INNOVATIONS - National Rural Health Mission

INNOVATIONS
October 2008
1
Arogyakeralam

2
NRHM Directorate
DHS Compound
Thiruvananthapuram

P.K.SREEMATHI TEACHER
MESSAGE
Arogyakeralam has started making its impact on the heath sector. The visible
changes and trends stand testimony to this. In a state like Kerala where the
health seeking behavior is very high, improving the quality of health care is of
utmost importance. The resource of NRHM came in an opportune time when
the state was finding it difficult to find resources matching the demand.
Though there were many challenges initially in rolling out the activities under
NRHM in the State, these challenges were later on converted to
opportunities through conscious efforts, dedication and commitment. The
initiatives under NRHM are pioneering as well as result oriented.
Arogyakeralam has been successful in adding innovativeness suiting the local
situation that made these initiatives all the more fruitful. The reports
enclosed in this document are examples to this. I congratulate the team led
by Dr. Dinesh Arora I.A.S, who made this happen and I am confident that we
will be able to make lasting impact in the lives of rural poor through more
such initiatives in the future.
Smt. P.K Sreemathy Teacher
Minister for Health and Social Welfare
3

Dr. VISHWAS MEHTA IAS
MESSAGE
The success of any programme depends on its flexibility to innovate and
contextualize. NRHM, in this context, is a paragon to other programmes
giving room to innovate and improve. Though a bit late to start off, through
our dedicated efforts we have progressed significantly. Many of the initiatives
mentioned in this document bears testimony to this. I am confident that the
State will become a model to others in implementing NRHM just like in many
other fronts where the state has been a torchbearer. It is heartening to see,
that we were able to do things galore in a short span of time. However, this
never makes us complacent but given us motivation and energy to excel and
improve. Further, I appreciate the hard work and sincerity of all those who
contributed towards making these innovations conceptualize and implement.
4
Dr. Vishwas Mehta I.A.S
Secretary (Health)
Govt. Of Kerala

PREFACE
It has been a Challenging and at the same time wonderful experience
implementing NRHM in a state having its own oddities. Though a bit slow at
the beginning, NRHM implementation in the state of Kerala has gained
significant momentum during the last couple of years and we are now in a
position to show case many of the visible changes in the field owing to
earnest efforts made in implementing innovative schemes and activities
which NRHM envisages.
Though Kerala has been in the forefront vis a vis health sector achievements,
a plethora of challenges too engulf us along with our hard‐earned
achievements. For example the burden of communicable and Noncommunicable
diseases is on the rise; the load of cancer patients and ageing
population remains a challenge. However we are now confident of dealing
with all the challenges with the advent of the revolutionary Rural Health
Mission initiative.
Like many other states, we too are forging ahead in many fronts. The
innovations enclosed here bears testimony to that and we are quite
confident that we would be able to come up with many other innovative
interventions that could make a lasting impact on the health of millions of
poor in our state. It is a proud moment to present this report which talks
about innovations under the following heads:
Human Resources Management under NRHM
Innovation By Engineering
Accreditation of Hospitals in Kerala
E‐banking practice under NRHM in Kerala
Accreditation of Government Medical Laboratories in Kerala
Telemedicine
ASHA workers ‐ Owning more responsibilities
Debit card scheme for ASHA Volunteers
Immunization Drive – October 2008
Behavioral Change Communication ‐ Innovations
Pain and Palliative Care under NRHM
Radio Health
Standardizing Health Institutions: Ensuring quality services
Effective utilization of untied funds and Annual Maintenance Grants
Health Management Information System for Kerala State
School Health Programme
Geospatial Rural Health Information System for Kerala State (G‐RHIS)
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Information Technology
Three Dimensional Interactive Digital Anotomy: 3D Indiana
Compulsory Rural Service: Bridging Critical gap in Manpower
Initiatives on Infection control at Medical College Hospital,
Trivandrum
Ensuring Quality Supply of Medicines in a Transparent and Efficient
way‐ The KMSCL initiative
Improving Efficiency of hospitals‐ the decentralized way
State Disease Control and Monitoring Cell: an innovative initiative
towards the control of Communicable diseases
Comprehensive Health Insurance Scheme
We acknowledge the support and guidance of all senior level officials of the
Ministry of Health and Family Welfare, without which we would not have
been able to produce results in a way it is envisaged. This unstinted support
from the Ministry will always remain an encouragement for us to innovate
and produce better results.
Dr. Dinesh Arora
State Mission Director
NRHM, Kerala
6

Contents
Page
1. HR Management under NRHM
2. HR Management in Nutshell
3. Engineering under NRHM
4. Accreditation of Hospitals in Kerala
5. E‐banking practice under NRHM
6. Accreditation of Government Medical Laboratories
7. Telemedicine
8. ASHA Workers owning more responsibilities
9. Debit Card Scheme for ASHA Volunteers
10. Immunization Drive ‐ October 2008
11. Behavior Change Communication
12. Pain and Palliative Care
13. Radio Health
14. Standardizing Health Institutions
15 Effective Utilisation of untied funds and Annual
Maintenance Grants: with special focus on Malappuram
16 Health Management Information System for Kerala State
17 School Health Programme
16. Geospatial Rural Health Information System
17 Information Technology
8
40
44
50
54
62
65
70
75
77
81
85
93
96
104
108
113
124
127
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18 Three Dimensional Interactive Digital Anotomy: 3D
Indiana
19 Compulsory Rural Service: Bridging Critical gap in
Manpower
20 Initiatives on Infection control at Medical College Hospital,
Trivandrum
21 Ensuring Quality Supply of Medicines in a Transparent and
Efficient way‐ The KMSCL initiative
22 Improving Efficiency of hospitals‐ the decentralized way
23 State Disease Control and Monitoring Cell: an innovative
initiative towards the control of Communicable diseases
24 Comprehensive Health Insurance Scheme
133
139
144
148
156
161
173
8

