by

Venkat Chekuri

Hon. Joint Secretary,

VGKK & Karuna Trust

“Reaching Health Care

to the Unreached”

Equity in Health Care

• We have PET, MRI and we can do heart

transplants

• But we have very few functional laboratories

in PHCs and people do not get treated for hook

worm anemia!

• Health services for SCs and STs

• Out of pocket expenditure for the poor– 70%.

Mostly spent on drugs & diagnostics.

Health Financing

• 0.9 to 1.6 of GDP – promised 2-3%

• Public vs Private spending 1.2% - 3.3% or

33%– 67% has to be reversed.

• Per capita public spending of Rs 675/- is

inadequate. Primary Health Care (PHC) is less

than Rs. 200/-

• Out of pocket expenditure is 70%

Quality in Health Care

• Poor quality in both public and private

• IPHS standards

• Accreditation: NABH, ISO, in house Quality

Control Cells (QCC)

• Corruption in public & private sector

• MCI and State Medical Councils

• Quality of Drugs

‘Reaching the Unreached’

• Started in Veerappan’s area

• Extended to Naxalite & insurgency areas

• Remote, hilly, tribal areas

• No electricity, no telephone connectivity, bad

roads - cut off during rainy season.

• Poor or unavailable public & private facilities

Vivekananda Girijana Kalyana

Kendra

VISION

A self reliant and empowered tribal society rooted in its culture & tradition, living in harmony with nature.

MISSION

Sustainable development of tribal people through rights based approaches to health, education, livelihood

security and biodiversity conservation.

B.RHills

B.R. Hills

Soliga Tribal people

• ‘Children of Bamboo’

• Veddoid group of aborginals. Pre-dravidian or

early-dravidians

• Shifting cultivation, food gathering and

hunting

• Lived in harmony with nature – ‘nature

worshipers’

Megalithic (800 BC) Burial Sites

B R Hills

Tribal Health Care

• Comprehensive Primary Health Care:

Preventive Promotive .

Curative Rehabilitative

• Understanding traditional health and

integrating/ building on it.

• Empowering people to manage their health

Tribal Education

• Started with 6 children in a hut – 1981

• 4 of them have done Post Graduation

• Jadyea has done MSc in Agriculture and

completed his PhD – Asst. Professor in

Forestry College – President of VGKK

• 2 MSWs & 1 MSc in Botany

Innovations in Education

1. Experiential learning

2. Life skills education

3. Computers in education

4. Value based education

5. Social work curriculum

6. Personality development

7. Environmental education

Women’s Self Help Groups

• Tribal women self help groups (SHGs) – 24

groups

• Micro credit: money lenders eliminated.

• Income generating activities: food processing,

bakery, weaving, hand made paper, herbal

medicines, dairy (with the help of Vetcare)

Technology & Resource Centre

• Food processing

• Organic farming

• Conservation, cultivation and commercialisation of

medicinal plants

• Alternate / cost effective rural building

• Sanitation & drinking water

• Rain water & roof water harvesting.

• Income generation & other rural development

activities

Community Organisation

• Soliga Abhivriddi Sanghas (SAS): village, taluka

and district level.

• Active participation in Panchayat Raj System

• Need based planning done by SAS and submitted to

ZP

• Land alienation and other exploitation stopped

• Taking active role in education of tribal children.

Gorukana Ecotourism

Empowering Communities

Through Conservation Tourism

To facilitate the empowerment and sustainable development of

people living in B R Hills, by forging unique partnerships

between tourism initiatives, conservation and communities.

The B.R Hills Wildlife Sanctuary

• BRT houses amazing number of animals including

tiger, leopard, wild dog, elephant, gaur, deer etc.

• Over 220 species of birds including black eagle,

Malabar whistling thrush etc.

• 800 plus species of plants from various families

and shows a close affinity to the Western Ghats.

Biligiri

Conservation Through Tourism

Care for the

LandCare for the

People

Care for the

Wildlife

Adventure

Guest

Soligas

BR Hills

Land &

Wildlife

Local economic

development

Skills development

through employment

Health & education

facilities

Benefits:

Benefits:

Memorable

Adventure holiday

Knowledge

acquisition

Environmental and

Social understanding

Maintenance of

biodiversity

Expansion of green

frontiers

Conservation of

Threatened species

Benefits:

The Biligiri Model

Conservation

Tourism

Experience100% eco-friendly wilderness lodge

Coverage

• Karnataka: Soliga, Jenu Kuruba, Betta Kuruba,

Yeravas,

• Arunachal Pradesh: Nocte, Wancho, Adi , Galo,

Mishimi, Nyshi

• Meghalaya: Khasis, Garos, Jaintias

• Andaman & Nicobar Islands: Great Andamanese,

Jarawas, Schompens, Onges, Sentinels

• Andhra Pradesh: Adilabad – Gonds, Kolams

Primitive Tribal Groups in

Andaman & Nicobar Islands

• Great Andamanese of Strait Island

• Onges of Little Andaman

• Jarawas of South and Middle Andaman

• Shompens of Great Nicobar

• Sentinelese of Sentinel Islands

Karuna Trust

• Founded in 1986

• Response to high prevalence of leprosy in

Yelandur- 21.4/1000 in 1987 to 0.2/1000 in

2005

• Community based, people oriented, need

based, culturally acceptable models using

appropriate technology with minimum cost to

the community

Private Sector

• Private Sector is an important player

• 80% of out patient care, 50% of inpatient care

is by private sector – 90% of preventive and

promotive health care is by public sector

• Involving private sector – purchasing the

services for BPL – Yashaswini, Arogya Shree,

RSBY.

• Regulating/accrediting private sector

Public Private Partnership

• Public – Government

• Private – For-profit private sector & not-for-profit sector ( NGOs, VOs)

• Privatisation: Partnership with not for private sector is not privatisation

• Partnership: It is not being “contractors” for implementation of Government Programs. Partnership in policy formulation, planning, implementation, monitoring, evaluation, training & research

Karuna Trust – PPP in India

• Karnataka State:

26 PHCs - one in each District

2 PHCs through other NGOs – Vivekananda Foundation &

Vemana Trust

Eye Hospital – Chamarajanagar Dt.

7 Mobile Medical Units (MMU)

Help Desk at two district hospitals.

FRU in Santhemaranahalli CHC, Chamarjanagar Dt

District Health Management – Tumkur Dt.

• Arunachal Pradesh – 11 PHCs

• Meghalaya State – 11 PHCs

• Manipur – 3 PHCs

• Odisha State – 6 PHCs

• Rajasthan – 12 PHCs

Comprehensive Primary Health

Care

• Rights based empowerment of people for managing

their health – Right to Health, Reproductive Rights.

• Community based Preventive, Promotive, Curative

and Rehabilitative services

• Mother & Child Health, all National Health

Programs and specific local problems.

• Addressing all other determinants of health – safe

water, sanitation, nutrition, livelhood etc.

Kammasandra

PHC

Needle pit

Labour room

development

Drugs, vaccines etc

Labour

wardIDP

Emergency Kit

PPP – The Process

Advocacy with respective state government

Expression of interest / direct application

Identification of PHCs – poor performance, remote / tribal areas

Dialogue with community and PRI members

Applying to ZP / state, sharing draft MoU

Finalising MoU

Recruitment and induction training

Withdrawal of govt. staff – option for continuing at PHC

Formal takeover of the PHC from DHO

58% 56%62%

77%

93%96%

0%

20%

40%

60%

80%

100%

120%

Percentage (%) of institutional

deliveries in

26 Karnataka PHCs

Infant Mortality Rate (IMR) in 26

PHCs of Karnataka State

20 20

2221

18

13

11

8.3

0

5

10

15

20

25

2006-07 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14

Rate

Year

254

81

0

50

100

150

200

250

300

National Average Karuna Trust PHC's

MMR

Innovations in Health Care

• Process Innovations : Innovations in Health

care delivery, good governance, community

participation

• Integrating traditional health practices

• ICT innovations: telemedicine, cell phone,

tablets, drones

• Appropriate technology

• Cost effective health care delivery

Innovations in Primary Health Care

Mental Health Program including epilepsy in PHC, lowcost management of epilepsy in PHC

Introducing Dental Health & Cancer Control Program inPHC – ANMs trained to take Pap Smears etc.

Vision Centers in PHCs

Integration of Rehabilitation (Palliative Care) into PrimaryHealth Care in addition to preventive, promotive & curativehealth care.

Promotion of Traditional Medicine – 20 herbs for PrimaryHealth Care. Integration of Ayurveda & Homeopathy(AYUSH)

Tribal ANMs program: training tribal girls as ANMs andposting them in the tribal sub-centers.

Innovations in ICT

• Telemedicine/ ECHO

• Logistimo –Supply chain management of drugs– cell

phone

• Sensors for monitoring of Cold Chain

• Drone for delivering emergency drugs

• Empowering health-workers with tablets and android

phone – Dtree, EMC2

• Digitization of health records of 23,000 people at

Gumballi PHC

ASHA Training

• Training of ASHA’a in 3 tribal Districts of

Karnataka

• In collaboration with NGOs in the Districts

• Nearly 3000 ASHAs already training.

• Supervision and Monitoring.

Community Health Insurance

• NGO, Government and UNDP

• Women’s self help groups - micro-credit for

out-patient care

• Pre-paid insurance for inpatient care -

hospitalization

• Lowest premium of Rs.30/- (50 cents) per

person per year, 100,000 people.

