance and in the government health institutions, limited social
travel allowance in tribal areas, provision of TB infrastructure etc.
Health Visitors (TBHVs) for urban areas. Similarly,
services under the National Leprosy eradication The Ministry of Health and Family Welfare and the
program include funds allotted to NGOs, who are Ministry of Tribal affairs constituted an expert
encouraged to work in tribal areas for providing committee on tribal health. The committee under
services like IEC, prevention of deformity, the chairmanship of Dr. Abhay Bang, suggested
intensified IEC activities, and follow up of cases. following measures to improve human resources
for tribal health (144)
Under National Vector Borne Disease Control
Programme, services for prevention and control of a. The tribal society demands that the healthcare
Malaria, Kala-azar, Filariasis, Japanese Encephalitis, provider should be a local tribe.
Dengue/Dengue Hemorrhagic Fever (DHF) and b. A vibrant, responsive and accessible health
Chikungunya, are provided to all sections of the workforce in tribal areas can be ensured
community without any discrimination. However, through training local people and deploying
since vector borne diseases are more prevalent in them as the health force.
low socio-economic groups, focused attention is
given to areas dominated by the tribal population in c. It is important to place the center of gravity of
Karnataka. The National program for prevention and workforce closer to the communities and not at
control of blindness and visual impairment has been the top.
strengthened in number of areas like Assistance for
construction of dedicated Eye Units in hilly States. (146) d. ASHA in tribal areas should have expanded role
with different functions and four hours of work
Various schemes and programs have been per day.
implemented in Karnataka to ensure the health and
wellbeing of the tribal population ; these include The e. Mid-level care providers should be created
Navsanjivani scheme, special schemes on Matrutva through bridge courses and placed at sub-centers.
Anudan Yojana, Pada Volunteer Scheme, Mobile f. To provide doctors dedicated to work in tribal
Medical Squad, Compensation for loss of daily areas, the committee recommends creation of
wages and Water Quality Monitoring. Many NGOs medical colleges in tribal districts exclusively
have focused their efforts on health and welfare of for tribal students in the scheduled areas.
tribal communities.
The global meanings of “development” or “progress”
Tribal development has been a challenge to the on tribal people do not make them happier or
planners and policy makers since independence. healthier. In fact, the effects are harmful. The most
This is mainly on account of their traditional life important factor by far for tribal peoples’ well-being
styles, remoteness of their habitation, dispersed is whether their land rights are respected. If they
population and displacement. Tribal sub-plan are to survive, indigenous people must control the
strategy now known as scheduled tribe component changes they want to make to their own lives.
was adopted in the 5th Five-year plan for
accelerated development of tribal people. Ministry
of Tribal Afairs and Ministry of Health and Family
Welfare are making efforts through tailored
48. Conclusion and
educational, infrastructural and livelihood schemes
for the improvement in terms of various indicators
Way forward
relating to literacy, health and socioeconomic
status etc. The preceding sections highlight the importance,
current scenario and action areas to improve and
Special provision has been made to scale up
strengthen health systems and services in
infrastructure under National Health Mission. (5)
As per the present norms, tribal and hilly areas Karnataka. It is hoped that the DoHFW takes
should have one health sub-center (HSC) per 3000 necessary steps to examine issues highlighted in
populations, one Primary Health Center (PHC) per this report and creates administrative, financial,
20,000 populations, and a community health center regulatory and technical frameworks to integrate
(CHC) per 80,000 populations. About twenty-seven and implement activities along with required
to forty percent deficient in the number of health investments on a prioritization mode to strengthen
institutions in tribal areas across India could be and reform health systems. The vision group has
noted. A huge gap in Human resources in health outlined this road map with the strong
centers in tribal areas is attributed to reasons such understanding that robust and responsive systems
as limited scope for professional interaction or are required in the coming days to improve people’s
growth for the staff, a feeling of social and health in Karnataka.