Human Resources Management under
NRHM
Human resources pertaining to Health Care
Our Mother Land is heading past to occupy number one position in
Population. Certainly it is not an achievement but probably a handicap for
our entire growth and relative development. This ignominious victory on
population growth in fact made so many inconveniences in our development.
But we also must recollect that India is the First country in the Universe in
passing a bill in Parliament on Population control. But, it is an irony that we
still take no strict remedial measures to curb this undesirable growth.
But, when we see the utilization of Human population, Western countries are
standing as specimen for Asian countries. With their minimum population
they create wonders and encourage growth in population. We are still
struggling hard to find out that population is really an asset. In fact it is high
time now to accept; Human Resources are an asset.
As far as Health Care is concerned, without the help of trained and able
Human resource, it is impossible to run a Health care system. So, broadly we
can classify these groups of Health care into two. They are: (1) Clinical and
Non Clinical, who are either directly or indirectly responsible for public health
and Individual Health. The maximum benefits on health system is depending
on the performance and the benefits, the system can deliver depend largely
upon the knowledge, skills and motivation of those individuals responsible
for delivering health services.
It is also essential to maintain an appropriate mix between the
different types of health promoters and caregivers to ensure the system's
success. Due to their obvious and important differences, it is imperative that
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human capital is handled and managed very differently from physical capital.
The relationship between human resources and health care is very complex.
Both the number and cost of health care consumables (drugs, surgical
and equipment) are rising astronomically, which in turn can drastically
increase the costs of health care. In publicly‐funded systems, expenditures in
this area can affect the ability to hire and sustain effective practitioners. In
both government‐funded and employer‐paid systems, HRM practices must
be developed in order to find the appropriate balance of workforce supply
and the ability of those practitioners to practice effectively and efficiently. A
practitioner without adequate tools is as inefficient as having the tools
without the practitioner.
Key questions and issues pertaining to human resources in
health care
When examining health care systems in a global context, many
general human resources issues and questions arise. Some of these issues are
the size, composition and distribution of the health care workforce,
workforce training issues, the attrition rate of health workers, and the level
of economic development and socio demographic, geographical and cultural
factors.
The variation of size, distribution and composition in our county's
health care workforce is of great concern. For example, the number of health
workers available in our country is a key indicator of that country's capacity
to provide delivery and interventions. Factors to consider when determining
the demand for health services include cultural characteristics, socio
demographic characteristics, economic factors and health seeking behaviour.
The factor of health seeking behaviour is especially important in the Kerala
context. The general public tends to approach specialists for all ailments
including minor ailments. The fact that deliveries never take place in sub
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centres and very rarely takes places in PHC indicates that public prefers
specialists.
Workforce training is another important issue. It is essential that
human resources personnel consider the composition of the health
workforce in terms of both skill categories and training levels. New options
for the education and in‐service training of health care workers are required
to ensure that the workforce is aware of and prepared to meet a particular
country's present and future needs. A properly trained and competent
workforce is essential to any successful health care system.
The migration of health care workers is an issue that arises when
examining global health care systems. Research suggests that the movement
of health care professionals closely follows the migration pattern of all
professionals in that the internal movement of the workforce to urban areas
is common to all countries. Professionals tend to migrate to areas where they
believe their work will be more thoroughly rewarded. Health care
professionals look to areas that will provide their families with an abundance
of amenities, including schools for their children, safe neighborhoods and
relatives in close proximity. This has caused a surplus in some areas and a
huge deficit in others. This is more relevant in the Kerala context. In the tribal
district of Wayanad, while only four specialist doctors are working on
contract basis, in the district of Trivandrum, there are 149 specialists working
on contract basis under NRHM. Workforce mobility can create additional
imbalances that require better workforce planning, attention to issues of pay
and other rewards and improved overall management of the workforce. In
these circumstances, it has been decided to give salary incentives, post
graduate quota, difficult and most difficult rural area allowances etc so that
the professionals don’t feel underpaid and dissatisfied.
Another issue that arises when examining health care systems is the
level of economic development. There is evidence of a significant positive
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correlation between the level of economic development in a country and its
number of human resources for health. States with higher gross domestic
product (GDP) per capita spend more on health care than states with lower
GDP. This is an important factor to consider when examining and attempting
for implementing solutions to problems in health care systems in our country.
Socio‐demographic elements such as age distribution of the
population also play a key role in a country's health care system. An ageing
population leads to an increase in demand for health services and health
personnel. This has specific relevance to the Kerala scenario where it is
expected that the age pyramid in the State will get reversed by the year 2061.
At present, productive age group is highest in Kerala. In the year 2061,
female preponderance will be high and those with age higher than 80 will be
maximum and the productive age group will be lower. The important
implication in this aspect is that additional training of younger workers will be
required to fill the positions of the large number of health care workers that
will be retiring.
It is also essential that cultural and geographical factors be considered
when examining the health care system. Geographical factors such as climate
or topography influence the ability to deliver health services.
The above are just some of the many issues that must be addressed
when examining global health care and human resources that merit further
consideration and study.
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The impact of human resources on health sector reform
When examining the health care system, it is both useful and
important to explore the impact of human resources on health sector reform.
While the specific health care reform process varies, some trends can be
identified. When NRHM began, Government of India had identified human
resources for health as its key challenge. The performance of the health
system rested upon equitable access, efficiency and quality services in the
rural poor.
One of the main human resources initiative employed in an attempt
to increase efficiency was to get the services of medical and Para medical
personnel on contract basis. While internal contracting was also resorted to
for medical professionals initially during the implementation of the program,
the process has been discontinued consequent on availability of these
professionals in the health institutions.
Some of the human resources initiatives for health sector reform
followed in the State include strategy of attempts to increase equity or
fairness. Some of these strategies include the strategy of payment
commensurate with experience, payment of additional allowances for
specific areas, re‐deployment services etc.
Human resources in health sector reform also seek to improve the
quality of services and patients' satisfaction. Health care quality is generally
defined in two ways: technical quality and socio‐cultural quality. Technical
quality refers to the impact that the health services available can have on the
health conditions of a population. Socio‐cultural quality measures the degree
of acceptability of services and the ability to satisfy patients' expectations.
One of the most important obstacle Human resource professionals
face is constraints in budgets, lack of congruence between different
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stakeholders' values, high rates of turnover, lack of timely capacity building
and low morale of health personnel.
Better use of the spectrum of health care providers and better coordination
of patient services through interdisciplinary teamwork have been
recommended as part of health sector reform. Since all health care is
ultimately delivered by people, effective human resources management will
play a vital role in the success of health sector reform.
Policy approaches in a global approach to health care
delivery
As mentioned earlier, there are three main health system inputs:
human resources, physical capital and consumables. Given that with
sufficient resources any country can obtain the same physical capital and
consumables, it is clear that the main differentiating input is the human
resources. This is the input that is the most difficult to develop, manage,
motivate, maintain and retain, and this is why the role of the human
resources professional is so critical. All health care is delivered by people, so
health care management can really be considered people management; this
is where human resources professionals must make a positive contribution.
Given the significant changes that globalization of health care can
introduce, it is important that human resources professionals be involved at
the highest level of strategic planning, and not merely be positioned at the
more functional, managerial levels. By being actively involved at the strategic
levels, they can ensure that the HR issues are raised, considered and properly
addressed. Therefore, human resources professionals will also need to have
an understanding not only of the HR area, but of all areas of an organization,
including strategy, finance, operations, etc. This need will have an impact on
the educational preparation as well as the possible need to have work
experience in these other functional areas.
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Human resources initiatives under NRHM in Kerala
Under NRHM, the policy of equitable accessible effective and quality
services has been the base principle for a proper human resource
management in the State. The need for skilled and trained professionals was
utmost felt in the State during the beginning of implementation of the
program in 2005. The main aim of the Government before embarking into a
process of effective human resource management under NRHM was to
ensure that all the sanctioned posts under various health institutions were
filled.
Need Assessment Study
The prime consideration of the department was effective utilization of
the existing work force. However, several shortfalls were felt in the service
delivery model. Consequently, the need of the hour was to have more
qualified and skilled personnel complimenting the existing work force. Before
embarking into a process of recruitment of medical and para medical
personnel in the State through NRHM, the need of the hour was a need
assessment survey in the State through which the critical gaps in Human
Resources could be identified. At the same time, upgradation of the CHCs to
IPHS was essential since facilities available in these institutions hardly
satisfied the norms for the same. The process of upgrading selected CHCs
were initiated in 2006 itself and the same was extended to all CHCs in 2007.
At the same time, based on the need assessment survey, providing quality
maternal health care was proposed and consequently, the contractual
recruitment of medical and para medical personnel was resorted to.
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Contractual appointment of Doctors & Specialists
Based on the need assessment, it was seen that there is a huge gap
between availability of doctors in the department and the requirement in the
field. Government took a conscious decision of appointing doctors and
specialists in selected health institutions in the State. Doctors were appointed
on contract basis in the State with honorarium commensurate with
experience. On assessment of availability of specialists in the State, it was
noted that specialists, especially Anesthetists, Gynecologists, Physician, and
Pediatrician etc were on shortage in the department. Consequently, it was
decided to appoint these specialists on a contract basis with payment
commensurate with experience.
Sl.
MBBS Doctors Specialty Doctors
District
No
(Contract)
(Contract)
1 Trivandrum 65 30
2 Kollam 28 6
3 Pathanamthitta 24 8
4 Alappuzha 29 6
5 Kottayam 21 8
6 Idukki 33 7
7 Ernakulam 43 25
8 Thrissur 40 27
9 Palakkad 26 7
10 Malappuram 39 11
11 Kozhikode 9 6
12 Wayanad 30 4
13 Kannur 38 2
14 Kasaragod 21 2
Total 446 149
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Compulsory Rural Service
While the availability of medical personnel was an easy process in
some districts, the same was a laborious one in some backward districts.
Consequently, the Government decided to invoke the clause of compulsory
rural services for doctors studying the various government Medical Colleges
in the State. They were appointed in various health care institutions in the
state with priority to backward districts. MBBS doctors were to serve in
health care institutions for a period of 1 year, PG diploma doctors to serve for
6 months and PG Degree doctors for two years. Even though objections were
raised from several quarters on the compulsory rural service, the government
was bent upon providing medical care to the rural poor especially backward
districts. Government ensured that all the doctors worked in the health
institutions for the prescribed period.
Later, government based on various orders decided to extend the
conditions of compulsory rural services to doctors who passed out from self
financing colleges and cooperative medical colleges in government seats, All
India Quota candidates etc.
The details of doctors now working in health institutions are as follows.
Sl.
Compulsory rural service‐
District
No
MBBS
Bonded PG Diploma / Degree
1 Trivandrum 27 4
2 Kollam 27 5
3 Pathanamthitta 13 1
4 Alappuzha 42 0
5 Kottayam 17 1
6 Idukki 17 0
7 Ernakulam 49 2
8 Thrissur 40 4
9 Palakkad 28 6
10 Malappuram 27 2
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Sl.
Compulsory rural service‐
District
No
MBBS
Bonded PG Diploma / Degree
11 Kozhikode 13 6
12 Wayanad 22 0
13 Kannur 43 3
14 Kasaragod 27 0
Total 392 34
The best possible outcomes as a result of appointment of doctors are
summarized as follows.
i. More institutions provided with 24 X 7 services
ii. OP increased
iii. OP time in selected institutions extended from 8 AM to 8 PM.
iv. Increase of deliveries as a result of increase of patients from
private to Government health care institutions
In addition, very few specialists are working in Medical Colleges on
bonded obligation under NRHM.
Financing qualified human resources
It was felt at the beginning itself that there should be a good package
on compensation for the Medical & para medical personnel in the State to
ensure that the persons posted in the institutions continue to serve the
Government on a continuous basis. A differential package was evolved for
doctors working in different areas. Even though many of the places in the
State can be classified as semi‐urban or semi‐rural, there are few areas which
have the problem of proper access. These areas have, therefore been,
classified as difficult and most difficult rural areas and doctors posted in these
areas are eligible to get additional honorariums which vary upon the
classification. Also, as mentioned earlier, honorarium was given
commensurate with experience. While doctors who work in health sector are
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financed by NRHM, those who work in the Medical Colleges (PG Degree
doctors) are paid from State Government budget.
Strengthening Of AYUSH
For Ayurveda, NRHM has taken the initiatives and selected 74
Ayurveda doctors and posted to various institutions by Ayurveda Directorate.
As far as Homoeo is concerned, NRHM has conducted the interview
and forwarded a list of 59 selected candidates to Homoeo Directorate and
they will be placed very soon, Government Order awaited.
Necessity for skilled manpower
While the appointment of qualified professionals in the health
institution was made, the simultaneous need of skilled manpower was felt in
the state. Even though Government had filled up all the vacancies of Staff
Nurses, Lab Technicians, Pharmacists etc., the gaps felt in the health
institutions consequent on patient influx was huge.
Internship of Nurses
Student of BSc Nursing undergoing their course in the Nursing
Colleges under Directorate of Medical Education have to undergo the training
for 4 years and the remaining 1 year as internship. During the internship the
student is paid Rs. 4500/‐ as stipend from NRHM. As of now, NRHM is giving
internship stipend to all the students studying in Nursing Colleges of
Thiruvananthapuram, Kottayam & Kozhikode.
As far as Diploma in General Nursing and Midwifery is concerned,
internship is not part of their curriculum. Instead, after the completion of 3
years training, every student of Government Nursing Schools in Kerala is
given a chance to work in any of the Government Hospitals for the duration
of 2 years and a remuneration of Rs. 7,480/‐.
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Providing Staff Nurse
Hospitals were crowded and the average OP in the recent times had
increased manifold. The ratio for Bed: Staff nurses which 1: 6 was
overstretched to 1 : 12. NRHM advocates on equitable accessible effective
and quality services. The quality aspect for providing by the skill manpower
was lacking due to the stretch.
Staff nurses who study in Government nursing colleges have to get
into an agreement with government for doing compulsory service for two
years when government calls for the same. This clause has been invoked and
all the bonded nurses are appointed for a period of two years on contract
basis. At present, 1395 Staff Nurses have been appointed in the State on
contract basis. Consequently, the strain in giving quality services has been
reduced to a great extent. Services of Staff Nurses have been ensured to get
24X7 basis and extended OP (upto 8 pm) in selected health institutions in the
State.
Sl.
No
District
Staff Nurse
1 Trivandrum 264
2 Kollam 94
3 Pathanamthitta 53
4 Alappuzha 138
5 Kottayam 115
6 Idukki 60
7 Ernakulam 155
8 Thrissur 96
9 Palakkad 24
10 Malappuram 84
11 Kozhikode 105
12 Wayanad 109
13 Kannur 45
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14 Kasaragod 53
Total 1395
Other Para-medical personnel
Consequent on extended OP (upto 8 pm), there were small shortages
of other manpower like Lab Technicians, Pharmacists etc. These staff also has
been appointed on contract basis on a need‐basis.
The para medical personnel taken on contract have been funded from
NRHM.
Sl.
No
District Lab Tech Pharmacist
1 Trivandrum 8 1
2 Kollam 0 0
3 Pathanamthitta 6 0
4 Alappuzha 1 7
5 Kottayam 4 0
6 Idukki 0 0
7 Ernakulam 2 10
8 Thrissur 0 0
9 Palakkad 5 0
10 Malappuram 3 9
11 Kozhikode 0 0
12 Wayanad 18 16
13 Kannur 0 0
14 Kasaragod 7
Total 47 50
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Program Management Professionals – State Level
While the process of appointment of medical and para medical
personnel were carried out in the district, it was imperative that the
management of the program was to be carried in a proper way such that
there occurred no deficiencies in the system. Experts in different fields were
handpicked and appointed in key posts in the State Program Monitoring &
Support Unit. The process of selection was based on criteria of knowledge,
commitment and enthusiasm to work in a Mission mode. The staff so
recruited has been used to their best potential, which has delivered desired
results. At present, a well planned mechanism is in place with which the
program is being run in a mission mode.
Program Management Professionals – District Level
Government of India had advised on taking MBA graduates as District
Program Manager (NRHM) in the State. The matter was discussed threadbare
in various forums in the State. While there was a very strong opposition on
appointing an MBA graduate, it was decided to appoint a doctor working in
the health department as the District Program Manager (NRHM). This has
resulted in deriving lots of results since initially many of the department
officials were very skeptical about NRHM. The District Program Manager
(NRHM) were able to integrate the department with program and
consequently, the activities are planned by NRHM and are now being carried
out in a time bound manner jointly by NRHM and Kerala Health Services.
Also, accounting personnel with requisite qualification was selected and
appointed in each district to ensure smooth flow of funds as well as proper
monitoring of funds to health as well as Panchayati Raj institutions.
22