• National Insurance Company – No exclusions

Health Insurance/ Health

Assurance

• Karuna Trust – Community Health

Insurance

• RSBY - Labor Department

• Yashashwini – Cooperative Department

• SAST: 1.Vajpayee Arogyashree, 2. Rajiv

Arogyabhagya, 3. Jyothi Sanjeevini, 4.

Mukhyamantrigala Santwana - Harish

Scheme

Present and Scaling up States

Boisor

Protocol for Emergency Care

• To integrate traditional medicines into PHC

• To make a rapid assessment and validation of sound local practices.

• To develop a cadre of ArogyaMitras to cater to the preventive, promotive and curative needs of the community

• To advocate for policy on mainstreaming the traditional medicine into official primary health care system.

Mainstreaming Traditional

Medicine in to PHCs

Management of Cancers in

Women at PHCs

• Cervical and breast cancers

• Early detection, referrals and after care

• Training Nurses, ANMs and ASHAs in visual

inspection for early detection of cervical cancers.

• Management of STDs and RTIs

• Cryotherapy for premalignant lesions – Train

medical officers.

• Specialist clinics at PHCs

ASHA Training

• Training of ASHA’a in 3 tribal Districts

of Karnataka

• In collaboration with NGOs in the

Districts

• Nearly 3000 ASHAs already training.

• Supervision and Monitoring.

Community Planning &

Monitoring

• Pilot of NRHM in 9 States

• Karuna Trust – Nodal agency for Karnataka

• Implemented in 4 districts in partnership with

local NGOs

• 49 PHCs & 562 Villages covered

• VHSC & RKS capacity building

• Village health plan and report cards

Community

Participation

Scaling Up – 5 states

Karuna Trust

Arunachal Pradesh

PPP for Primary Health Care in

Arunachal Pradesh

• Year 2005

• To improve the health facilities in the state

• One Primary Health Centre (PHC) in each

district of the state will be managed and

operated through a selected non government

organization (NGO)

PHC Bameng

• 380 km. from Itanagar in East Kameng district

• The mud road from Seppa to Bameng is very

often blocked by landslides

Then…

…now

PHC Wakka

Wakka PHC, Tirap Dist

Wakka PHC staffs

Labour roomX-Ray room

PHC Jeying

PHC building 2007 PHC staff in front of quarter

Medical officer in front of his quarterA view of staff quarter

Road to PHCs

Road to PHC Bameng

Brahmaputra river crossing Road to Dambuk- Anpum

Road to Etalin

Brahmaputra Delta

Road to PHCs

Road to Dambuk & Anpum

Road to Dambuk & Anpum Road to Etalin

Road to Walong

District Water Quality Management

• Monitoring water quality in Chamarajanagar

and Chikkaballapur districts of Karnataka.

• Flouride, Arsenic, Nitrates and Chlorites.

• Convergence between the Health Department

(Bacteriological Contamination) and RDPR

Department (Chemical contamination).

Quality in Health Care

• NABH Accreditation for Gumballi PHC

– First PHC to get it other than Gujarat

State.

• Standard Operating Procedures (SOPs)

• 14 PHCs and the FRU accreditation in

process.

Cost Benefit

• PPP 75% to 90% to 100%

• Cost of Primary Health Care: Per

capita cost Rs.180/- for one year

• Spend less than Government

• Better Health out comes

Present and Scaling up States

Boisor

OBJECTIVE AND THE PATH

Objective:

Achievement of Equity, Quality and Integrity in

Health Care

The Path:

Revamping the organisation and structure

Capacity Building

Task Force on Health and Family

Welfare

Final Report

• Vision, Mission & Goals

• Comprehensive Health Policy which includes

Health Policy

Population policy

Drug policy

Nutrition policy

Education for Health Sciences – Policy

Blood banking policy

Policy on Control of Nutritional Anaemia

AIDS Prevention & Control Policy (draft)

ISM&H Policy (draft)