107
Annexures
Annexure 1 - Government Order
Annexure 2: Karnataka at a Glance, 2020

Variable Year 2020 Household information

Geographical area (in sq km) 191,791 Households 15538187

Districts 31 Households with electricity (%) 88.75

Talukas 227 Household with tap water source(%) 62.5

Towns 347 Household using LPG/PNG 27.4

Hobli 776 Key facilities

Villages 29340 Police stations 1150

Socio-Demographic Fire Brigade Stations 213

Population (Female) Post offices 9618

(Census 2011) 61095297 (30128640)
Ration shops 19870
Estimated population
(M: F) 2021 71957278 (35458389) Health related

Child population (%) (0-6 years) 11.7 Life expectancy at birth 65.15

Senior citizens (60+ years) % 9.4 IMR per 1000 live births 38

Literacy (%) (Total; Female) 75.6; 68.1 MMR per lakh live births 178

Sex ratio (females per 1000 males) 973 Medical colleges 60

Economic Total Govt hospitals (Allopathy; AYUSH hospitals

2844;624
Per capita income in rupees
(At constant Prices (2017-18) 143827 Private hospitals (registered) 16993

Below Poverty Line (%) 21 Doctors: Hospital Beds 37419; 192508

Urbanization, industrialization, Pharmacies; Blood banks 39521;261

and motorization
108 Ambulances 743
Urban population (%) (Census 2011) 38.7
Anganwadi Centres 66015
Workers (% of population) 45.6
Other information
Number of factories 21162
Mobile phones in use 56,626,957
Number of registered motor vehicles 22139958
Internet connections 249071
Highways (National +State) in kms 86052
Number of excise shops 11228
Education
Income from excise in crores (2019-20) 22618.55
School drop out ratio (6-14 years) % 0.07

Pre-university Colleges 5004

Degree colleges 1058

Source: Department of Economics and Statistics. Karnataka at a glance. 2021. Government of Karnataka
Annexure 3: Health Programmes in Karnataka
Supported by Ministry of Health and Family Welfare