Program Management Professionals – Block Level
The need for a person to coordinate all the activities at the block was
felt and hence Block Coordinators for all 234 health blocks were selected in
the State. They are professionals mainly in Social Work or with Master degree
in Business administration.. They coordinate the activities in block level as
well as act as counselors for the general public at large at specific times. The
experience of appointment of block coordinators has derived wonderful
results.
DETAILS OF BLOCK AROGYAKERALAM COORDINATORS AS ON
30‐09‐2008
Sl.no District
Total On On Vacant
Post Contract Deputation
1 Thiruvananthapuram 25 20 03 02
2 Kollam 19 12 04 03
3 Pathanamthitta 13 12 0 01
4 Alappuzha 17 14 02 01
5 Kottayam 19 07 09 03
6 Idukki 08 01 07 0
7 Ernakulam 20 10 10 0
8 Thrissur 28 25 02 01
9 Palakkad 17 10 01 06
10 Malappuram 21 15 02 04
11 Kozhikode 16 14 01 01
12 Wayanad 06 02 04 0
13 Kannur 15 11 02 02
14 Kasargode 10 0 08 02
Total 234 153 55 26
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Personnel not appointed
As per several guidelines of NRHM, some posts were to be hired and
appointed at State / District / Block / Health Institution / Community level.
The broad reasons for not appointing such personnel can be summarized as
follows.
District Data Officers: There is sufficient and perfect coordination between
NRHM officials and Statisticians in the Health Services Department who
compliments the activities in the district collecting necessary data from
districts.
Block Program Managers: The Block level Medical Officers with the help of
Block Coordinators ensure that the activities in each block are carried out in a
time bound manner.
Registered Medical Practitioners: The health seeking behaviour of the
community led to the decision of non‐appointment of Registered Medical
Practitioners in the State. The Community opts to see a specialist for even
minor ailments due to which the necessity of RMP was not there.
Trained Birth Attendants: When the State has an Institutional delivery
percentage of more than 99% every year, the need for TBAs does not rise at
all. These were the broad reasons for non‐appointment of some staff under
NRHM.
PRO Cum Liaison Officer
National Rural Health Mission is constantly engaged in supporting all the
health care systems of the hospitals. At times it is felt that, many hospitals
do not have adequate staff to work with liaison activities between NRHM &
Hospital and also with various other agencies associated with hospitals. In
this circumstances, NRHM, has appointed 39 MBA/MHA degree holders with
2 years experienced as PRO cum Liaison Officer to work in all major
24