Pharmaceutical Policy

Karnataka State Integrated Health

Policy

12 Major Issues of Concern

1. Corruption

2. Neglect of Public

3. Distortions in Primary Health Care

4. Lack of Focus on Equity

5. Implementation Gap

6. Ethical Imperative

Task Force on Health and Family

Welfare Final Report

Task Force on Health and Family

Welfare Final Report

12 Major Issues of Concern

7. Human Resource Development

8. Cultural Gap and Medical Pluralism

9. From Exclusivism to Partnership

10. Ignoring the Political Economy of Health

11. Research

12. Growing Apathy in the System

GOOD GOVERNANCE IN

HEALTH

By

Dr. H. Sudarshan

Ex-Vigilance Director

Year Score Rank First Rank Last Rank

1995 2.78 34/41 New Zealand Indonesia

2000 2.80 69/90 Finland Nigeria

2005 2.90 88/158 Iceland Bangladesh & Chad

2006 3.30 74/163 Iceland Haiti

2007 3.50 72/180 New Zealand Myanmar/Somalia

2008 3.40 85/180 Denmark Somalia

2009 3.40 84/180 New Zealand Somalia

2010 3.30 87/178 Denmark, NZ Somalia

2011 3.10 95/182 New Zealand Somalia

2012 3.60 94/174 Denmark, Somalia

2013 3.60 94/175 Denmark Somalia & N Korea

2014 3.80 85/174 Denmark Somalia & N Korea

2015 3.80 76/167 Denmark Somalia & N Korea

85

The India Corruption Study 2005

by Transparency International India

State C. Index Rank

Kerala 240 1

Him Pradesh 301 2

Gujarath 417 3

Andhra Pradesh 433 4

Maharashtra 433 5

Chattisgarh 445 6

Punjab 459 7

West Bengal 461 8

Orissa 475 9

Uttar Pradesh 491 10

State C.Index Rank

Delhi 496 11

Tamil Nadu 509 12

Haryana 516 13

Jharkhand 520 14

Assam 542 15

Rajasthan 543 16

Karnataka 576 17

M.P. 584 18

J & K 655 19

Bihar 695 20

Reforms for Good Governance in

Health Services

Proactive Lokayukta – Ombudsman for PRI and

active monitoring – institutionalize the reforms

Vigilance cell in Health Department – Strengthen and

capacity building – expertise

E-Governance: HMIS – Program and HRM,

computerize transfers, recruitment, promotions, e-

procurement, web site for transparency and

accountability

Integrity Pact – black listing and debarring

Effective management and supervision by

administrators and senior staff – Field visits

87

Good Governance

• Mere technological packages can

improve the health outcomes

marginally

• Good governance can provide

quantum jump in the health outcomes

3 Qualities for a Leader

1. Concern and Empathy for the poor &

marginalized

2. Ability to understand their problem and find

a solution.

3. Will to put in to practice in spite of

insurmountable obstacles

Be & Make – Integrated personality – “Self –

love”, “Self-hatred” & “Love for others”

Transforming India through Quality

Leadership

• Working as a team – Net working

• Living practitioners of values – Human Resources

for Development

• Inner strength - Moral/ Spiritual

• “My life is my message” – M K Gandhi

• “They alone live who live for others; others are

more dead than alive” – Swami Vivekananda

MANASA – Care of Homeless,

Mentally Ill WomenThe activities of Manasa are:

1. Rescuing homeless, mentally ill women roaming in the streets

2. Providing psychiatric and other healthcare at Transit Care Centre for 6 to 8 months

3. Rehabilitation and reintegration with the families

The cost of providing the above care is about Rs.50,000/- per

patient X 25 patients

Cost of Providing Comprehensive

Primary Health CareCost of Comprehensive Primary Health Care:

Per capita cost Rs. 180/- for one year. Rs. 45

lakhs per PHC with 25,000 population.

Government pays 90% of the cost and KT has

to raise 10%+

Supporting Primary Health Care in North East

Arunachal Pradesh, Meghalya and Manipur

10% cost Rs. 4.5 lakhs per PHC x 25 PHCs

Vivekananda Eye Hospital and

Blindness Control Program

Karuna Trust runs blindness control program for the

poor people of Chamarajanagar District

We identify cataract cases and provide free surgeries

including intraocular lenses.

Annually we conduct about 1000 surgeries

In addition to the what the Govt

provides we need an additional Rs.500/-

per surgery x 1000

Mobile Dental Unit

Yelandur taluk, Chamarajanagar

Dt., Karnataka

Dental Health care is available only at district

and a few sub-district hospitals.

Karuna Trust runs a model Mobile Dental

Unit to go round the Villages to provide

dental health care.

The mobile unit donated Rotary Club,

Bangalore has dental chair with X-ray.

Cost of running Mobile Dental Unit per

month is about Rs. 30,000/- x 12 months

Karuna America: Team

Srinivasa Bhat

Secretary

Dr. H Sudarshan

Hon. Chairman

Dr. Surya Prakash

President

Vijay Kotrappa

Treasurer

Majunath Subbarao

Director

Dr. Arvind Halliyal

Director

Dr. Makum L. Ramesh

Director

B.V. Muralidhara

Director

Tax Exempt 501(c)3

Organization

US 501c-3 Fully Federal and State Tax

Exempt Organization.

Donations are tax exempt

Tax ID#: 47-4565265

21 Silverwood Lane, Pomona, CA

91766

Email: info@karunaamerica.org

Web site: www.karunaamerica.org

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www.vgkk.org

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