Health Programme Target Groups

S.N
Central Government Initiatives
1 Reproductive, Maternal, National and Child Pre-pregnant, pregnant and lactating women,
Health Plus Adolescent Programme neonates, infants, children and adolescents
https://nhm.gov.in/index1.php?lang=1&level=1&sub
linkid=805&lid=557
2 Revised National Tuberculosis Control All tuberculosis patients, HIV-Coinfected patients,
Programme population at risk etc.
https://www.nhp.gov.in/revised-national-tubercu
losis-control-programme_pg
3 National AIDS Control Programme Most at-risk population like female Sex workers, Men
https://www.nhp.gov.in/national-aids-control-pr having sex with men, transgenders; bridging
ogramme_pg population like migrants, truck drivers, and general
population at risk along with those affected with HIV
and AIDS Patients including orphaned and vulnerable
children etc.
4 National Vector Borne Disease Control Population at risk, patients with the conditions etc.
Programme An umbrella program to control, prevent and
https://www.nhp.gov.in/national-vector-borne-di efficiently manage Malaria, filaria, Kala-Azar,
sease-control-programme_pg Japanese Encephalitis, and Dengue
5 National Programme for Control of Blindness Population at risk, patients with the conditions etc.
https://www.nhp.gov.in/national-programme-for
-control-of-blindness_pg
6 National Iodine Deficiency Disorders Control General population
Programme
https://www.nhp.gov.in/national-iodine-deficienc
y-disorders-control-progr_pg
7 National Mental Health Programme Most vulnerable, at risk and underprivileged section
https://www.nhm.gov.in/index1.php?lang=1&level= of population
3&sublinkid=1117&lid=353
8 National Programme for Prevention and control Population at risk, patients with the conditions
of Cancer, Diabetes, CVD and Stroke
https://www.nhp.gov.in/national-programme-for
-prevention-and-control-of-c_pg
9 National Tobacco control Programme Adolescents and general population
https://www.nhp.gov.in/national-tobacco-control
-programme1_pg
10 National Oral Health Programme Apparently healthy individuals, Patients with dental
https://www.nhp.gov.in/national-oral-health-pro ailments
gramme_pg
11 National Organ Transplant Programme Patients or individuals who are in need of organ
https://notto.gov.in/ transplantation.
12 National Programme for Health Care of Elderly Elderly individuals (60+ years)
https://www.nhp.gov.in/national-program-of-hea
lth-care-for-the-elderly-n_pg
13 National Programme for Prevention and control Patients with conditions
of Deafness
https://dghs.gov.in/content/1362_3_NationalProgr
ammePreventionControl.aspx
14 Pharmacovigilance Programme of India Patients and healthcare professionals
https://cdsco.gov.in/opencms/opencms/en/PvPI/
16 Yaws Eradication programme Population at risk and patients
https://ncdc.gov.in/index1.php?lang=1&level=1&su
blinkid=148&lid=76
17 National Leprosy Eradication Programme Population at risk and leprosy patients
https://nhm.gov.in/index4.php?lang=1&level=0&lin
kid=281&lid=348
18 Guinea Worm Eradication Programme Population at risk and patients
https://ncdc.gov.in/index1.php?lang=1&level=1&su
blinkid=142&lid=73
19 Rabies Control Programme Population and animal bite victims
https://www.nhp.gov.in/national-rabies-control-
programme_pg
20 Integrated Disease Surveillance Programme All patients affected by the listed conditions.
https://idsp.nic.in/
21 National Programme for control & Treatment of All workers.
Occupational Diseases
https://www.nhp.gov.in/national-programme-for
-control-and-treatment-of-oc_pg
22 National Nutritional Programme Children, adults, pregnant women, economically
backward sections of the population, etc
23 National Nutritional Anemia Prophylaxis Population at risk and anaemia patients.
Programme
https://www.nhp.gov.in/national-iron-plus-initiati
ve-for-anemia-control_pg
24 National Programme for prophylaxis against Children at risk and blind children
Blindness in children
https://www.nhp.gov.in/national-vitamin-a-proph
ylaxis-program_pg
25 National Adolescent Health Programme Adolescent population
https://nhm.gov.in/index1.php?lang=1&level=1&sub
linkid=805&lid=557
26 Universal Immunization Programme New born, children, adolescents and pregnant women
https://www.nhp.gov.in/universal-immunisation-
programme_pg
27 National Filaria Control Programme Population at risk, filarial patients.
https://nvbdcp.gov.in/index4.php?lang=1&level=0&
linkid=450&lid=3727
28 National Cancer Control Programme Population at risk and patients affected by Cancer
https://main.mohfw.gov.in/Organisation/Departm
ents-of-Health-and-Family-Welfare/national-ca
ncer-control-programme
29 National Iodine Deficiency Disorder Control General Population/ Population with Iodine Deficiency
Programme Disorders like mental and physical retardation, deaf
https://www.nhp.gov.in/national-iodine-deficienc mutism, cretinism, still births, abortions etc.
y-disorders-control-progr_pg
30 National Programme for Prevention and Control • Population at risk and population/patients
of Fluorosis (NPPCF) affected by Flurosis
https://nhm.gov.in/index1.php?lang=1&level=3&su
• Fluorosis endemic regions/populations
blinkid=1055&lid=611
31 Pradhan Mantri Swasthya Suraksha Yojana General population with more focus on under-served
(PMSSY) http://pmssy-mohfw.nic.in/ areas
32 National programme for Palliative care Patients suffering from terminal illness like Cancer,
https://nhm.gov.in/index1.php?lang=1&level=2&su AIDS etc
blinkid=1047&lid=609
33 National AYUSH Mission https://namayush.gov.in/ General population
34 National Programme for Prevention & Population at risk and patients with trauma and/or
Management of Trauma and Burn Injuries burn injuries.
https://main.mohfw.gov.in/basicpage-6
 State Government Initiatives
1 Vajpayee Arogyashree BPL families
https://elibrary.worldbank.org/doi/10.1596/978082
1396186_App-G
2 Rajiv Arogya Bhagya APL families
http://arogya.karnataka.gov.in/sast/English/index
.php/using-joomla/extensions/components/cont
ent-component/article-category-list/35-rajiv-ar
ogya-bhagya-scheme
3 Jyothi Sanjeevini Scheme Government employees
http://arogya.karnataka.gov.in/sast/English/index
.php/site-map/2017-12-20-22-15-29/jss/50-jyothi
-sanjeevini-scheme
4 Janani Suraksha Yojana BPL pregnant women
https://www.nhp.gov.in/janani-suraksha-yojana-
jsy-_pg
5 Madilu Newly delivered poor mothers and infants
https://karunadu.karnataka.gov.in/hfw/nhm/page
s/mh_schemes_madilu.aspx
6 Prasuti Araike BPL, SC and ST women
https://karunadu.karnataka.gov.in/hfw/nhm/page
s/mh_schemes_paraike.aspx
7 Shuchi Adolescent girls
https://karunadu.karnataka.gov.in/hfw/kannada/
Documents/HFWS
%20Annual%20Eng%202018-19.pdf
8 Rashtriya Bala Swasthya Karyakrama (RBSK) Children- 0-18 years
https://karunadu.karnataka.gov.in/hfw/nhm/page
s/nbch_nbs_rbsk.aspx
9 Indradhanush Children
https://karunadu.karnataka.gov.in/hfw/kannada/
Documents/HFWS%20Annual%20Eng%202018-19.
pdf
10 Nutritional Services Children and women
https://karunadu.karnataka.gov.in/hfw/kannada/
Documents/HFWS%20Annual%20Eng%202018-19.
pdf
11 Mobile Health Units Pregnant women
https://nhm.gov.in/index1.php?lang=1&level=2&su
blinkid=1221&lid=188
12 Arogya Sahayavani-104 Pregnant women
https://nhm.karnataka.gov.in/page/NHM+COMPO
NENTS/Health%
20System%20Strengthening/Arogya+Sahayavani
+(104)/en
13 EMRI (Arogya Kavacha-108) Pregnant women and general public
https://karunadu.karnataka.gov.in/hfw/kannada/
Documents/HFWS%20Annual%20Eng%202018-19.
pdf
14 Nagu-Magu Postnatal mothers and new born
https://karunadu.karnataka.gov.in/hfw/nhm/page
s/refserv_nagumagu.aspx
15 Bike Ambulances (First Response Unit) Population at risk
https://karunadu.karnataka.gov.in/hfw/nhm/page
s/refserv_bikeamb.aspx
16 SwachhSwasthSarvatra (SSS) General public
https://karunadu.karnataka.gov.in/hfw/kannada/
Documents/HFWS%
20Annual%20Eng%202018-19.pdf
17 Swachhata Pakshika General public
https://karunadu.karnataka.gov.in/hfw/kannada/
Documents/
HFWS%20Annual%20Eng%202018-19.pdf