MCH/District and General Hospital across Kerala on an honorarium of Rs.
10000/‐ per month. They are expected to work along with Superintendent
Office and act as per his instruction. He will have a word in implementing
various NRHM activities in the Hospital and also suggest the measures
involved in implementing such schemes.
Bio Medical Engineering
It is felt that on the part of the up gradation of Hospitals and accreditation,
NRHM, needs to have trained manpower on Bio medical field. It is technical
in nature and they can very effectively have a thorough check in Hospital
Equipments and its functioning. People with such quality has been selected,
initially, three in number with Rs.20000/‐ for Bio Medical Officer and
Rs.25000/‐ for Bio Medical Officer one) as monthly payment. Now they are
under training and will be trained further in such activities.
Quality Control Officers
Selection process is over and they will act as one Regional Quality control
Officer and four candidates as Asst. Quality Control Officers. They are yet to
be inducted in NRHM and final selection is just completed on a monthly
payment of Rs. 16000/‐ and Rs.12000/‐ respectively.
Capacity Building under NRHM
Capacity building involves a variety of activities. It includes the
building of skills in the work force to cope with change and adding to the
capacity of officials to build up health institutions. When implementing an
integrated health promotion program, it is important to create optimal
conditions for success. Capacity building involves the development of
sustainable skills, organizational structures, resources and commitment to
health improvement in health and other sectors, to prolong and multiply
25

health gains many times over. It can occur both within a specific program
and as part of broad agency and system development.
In the Kerala context, the capacity building exercise faced a general
slackness during the years 2005‐06 and 2006‐07. However, the importance
of training health staff was realized and during the year 2007‐08, several
training programs were conducted. Further, during the present year, all
categories of staff in districts are being imparted training. Further,
underlining the importance of training program management staff, induction,
financial as well as detailed activity‐wise training was given to program
management staff at various levels.
Admin Training to Superintendent of CHC & all other
Government Hospitals
An initiative has been taken to offer training on various aspects of
health, which is not otherwise part of medical curriculam of Superintendents
of hospitals. As we all are aware, Superintendents of hospitals play a pivotal
role in the day to day functioning of hospitals pertaining to General
Administration, Medical, Laboratory Facilities, Human Resourse Management
and its deployment in addition to all other daily function whether it is clinical
or non clinical. Often it is found that as a single individual who himself is
specially devoted / trained to Medical field, face difficulties in dealing all
these routine functions within the timeframe. This is the general background
on which NRHM thought to provide a very useful and comprehensive training
which provide a deep insight into these aspects and this knowledge is
expected to use to tackle any situation which arises in the normal course of
any hospital, will be master tool to tackle such situation.
26