18 Vatsalyavani General public and pregnant woman

https://karunadu.karnataka.gov.in/hfw/kannada/
Documents/
HFWS%20Annual%20Eng%202018-19.pdf

19 Pre-Conception and Pre-natal Diagnostic Pregnant women & New born

Techniques Programmes (PC. & PNDT)
https://karunadu.karnataka.gov.in/hfw/nhm/page
s/rh_pcpndt.aspx#

20 Janani Suraksha Vahini Pregnant women and female children

https://karunadu.karnataka.gov.in/hfw/kannada/
Documents
/HFWS%20Annual%20Eng%202018-19.pdf

21 Arogya Kavacha (108) Pregnant women and sick neonates/ infants

https://karunadu.karnataka.gov.in/hfw/kannada/
Documents/HFWS%20Annual%20Eng%202018-19.
pdf

Initiatives by other ministries and departments relevant to health

1 Road Safety program/ initiative by Ministry of General Population

Road Transport and Highways National Highway
Accident Relief Service Scheme
(http://morth-roadsafety.nic.in//WriteReadData/li
nks/File387ec1d6c23-d6ac-4d5f-84a8-41d6b534
5a66.pdf )

2 National Sub-Mission to provide safe drinking All the arsenic & fluoride affected habitations.
water
https://www.mdws.gov.in/national-sub-mission-
guidelines-provide-safe-drinking-water-remaini
ng-arsenic-and-fluoride-affected

3 National Emergency for Preparedness Plan: People affected by disasters

Disaster Management
https://nidm.gov.in/pdf/guidelines/new/sdmp.pdf

4 Programmes for Water and Sanitation Rural India, small and medium towns, NGO, Private
https://www.unicef.org/wash sector and community

5 National Biomass Cook stoves Programme General population

http://164.100.94.214/national-biomass-cookstove
s-programme

6 Rajiv Gandhi National Drinking Water Mission General population

(RGNDWM)
https://www.indiawaterportal.org/sites/default/fi
les/iwp2/RGNDWM_
Evaluation_Study_Planning_Commission_2010.pdf