ACR Lab in Major Hospitals on 24 X 7 basis
Many of the hospitals are now equipped with basic laboratory
facilities which includes men and material. This is very essential for finding
out the proper diagnosis. As the time changes, it is seen that many of the
new diseases are cropping up and often it is becoming an epidemic, which
creates a lot of hue and cry. Recently it is experienced that the diseases
which was either eradicated or vanished have re‐emerged in various part of
our country, which challenges the efficiency of our capacities and claims.
This alarming situation reminds us to have a more advanced version of
laboratory facilities with properly trained technicians and pathologists to find
out the cause behind such kind of disease. Presently ACR Labs are
established only in very few centres mainly Medical Colleges and Regional PH
Labs etc.
The proposal is for the establishment of ACR Labs on 24 hours basis in
Major hospitals of every districts. This will change the total scenario, and the
patients can directly rush up to these labs instead of standing behind the
serpentine queue in the existing ACR Labs. In addition, during the epidemic
situation, re‐appearance of any major disease, the health department
officials can combat and bring out the best results with minimum possible
delay.
Paramedical Education
1. Paramedical Education in Government Sector
Director of Medical Education was conducting about 5 Paramedical courses in
Government Medical/ Dental Colleges from 1985 onwards with about 400
admission/ year. After 2000 many new courses were introduced and
permission was given to self financing colleges for starting paramedical
course. Now there are about 12 paramedical courses which are being
27

conducted in about 20 self financing institutions also. All diploma courses are
conducted by Director of Medical Education and Degree courses like BPT, BSc
MLT etc are conducted by universities. Director of Medical Education is
admitting about 1600 students/ year. Director of Medical Education is
conducting periodical camps to asses the quality of education
2. New courses and institutions.
Numerous request to start new courses and existing courses in new
institutions are pending with Government for sanction of LOI/ NOC and LOP.
3. Paramedical staff in Government hospitals.
Many paramedical post of Government hospitals are having recognized
paramedical courses as basic qualification.
Eg: DMLT for Lab Technicians
DOA for Ophthalmic Assistant
DRT for Radiographers etc.
But to many posts due to lack of specific courses, persons from service
are given in‐service training.
Eg: EEG training
ECG training
MRL training
JLA training etc.
These training are not being done in a scientific way. So steps are being
taken to form in‐service training module for all these posts. One such ie.
Nursing Assistant Training Module is approved by Government.
4. Fixing of qualification of Paramedical posts
Many paramedical posts are remaining unfilled due to lack of fixing of
minimum qualification.
Eg. Theatre Technician
28

Mortuary Technician
Blood Bank Technician
Research Assistant/ Officer
Perfusionist etc.
Now steps are being taken to include new paramedical courses as
minimum qualification for existing paramedical posts.
5. Paramedical Council/ Bill and Registration
Till now there is no system of Registration for Paramedical personnel.
There is no Central Paramedical Council.
State Paramedical Bill was
approved by cabinet in 2007 and waiting for submission to assembly and
approved. State Paramedical Council was formed under Chairmanship of
Health Secretary and it is now functioning. Registration of Paramedical
certificate holders of courses conducted by DME, DHS and Universities
approved by Paramedical council were just started.
About 50 lakhs is being sanctioned in this year’s budget for formation of
Paramedical Council. Steps are being taken up to utilize the amount for
renovation of an existing building, post creation and for improvement of
infrastructure facilities
6. Regional Institute of Paramedical Sciences at Medical College,
Calicut
A proposal was given to Central Ministry and a Regional Institute of
Paramedical Sciences was sanctioned attached to Medical College, Calicut
with central funding under this about 54 paramedical courses (Diploma,
PG Diploma, Degree and PG Degree) was proposed. The academic work
like formulation of syllabus, curriculam etc are under progress.
29

7. Paramedical Institutes under SI‐MET
Two institutes are sanctioned under SI‐MET. One at Payyannur and one
at Kuzhalmannam.
8. Priyadarshini Institute of Paramedical Science (PIPMS)
A Paramedical Institute attached to Medical College,
Thiruvananthapuram conducting paramedical courses exclusively for
SC/ST student.
9. One such institute is proposed and under progression at Medical
College, Alappuzha
DRAW BACKS
1. Lack of Central Paramedical Council
2. Lack of State Paramedical Council
3. There is no uniformity in
Nomenclature
Minimum standards
Syllabus
Course donation, curriculum
Exam pattern etc.
of various courses conducted inside and outside the State.
4. Non – recognized institution
Various Universities are permitting paramedical courses in May
private institution, which do not have attached hospital or clinical
facilities.
Many private agencies are conducting numerous diploma and
certificate courses with affiliation to any Universities or
Government.
30

In the absence of a Central/ State law legal action against this institution
cannot be initiated.
5. Lack of assessment of need of the State
Requirement of the state with respect to Paramedical personnel for
conduct of Government/ private hospitals and Labs are not yet
assessed.
6. There is no law governing the private hospitals and labs.
Lack of creation of entry cadre post in the Government sector for existing
paramedical courses.
7. Lack of Carrier advancement and training programmes for
Paramedical Technicians who are already there in the service.
Conclusion
It is seen that the relationship between human resources
management and health care is extremely complex. Several research and
analysis have indicated that several key questions must be addressed and
that human resources management can and must play an essential role in
health care sector reform.
The migration of health workers to more affluent regions and/or
countries is a major problem, resulting in citizens in rural areas of developing
countries experiencing difficulties receiving adequate medical care. Since all
health care is ultimately delivered by and to people, a strong understanding
of the human resources management issues is required to ensure the success
of any health care program. Further human resources initiatives are required
in many health care systems, and more extensive research must be
conducted to bring about new human resources policies and practices that
will benefit individuals in the country.
31

HUMAN RESOURCES MANAGEMENT
IN NUTSHELL
Every innovation need a proper planning based upon conditions available in
the location. As far as Kerala is concerned, is a fully literate and highest
achievement holder in Health Sector in our country. It is very proud to say
that Kerala has achieved several feats in health, which is on par with World
Health Standards. So it became very essential and careful, while selecting
and implementing new methods and innovations of HR in Kerala. NRHM
Kerala put an extra consciousness since the population of Kerala is highly
educated and very spontaneous in actions and re‐actions. So the activities
expected to project as new should have a real and result oriented otherwise
it may boomerang on us, which may tarnished the image of NRHM activities.
Yet the following introductions were either implemented or planned to
implement in near future.
Internship of BSc Nursing Students
It was the introduction of National Rural Health Mission. Through this
every student get an opportunity to work in hospitals and can have a hands
on experience from the real life situation in the hospitals. Their course will
be completed only after the fulfillment of this internship programme. The
NRHM is also offering an honorarium of Rs. 4500/‐ per month to these
internees.
32

Introduction of Bonded obligation to General Nursing
Students
National Rural Health Mission took a very firm step in implementing
bonded obligation to all students of Government Nursing Schools who are
undergoing Diploma in General Nursing. Their bonded obligation is for two
years on monthly remuneration of Rs. 7480/‐. This scheme has changed the
hospital environment drastically and given awareness to patients that a
trained medical professional will be available on all 365 days in the hospitals.
This introduction is apart from the existing staff strength.
Compulsory Rural Service to MBBS Doctors and PG
Doctors
This was another feat launched by NRHM in Kerala. This scheme was
ensured that all the MBBS students are given a chance to work in the
Government Hospitals to test and experienced their knowledge acquired
from the colleges.
NRHM is offering a pay packet of Rs. 15000/‐ for
compulsory rural service and Rs. 20,000/‐ to those who are posted to Difficult
to Rural Areas.
Likewise the PG Students also given same opportunity in their field
and they are given Rs. 17,000/‐ as they are posted in Medical Colleges and
Other Major Hospitals.
Strengthening of AYUSH
NRHM selected 74 Ayurveda Doctors and posted to various ayurveda
hospitals across the State by Ayurveda Directorate.
NRHM also selected 59 Homoeo Doctors and their posting is awaited
to get a final nod from Government of Kerala.
33

Block Arogyakeralam Coordinator
Our country is on the threshold of developmental activities and in this
modern era no establishment can survive without the help of management
skilled personnel. This is the background on which NRHM Kerala has selected
a cream of 153 MBA/MSW Graduates with a minimum of 2 years experience
to implement, monitor and project entire range NRHM activities in block
level. Now it is found that this venture by NRHM Kerala is a grand success. In
addition 55 candidates from Health Services in the cadre of Health Supervisor
/ Health Inspector are also selected to work as Block Arogyakeralam
Coordinator.
Public Relations Officer
Another notable feature of NRHM Kerala is the appointment of Public
Relations Officer in all selected Major Hospitals. Their qualification was
either MBA or MHA with 2 years experience in health sector. The output
given by these gentlemen are extremely good and they are an asset to the
hospital and NRHM in implementing programmes in the hospital.
Bio Medical Engineers
Candidates with Degree / Diploma in Bio Medical Engineering /
Instrumentation Egg are qualified for this post. As an initial step 1 (one) Bio
Medical Officer and 4 Assistant Bio Medical Officers are selected and under
training.
Quality Assurance Officers
Initially 1 (one) Regional Quality Assurance Officer and 3 (three)
Assistant Quality Assurance Officers are selected and they are under training.
34

Administrative Training to Superintendent of CHC and all
other Government Hospitals
This is meant for providing training to all Superintendents of the said
hospitals, designed to give training on various aspects of management,
logistics, technical, administration etc. This training is expected to equip all
the Superintendents to handle various problems arising in the hospital from
time to time.
ACR Lab
ACR Lab will be introduced to all major hospitals on 24 hours basis.
The needy will get speedy and accurate clinical facilities within their reach on
an affordable cost. Thereby the private sectors who are grabbing a lion’s
portion with their outdated equipments will automatically wither away.
35

Innovation By Engineering wing of
NRHM, Kerala
Engineering is not an experiment but certainly an art and execution of the art
depends on will power and planning. With regard to Engineering wing of
NRHM in Kerala and its challenging activities undertaken in this tiny state is
most certainly an example of this will power. With in the span of two years it
has undertaken so many projects and brought to a level of perfection in
almost all the work of its inventory. It is an accepted fact that, money alone
will not bring the desired changes but efficiency, sincerity and proper
planning also required to fulfill the dream to a reality. Pertaining to this
situation NRHM, Engineering Wing deserves applaud from all.
The following are the innovations with regard to the work initiated from the
Engineering wing of NRHM.
The up gradation of health care institutions to Indian Public Health Standards
(IPHS) is being carried out through external agencies like Hindustan Latex Ltd,
Hindustan Prefab Ltd. and Kerala Health Research and Welfare Society. These
agencies are Government owned institutions and conducts necessary surveys
and prepare detailed project reports in conformity with the specifications
and standards. This enables better quality of work, which was earlier absent
when PWD was doing the construction activities.
Community Health Centers were the next objects. The up gradations of these
Health centers were carried out with the participation of the local authorities,
the hospital authorities and other stakeholders. An institutional level
committee has been constituted for each CHC and this ensured that the
projects prepared by the implementing agencies are thoroughly discussed by
36

all stake holders. The monitoring and evaluation of the work by the ILC was
also ensured in each point.
The only Marmachikitsa Hospital, under the Government sector at
Kanjiramkulam in Thiruvananthapuram district was also selected for up
gradation and work is nearing completion.
Emergency situation call for an urgent attention by the concerned authority.
We recall, the emergency situation cropped up in the SAT Hospital and
Renovation and infection prevention work was carried out in record time,
when there was an incidence of outbreak of Sepsis at the SAT Hospital at
Thiruvananthapuram. Another example is the completion of an idle building
at Sabarimala by PWD during the Pilgrim season on a record time. The
renovation work undertaken to repair the building for the benefit of pilgrim is
a classic example of this.
All the agencies have been directed to prepare a master plan for the hospitals
and any further expansion would be based on such master plans.
It is decided to complete a sewage treatment plant at Kozhikode MCH. At
present there is no such system and the people in the vicinity of MCH, are
facing pollution and unhygienic situations due to this. This situation is taken
with utmost seriousness and within a short time, a fully functional sewage
treatment plant will come up to alleviate the era of such pollution. The work
will form part of the up gradation of IMCH Kozhikode and is nearing
completion.
The Bio‐ Medical waste disposal from each health care institution is a big
challenge before the Government and Health conscious Population. This is
presently being carried out in some major institutions through IMAGE, an
organization under the Kerala chapter of IMA. It is now proposed to extend
the agreement with IMAGE to all the other institutions, which are being
upgraded.
37

A proposal for Emergency Management of health and accident related issues
was prepared and forwarded to the Government for consideration. This is
now with the Government for approval.
The Tsunami Rehabilitation Programme under the Health Department is
being implemented by the Engineering wing of the Sate NRHM through the
State Mission Director who is the nodal officer of the Project Implementation
Unit. The progress is relatively fast when compared with other departments
and also the works are in conformity with the IPHS specifications, carried out
through implementing agencies like HLL, HPL, and KHRWS etc.
In all construction activities priority is given to renovate/modify existing
usable buildings, including heritage buildings and demolition is adhered to
only in unavoidable circumstances. This will surely, save time, money and
energy.
Bio‐Medical engineers have been appointed to take care of the equipment
needs in the Health sector and they are preparing the requirement of each
institution in the state. Once this work is completed procurement is planned
through the Government owned Kerala Medical Services Corporation.
38

Progress of Engineering Works at various Districts
CHC Enadhimangalam
(Before renovation )
CHC Enadhimangalam
(work in progress )
CHC Thamarassery
(Before renovation )
CHC Thamarassery
(Work in progress )
CHC Neendakara Old OP Block
(Before Renovation )
CHC Neendakara Old OP Block
(After Renovation )
39

CHC Kanjettukara old building
(Before Renovation )
CHC Kanjettukara old building
(Work in progress )
CHC Kadakkal
(Before renovation )
CHC Kadakkal
(work in progress )
CHC Anchal Old OP Block
(Before renovation )
CHC Anchal New OP Block
(work in progress )
40

CHC Mayyanad Old OP Block &
Entrance Zone (Before Renovation)
CHC Mayyanad Old OP Block &
Entrance Zone (work in progress)
CHC Kalpetta (After Renovation)
CHC Perambra (Upgraded)
CHC Vadanappally (Before Renovation)
CHC Vadanappally (work in progress)
41

Accreditation of Hospitals in Kerala
Government has initiated steps for Standardization of Hospitals and
Public Health Institutions in the State. Up gradation and Standardization of
services including diagnostic facilities in the Government Hospitals need to be
implemented as a prelude. Specialty cadre is also being implemented in the
state. This will rationalize the posting of doctors especially Specialists.
Government of Kerala has implemented the scheme of
Comprehensive Health Insurance Scheme from October, 2008. Government
Hospitals and other health facilities with desired infrastructure for inpatient
and day care facilities will be empanelled with the selected insurance
company. Accreditation of Public Health Institutions can help us achieving the
above mentioned points especially the Up gradation and Standardization of
services.
Quality council of India (QCI) is an autonomous body set up by
Government of India to establish and operate the National Accreditation
Structure in the country. National Accreditation Board for Hospitals &
Healthcare Providers (NABH) is a constituent board of Quality Council of
India, set up to establish and operate accreditation programme for
healthcare organizations. Initiating the process of accreditation will help the
Health Department to assess the existing service delivery standards of the
said facilities, to identify the baseline level of all quality indicators; to
benchmark the indicators, to suggest alterations in structural designs of the
facilities to meet the requirement.
It was decided to include one hospital from one district for
accreditation with NABH. The hospitals selected for the accreditation process
are given below.
42