7 National Program for rehabilitation of persons Persons with disability

with disability

8 Mid-day meal program Children in government and government-aided

http://mdm.nic.in/mdm_website/ schools

9 ICDS scheme http://icds-wcd.nic.in/ Children in the age-group 0-6 years and pregnant and
lactating mothers
Annexure 4: Infrastructure and range of services at different levels of health care as per IPHS guidelines

Population: Location Type of health worker Delivery Range of services offered

Centre norm strategies

Health and - Primary Two Medical Officers, Seamless RCH Services: Care in
wellness level (Sub Staff nurses, lab continuum of pregnancy and childbirth,
centres enters and technician, care: Outreach Neonatal and infant health,
primary Pharmacist, LHV, services, Child and adolescent health
health Mid-Level Health Mobile Medical care services including
centres ) provider, MPW (F/M), Units, Camps, immunization, family
-Villages (SHC- 2 MPW (F) and Home and planning, contraceptive
1 MPW (M), UPHC- community-bas services, and Reproductive
one MPW (F) per ed care care services
10000Population),
Management of
ASHA (1/1000 or 1 / communicable diseases:
500 for tribal and hilly General Outpatient Care for
areas/ 1 / 2500 in simple acute illness and
urban areas), Village minor ailments
Health Sanitation and
National Health
Nutrition Committees,
Programmes: Prevention,
Mahila Arogya
screening, and
Samitis, Self-Help management of
Groups, Women
non-communicable
Collectives, Patient
diseases, screening and
Support Groups,
essential management of
AYUSHMAN
mental health ailments,
Ambassadors (One
care for common
male and One female
ophthalmic and ENT
School Teacher for
problems, primary oral
School health
health care, elderly and
Promotion)
palliative health care
services,
Emergency medical
services: Including for
Trauma and Burns

Sub centre 1: 5000 in Village Health worker – Outreach RCH Care: Antenatal care,
plain areas male/female 1 / 5000 services, and a intranatal care, postnatal
and 1: 3000 minimum of six care, essential newborn
in hours of routine care, family planning
challenging OPD services in services, safe abortion
to reach a day for six services, adolescent health
areas days a week care services, school health
services
General health services:
Curative services for minor
ailments, first aid for animal
bite
National Health
Programmes: control of
locally endemic diseases,
disease surveillance under
IDSP, promoting safe water
and sanitation, field
services such as village
health and nutrition day,
community interactions, etc.
Recording and reporting of
vital events Monitoring vital
events and their reporting
Primary 1: 30000 in Village 1 Medical Officer / 24-hour facility Medical care: OPD services, 24
Health plain areas 30000 with nursing hours emergency services,
Centre and 1: 20000 facilities for referral services, in-patient
1 Pharmacist / 30000
in difficult to emergency services(6 beds)
reach areas 3 Nurses (Type A hospital care,
PHC) / 30000 RCH services: Antenatal care,
for curative, intranatal care, postnatal care,
4 Nurses (Type B preventive proficient in identification and
PHC) / 30000 and promotive essential first aid treatment for
1 Health Worker health care complications and referral,
Female newborn care, care of child,
family planning services,
1 Health Assistant medical termination of
Male / 30000 pregnancies, management of
1 Health Assistant reproductive tract infections
Female / 30000 Nutrition services: Coordinated
1 Laboratory with ICDS, school health
Technician / 30000 including school visit,
screening, treatment, and
2 Group D workers referral as well as
and 1 Sanitary worker immunization, adolescent
cum watchman / health care
30000
National health programmes:
1 Accountant cum Promotion of safe drinking
Data Entry Operator water and basic sanitation,
per PHC Prevention, and control of
locally endemic diseases.
collection and reporting of vital
events, IEC / BCC activities,
training of medical and
paramedical staffs, Referral
services, basic laboratory and
diagnostic services, selected
surgical procedures,
monitoring, and supervision,
functional linkages with
sub-centers, Mainstreaming of
AYUSH
Essential AYUSH services for
ailments
Record of vital events and
reporting