S.No District Name Hospital Name Bed Strength
1. Trivandrum W and C Hospital, Trivandrum 428
2. Kollam District Hospital, Kollam 471
3.
4.
Pathanamthitta
Alappuzha
General Hospital,
Pathanamthitta
Taluk Head Quarters Hospital,
Cherthala
414
251
5. Kottayam District Hospital, Kottayam 374
6.
Idukki
Taluk Head Quarters Hospital,
Thodupuzha
304
7. Ernakulam General Hospital, Ernakulam 779
8.
Thrissur
Taluk Head Quarters Hospital,
Chavakkad
140
9. Palakkad District Hospital, Palakkad 562
10. Malappuram District Hospital, Manjeri 501
11. Kozhikode W and C Hospital, Kozhikode 295
12. Wayanad
Taluk Head Quarters Hospital,
Sulthan Bathery
13. Kannur District Hospital, Kannur 616
14. Kasaragod District Hospital, Kanhangad 400
57
An agreement has been signed between Government of Kerala and
Quality Council of India for accreditation of hospitals in Kerala. The Quality
Council of India, New Delhi shall carry out the activities specified as follows:‐
►
►
►
►
To understand the existing level of health care delivery by discussion
with policy makers and senior officers and other stake holders;
To review the secondary data available like bed occupancy rate,
OPD Attendance, No. of Discharges, Average length of stay, number
of samples etc.;
To have a sensitization workshop for policy makers and officials of
the Dept. of Health and Family Welfare;
To suggest any basic minimal civil structural alteration, if required in
the identified hospitals and labs;
43

►
►
►
►
►
►
►
►
►
►
►
►
►
To study the manpower deployment against any pre set norms
appropriate to the needs as per the requirement of NABH;
To indicate the gap in the terms of manpower, equipments and
drugs
To study the equipment and instrument functionality, maintenance
and calibration of the same;
To identify senior and potential trainers from within the facilities at
all the facilities;
To conduct training of trainers of various facilities;
To do the training needs assessment of all personnel in relation to
achieving NABH standards;
To prepare training modules based on Training needs assessment
(TNA) and the Accreditation standards of NABH;
To assist in organizing Training Program for all personnel;
To observe and analyze the effectiveness of such training by
carrying out patient satisfaction survey, employee satisfaction
surveys and hospital utilization rates coupled with analyzing the
health indicators;
To assist to create signage, work instructions, manuals etc.
necessary for the facilities;
To facilitate carrying out internal audit as per NABH Standards for
the facilities;
To assist in carrying out the self assessment as per NABH standards;
and
To assist in follow up action after preliminary assessment and final
assessment by Assessors.
Under NRHM, for accreditation, equipping the hospitals with medical
equipments and providing other facilities like cots, linen etc., has been
decided in principle by the Government that henceforth the equipment
purchase in all the institutions shall be under the aegis of Kerala Medical
Services Corporation for which Bio Medical Engineers are appointed. It has
also decided to modify the State and District Quality Assurance Committees
to widen the scope from only sterlisation and Family Planning services to up
44

gradation and quality assurance of hospital inpatient care and diagnostic
services.
After completion of this phase the hospitals will have to apply for
accreditation with NABH. Accreditation process includes application for
accreditation, pre assessment visit by NABH, final assessment of hospitals,
scrutiny of the assessment report by NABH secretariat and recommendation
for accreditation by Accreditation Committee, approval for accreditation by
Chairman NABH and issue of accreditation certificate by NABH secretariat.
45

E-banking practice under NRHM in
Kerala
Achieving heights with new experiments and the implementation of
the said results in the existing scene is the collective effort of many. As we all
are aware that Finance is the
backbone of any activity in motion, it
is essential that a strict monitoring
about its movement is mandatory to
have a control over it. During the
introduction of NRHM in Kerala, it
was the big concern of finance
department to have a day‐to‐day control over the inflow and outflow of
money in NRHM activities. This has led to the innovation of e‐banking in
Kerala thus became the pioneer among NRHM states. When the NRHM was
initiated in 2005‐06, Kerala
was the first state to
understand that the
conventional way of
transacting money was no
longer feasible. Innovation
was needed and on an
experimental basis a pilot
programme was launched
in Kerala. The response from the state was overwhelming and with many
months of hard work put in all the financial transactions under NRHM have
been put under the e‐ Banking platform in Kerala. What is unique about this
46

innovation is that, this is the first time to happen anywhere in the country in
the health sector. This is a ground‐breaking change and will go a long way in
establishing a firm grip over the finances of the mission at the national level.
The experiment was initiated around 2 years back, and through a
progression of feedback from the grass root, continuous improvements were
made on the software. As a result, today the software is user friendly, flexible
and is an effective financial information tool. Not only are the transactions
under the e ‐ banking platform faster and safe, but the exquisiteness of the
system is the online information system.
e‐ Banking solution for
NRHM has been put in place in
Kerala, through Customized
software developed by ICICI on
a consultative process with the
users. The software is named
“i‐check pay software”. The
state is now completely online
in transacting funds under
NRHM at both the state headquarters as well as in the 14 districts. The users
are finding the online system not only user friendly but also has given the
state with the desired freedom of flexibility along with increased control over
transactions and minimal delays in transfer of funds. The ease, speed and
increased control over transactions are found to be very effective in the
financial management of NRHM considering that over 70% of funds are
devolved to the institutions at the grass root level. The simple, safe and easy
to use solution for transfer of funds has proved as a boon to NRHM,
considering that adequate and timely devolution of funds are essential to
support the massive works taken up under NRHM on a scale never seen
before. Currently, the solution is offered up to the district level, but
47

eventually it is the desire of the state to enlarge the solution up to the block
level.
From the Ministry, Grants are released online to the designated bank
account of the State with ICICI Bank, and sanction order is posted on the web
site. Grants are booked under main heads: RCH – II / Mission Flexible
Pool/Immunization/Ayush/Others as the case may be. A single bank account
with ICICI is maintained at state
level and district level for RCH
Flexi pool + Mission Flexible
Pool+ Immunization. Below
district level, the beneficiary
institution maintains bank
account with any scheduled
commercial bank. Similarly, each
of National Disease Control Program has one bank account at state
level/district level with ICICI Bank
Fund transfer from the state to districts and vendors are done online
from the designated bank
account. Each release is
captured from the main heads:
RCH – II / Mission Flexible
Pool/Immunization/Ayush/othe
rs as the case may be, and this
enables at any point of time the
bank balance in the main
heads. Also automatic computation of expenditure and advances is made
possible.
The traditional system of writing cheque has been totally
discontinued at the state level and in the districts. From the state, funds are
48