Commun 1: 120000 in Block Specialists from Block-level OPD & IPD services of General
ity plain areas Surgery, Medicine, health Medicine, Surgery, OB&G,
Health and 1: 80000 Obstetrics and administrative Paediatrics, Dental and AYUSH
Centre in Gynaecology and unit and services; Care of routine and
challenging Paediatrics; emergency cases in Medicine
gatekeeper for
to reach and Surgery,
1 Block Medical referrals to a
areas
Officer/Medical higher level of RCH services; National health
superintendent; programmes
facilities
1Public Health Blood storage facility;
specialist, Diagnostic services
Anesthetist, and at
Referral/ Transport services
least 1 Public Health
Nurse and Support
Staffs

Subdivisi 1 per 5-6 Tehsil/Taluk 20 doctors and 45 Link between Essential specialty services,
onal or lakhs paramedical staffs in SC, PHC, and RCH services, Psychiatric
Taluka population 31-50 bedded CHC on one end services, Rehabilitation
hospital hospitals;24 doctors and District services. Geriatric services,
and 73 paramedical Hospitals on Accident and trauma services,
staffs in 51-100 the other end counseling and testing centre
bedded hospitals
District 1 per District District Two doctors each of A secondary Basic specialty services
hospital Medicine, Surgery, level referral specialty services, Epidemic
Obstetrics and centre for the and disaster management,
Gynaecology, public health Special Newborn Care Units
Paediatrics and institutions; (SNCU), Mental health services,
Anaesthesia; One Curative rehabilitation services, Accident
doctor each for including and trauma services, Dialysis
Ophthalmology, specialist services, Anti-retroviral
Orthopaedics, services, therapy, Related diagnostic
Radiology, Pathology, preventive and facilities, Patient safety,
ENT, Dental, promotive infection control and Health
Psychiatry, and services care workers safety services
AYUSH Doctors; 76 covering an
paramedical staffs, urban and rural
including Nurses, Lab population of
Technicians, the District
Pharmacists, Social
Workers, Dietician,
Technicians, etc.
 Sl.No Districts No. of Populatio Health & Sub- PHCs CHCs Taluka District Medical Laboratory X-ray^ CT Scan^ MRI^ Dialysis^
Talukas n in 2021 wellness centres n (%) n (%) hospital hospital college facilities centres facilities Centres Facilities
centres n (%) n (%) n (%) hospital n n n n n
n
1 Bagalkot 7 2169452 155 234(-46) 49(-32) 8(-56) 5(+15) P* 1 7 13 2 - 7
2 Ballari 5 3380240 248 272(-60) 73(-35) 11(-61) 6(-11) P* 2 5 18 - - 8
3 Belagavi 15 5426096 476 549(-49) 148(-18) 16(-65) 9(-17) P* 1 15 24 2 1 7
4 Bengaluru Urban 4 6472160 81 195(-85) 36(-83) 5(-91) 3(-77) P* 14 4 16 1 - 8
5 Bengaluru Rural 4 1167401 142 167(-28) 48(+23) 2(-79) 4(+71) P* 2 4 6 - - 4
6 Bidar 8 1935760 215 280(-28) 58(-10) 8(-50) 4(+3) P* 1 8 13 2 - 4
7 Chamarajanagara 5 1082139 221 245(+13) 64(+77) 3(-67) 3(+39) P* 1 5 7 1 1 3
8 Chikkaballapura 7 1379908 161 199(-28) 60(+30) 2(-83) 5(+81) P* 0 7 8 2 1 6
9 Chikkamagaluru 8 1136942 228 375(+65) 90(+137) 5(-47) 6(+164) P* 0 8 14 - - 6
10 Chitradurga 6 1818420 249 283(-22) 82(+35) 11(-27) 5(+37) P* 1 6 16 1 1 7
11 Dakshina Kannada 7 2310853 323 440(-5) 72(-7) 8(-58) 4(-13) P* 8 7 11 1 1 5
12 Davanagere 6 1794310 147 301(-16) 101(+69) 6(-60) 5(+39) P* 2 6 13 2 - 3
13 Dharwad 9 2129928 122 194(-54) 45(-37) 0(-100) 3(-30) P* 2 9 4 1 - 4
14 Gadag 7 1167084 122 168(-28) 39(0) 2(-79) 4(+71) P* 1 7 7 1 2 5
15 Hassan 8 1848630 - 456(+23) 136(+121) 15(-3) 7(+89) P* 1 8 21 2 1 6
16 Haveri 8 1776077 212 303(-15) 69(+17) 5(-66) 6(+69) P* 0 8 12 1 - 7
17 Kalaburagi 11 3029841 246 347(-43) 94(-7) 16(-37) 6(-1) P* 4 11 23 2 - 7
18 Kodagu 6 560990 160 206(+84) 29(+55) 7(+50) 2(+78) P* 1 6 10 1 - 3
19 Kolar 5 1705436 190 230(-33) 69(+21) 2(-86) 4(+17) P* 2 5 9 1 2 5
20 Koppal 6 1615277 145 185(-43) 49(-9) 9(-33) 3(-7) P* 1 6 13 2 - 4
Annexure 5: Health care facilities across districts in Karnataka, 2021

21 Mandya 7 1850467 267 385(+4) 115(+86) 10(-35) 6(+62) P* 2 7 15 - 2 6

22 Mysuru 8 3437914 327 438(-36) 147(+28) 10(-65) 6(-13) P* 2 8 19 1 - 6
23 Raichur 7 2225308 175 223(-50) 52(-30) 6(-68) 4(-10) P* 2 7 11 1 2 4
24 Ramanagara 5 1147733 - 275(+20) 63(+65) 5(-48) 3(+31) P* 1 5 8 1 1 4
25 Shivamogga 7 1875987 211 305(-19) 110(+76) 7(-55) 6(+60) P* 2 7 15 2 1 6
26 Tumakur 10 2790349 404 487(-13) 147(+58) 4(-83) 9(+61) P* 2 10 15 2 1 10
27 Udupi 6 1326053 249 301(+13) 62(+40) 6(-46) 2(-25) P* 1 6 9 2 - 3
28 Uttara Kannada 11 1526064 292 343(+12) 83(+63) 3(-76) 10(+228) P* 1 11 14 2 - 11
29 Vijayapura 12 2625816 - 309(-41) 67(-23) 9(-59) 4(-24) P* 2 12 5 2 - 5
30 Vijayanagara - - - - - - - - - - - - -
31 Yadgiri 6 1445226 149 176(-39) 42 (-13) 6(-50) 2(-31) P* 0 6 9 2 - 3
Total 221 64157861 5917 8871 2299 207 146 31 60 221 378 40 17 167
Note: There are 66015 Anganwadi centers are present in the state and district wise information is maintained by Child and Family Welfare Department.
No prescribed population norms exist for District Hospitals and Medical Colleges follow NMC norms. Vijayanagara District is recently formed and therefore data is unavailable; Data on Urban facilities may vary.
A District hospital is present in all districts under the control of Health or Medical Education department. *P refers to Present; ^Includes both public and private facilities
Annexure 5.1: Health care facilities across cities in Karnataka (as per latest available data as on 2021)

Sl.No Cities No. of Populatio Health & Sub- Anganwadis PHCs CHCs Taluka District Medical
Talukas n in 2021 wellness centres hospital hospital college
centres n (%) hospitals

1 Belagavi City - 5426096 476 549 12 148 16 9 0 1

2 Bengaluru City - 6472160 81 195 160 36 36 3 0 14
3 Hubli Dharwad City - 2129928 122 194 19 45 101 3 1 2
4 Kalaburagi City - 3089841 246 347 15 94 5 6 1 4
5 Mangaluru City - 1526064 323 440 12 72 8 4 1 6
6 Mysuru City - 3437914 237 438 23 115 10 6 0 2

Sl.No Cities Laboratory Blood X ray CT scan MRI Dialysis

facility in banks centres facilities centres facility
Public Private Public Private Public Private Public Private Public Private Public Private

1 Belagavi City 24 1 1
2 Bengaluru City 14 1 1 1
3 Hubli Dharwad City 4 1 1 1
4 Kalaburagi City 23 1 1
5 Mangaluru City 11 1 1 1
6 Mysuru City 19 1
Sl. Districts No. of Health Health Nurses Phar Lab Radiolo Programme OBG Paediatrician Physician Surgeon Dentists Other
Taluk ASHAs worker worker macist Techni gists Officers Specialists
as Male Female cian
S F V V% V% V% V% V% V% V% V% V% V% V% V% V% V%
1 Bagalkot 7 1447 1430 17 1 36 19 7 7 1 0 0 5 41 0 0 33 28
2 Ballari 5 2088 2076 12 1 15 13 35 14 24 3 14 4 22 0 0 44 16
3 Belagavi 15 3862 3855 7 0 67 30 16 11 11 6 0 3 33 0 0 42 19
4 Bengaluru Urban 4 873 848 25 3 65 11 23 0 3 6 0 0 0 0 0 0 0
5 Bengaluru Rural 4 834 828 6 1 69 25 33 0 8 0 20 0 0 0 0 0 0
6 Bidar 8 1362 1355 7 1 2 7 42 15 0 0 0 33 20 0 0 44 19
7 Chamarajanagara 5 800 785 15 2 90 65 40 74 63 15 0 0 0 0 0 25 13
8 Chikkaballapura 7 1064 1054 10 1 80 52 27 21 4 31 0 0 0 0 0 10 8
9 Chikkamagaluru 8 959 943 16 2 46 48 6 62 30 18 0 7 0 0 0 15 17
10 Chitradurga 6 1481 1476 5 0 13 15 7 48 0 13 0 10 0 0 0 33 2
11 Dakshinakannada 7 1381 1372 9 1 85 32 1 - 34 27 17 0 0 0 0 18 17
12 Davanagere 6 1228 1215 13 1 16 20 7 31 0 0 0 0 0 0 0 10 0
13 Dharwad 9 1033 1010 23 2 49 17 17 0 0 0 0 0 0 0 0 0 8
14 Gadag 7 767 754 13 2 19 17 35 8 13 0 33 0 13 0 0 25 33
15 Hassan 8 1498 1497 1 0 54 36 23 66 21 4 33 0 6 0 0 14 27
16 Haveri 8 1501 1469 32 2 41 30 36 32 30 0 33 0 6 0 0 14 27
17 Kalaburagi 11 1899 1855 44 2 5 9 32 43 4 48 0 25 4 0 0 19 40
18 Kodagu 6 502 472 30 6 72 39 10 - 71 33 50 0 8 0 0 45 20
19 Kolar 5 974 962 12 1 57 57 36 21 26 6 0 0 10 14 0 0 11
20 Koppal 6 1343 1311 32 2 35 4 29 13 27 13 33 7 64 0 0 64 28
21 Mandya 7 1343 1387 10 1 43 43 41 40 31 0 0 0 0 0 0 64 28
Annexure 6: Health manpower across districts in Karnataka (June 2021)

22 Mysuru 8 1839 1810 29 2 68 44 17 45 27 0 0 0 0 0 0 6 2

23 Raichur 7 1508 1497 11 1 25 6 48 20 38 0 0 0 0 25 0 55 100
24 Ramanagara 5 879 857 22 3 57 27 17 0 14 0 0 0 0 0 0 0 4
25 Shivamogga 7 1362 1331 31 2 48 31 13 43 30 10 0 6 0 0 0 29 4
26 Tumakur 10 2154 2136 18 1 52 33 13 26 24 9 0 4 0 0 0 12 3
27 Udupi 6 1028 1010 18 2 82 43 2 47 12 0 0 0 40 33 0 0 4
28 Uttara Kannada 11 1400 1388 12 1 80 39 25 60 - - 17 6 43 0 0 44 18
29 Vijayapura 12 1808 1784 24 1 18 28 18 7 8 0 0 53 38 0 0 63 23
30 Vijayanagara - - - - - - - - - - - - - - - - - -
31 Yadgiri 6 1024 1007 17 2 11 14 37 34 33 45 33 40 22 0 0 80 40
Total 221 41241 40774 521 1 43 30 23 31 19 10 9 7 13 2 0 30 16
S – sanctioned ; F – filled ; V-vacant.: Data as on June 2021 | Numbers shown in all categories from health workers male onwards correspond to % of vacancies
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of vacant positions was only 1.26%. Almost all the districts met the
requirement of appointment of the sanctioned number of ASHA
workers, except Kodagu district, where the proportion of vacant
positions of ASHA workers was 5.98%.
1. World Health Organization. Basic documents. 2020. Available from
The total number of sanctioned positions of health worker male was https://apps.who.int/gb/bd/
5686 in the state of which the proportion of vacant positions was 2. Mathiharan KD. The fundamental right to health care. Indian
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