eleased online to the designated bank account of the district and sanction
order is posted on the web site. The district gets the amount within 24 Hours
to the Bank Account. The districts are enabled at any point of time to have
the bank balance in the main heads, and automatic computation of
expenditure and advances is done. Not only the districts, but to employees
and any other vendor each payment is electronically transferred to the bank
account of beneficiary/recipient. Accountant is the first level operator to
enter the transactions on line. Authorized signatory 1 and Authorized
signatory 2 approves the transactions. Once transactions are approved,
transfer of money to the designated bank account of the beneficiary/vendor
is done within 24 hours
Along with the transfer of funds, the system captures the transfer
either as an advance or as expenditure as the case may be, into the
designated programme (RCH‐II/Mission Flexible Pool/Immunization). The
advance when settled is captured and adjusted from that of advance to the
expenditure. The software is so user friendly that it is very easy to track
pending transactions and understand the balance position of different
segments. Transactions Reports and advance positions are generated by the
system. SOE positions and utilization reports are generated on line.
49

How it has helped the state of Kerala …
Example: Because more than 1000 Doctors and 1500 Staff Nurses are
in place, substantial amounts were being devolved from the District
Societies to PHC/CHC etc. for salary payment – getting back UC was
problem. With e‐ Banking all the Doctors/Staff Nurse/Lab
Technicians/Block Coordinators have been asked to intimate their
personal bank account details so that on the basis of attendance
certificate from Medical Officer, the District Societies can directly
credit the salary to the bank account of the employee. THIS WILL
ENABLE INSTANT CAPTURE OF EXPENDITURE RATHER THAN WAITING
FOR SOE/UC FROM THE PHC/CHC.
Example: More than 8000 ASHAS have been selected and trained in
Kerala. The number will be much higher in the days ahead. Rather
than following the conventional route of transfer of funds to PHC/CHC
ASHAS will be issued a CARD and payment to ASHA will be routed by
the Districts through CARD System. This enables immediate capture of
SOE and is also more secure. It is also user friendly as the CARD can be
used through ATMs of any bank
Con‐Current Auditing
The Financial Management system in NRHM was further strengthened
and better internal controls established both at State as well as Districts. A
fool proof system of capturing the monthly expenditure was put in place. As a
new initiative, Concurrent Audit was set up at Head quarters and all the
districts. The purpose of Con current audit is to determine whether the
financial management arrangements including internal control mechanism as
developed are working effectively, identify areas for improvement and
enhancing efficiency.
1. The focus of the concurrent audit is to see that:
a. Accuracy is ensured in maintenance of books of account
and these are maintained on a timely basis;
b. Advances are tracked, followed up and settle on a priority
basis;
50

c. Exclude advances being shown as expenditure in the FMRs;
d. Bring in accuracy to the monthly/quarterly Financial
Monitoring Reports based on books of accounts;
e. Ensure voucher/evidence based payments to improve
transparency.
f. Enable timely and accurate submission of financial MIS to
the management.
g. Improve the accuracy and timeliness of financial reporting
from sub‐District levels; and
h. Improve the internal control systems in the society.
The monthly concurrent audit report includes:
Audited Receipts & Payments Account,
Audited Income and Expenditure Account,
Audited Balance Sheet,
Audited Statement of Expenditure,
Bank reconciliation,
Age‐wise report of Advances,
Visited block’s Report, (one or two blocks per month),
Comparison of physical Vs financial,
Reporting in the checklist format,
Auditor’s comments,
Actions taken on previous month’s observations.
In addition to the audit report a “Management Letter” is also to be furnished
which contains the following:
a. Comments and observation on the notes to the accounts,
accounting policy, accounting records, systems and internal
controls.
b. Identify specific deficiencies and areas of weaknesses in the
systems and internal controls and make recommendations for
their improvement.
c. Communicate matters that have come to the attention of the
auditors, which may have a significant impact on the project
implementation.
d. Bring to attention any other matters that the auditor considers
pertinent.
51

Accreditation of Government Medical
Laboratories in Kerala
Quality council of India (QCI) is an autonomous body set up by
Government of India to establish and operate the National Accreditation
Structure in the country. National Accreditation Board for laboratories (NABL)
is a constituent board of Quality Council of India, set up to establish and
operate accreditation programme for healthcare organizations.
There are 348 Government Medical Laboratories in Kerala. This
includes large laboratories, medium laboratories and small laboratories. Most
of the Laboratories under Health department in Kerala are devoid of essential
standard inspection, enforcement and public accountability regulation of
diagnosis services. These Medical Laboratories need specific essential
standards for diagnostic services at all levels. Accreditation of QCI certified
standards, ISO certification and eventually NABL accreditation of Laboratory
Diagnostic Services will improve the quality of health care services.
Health care traditionally has been physician focused. Evidence based
medical laboratory diagnostic services play key role in improving quality of
health care services. This can be made possible only by adopting state‐of‐the
art laboratory facilities along with competent technicians, supervisory and
managerial staff. Medical Laboratories are central function for clinical
diagnosis and treatment.
More over Government of Kerala has decided to implement the
scheme of Comprehensive Health Insurance Scheme from October, 2008 in
Kerala. Government Hospitals and other health facilities with desired
52

infrastructure for inpatient and day care facilities will need to be empanelled
with the selected insurance company.
A Memorandum of Agreement has been signed between Government
of Kerala and Quality Council of India (QCI), for Accreditation of Laboratories
in Kerala. QCI, will begin the execution of lab awareness programme and the
lab application process soon. QCI will implement a customer service
telephone helpline prior to the commencement of awareness programming
to answer lab process implementation. QCI will provide to the State, a
complete set of the QCI Programme manuals, educational guidelines, criteria,
templates and forms to be provided to the labs. QCI will prepare and provide
online access for State personnel to its lab database.
Initiating the process of Accreditation will help the Health Department
to assess the existing laboratory service delivery standards of the said
facilities, to identify the baseline level of all quality indicators and to suggest
alterations in structural designs of the facilities to meet the requirement. A
review of facilities including laboratory space and laying down standard
operating procedures for various activities, training of the key personnel will
help in getting ISO/ NABL Accreditation.
Under NRHM, for accreditation, equipping the hospitals with medical
equipments and providing other facilities like cots, linen etc., it has been
decided in principle by the Government that henceforth the equipment
purchase in all the institutions shall be under the aegis of Kerala Medical
Services Corporation for which Bio Medical Engineers were appointed. It has
also been decided to modify the State and District Quality Assurance
Committees to widen the scope from only sterilization and Family Planning
services to up gradation and quality assurance of hospital care and diagnostic
services.
It was decided to include all Government Laboratories in Kerala
namely State Public Health Laboratory, Regional Public Health Laboratories,
53

District Public Health Laboratories, Medical Laboratories attached to District
Hospitals, General Hospitals, Women and Children Hospitals, Specialty
Hospitals, Thaluk Head Quarters Hospitals, Government Hospitals, CHCs,
Block PHC, PHCs and Medical College Hospitals for accreditation.
54

Telemedicine
Introduction
Telemedicine is the use of
electronic signals to transfer
medical data (photographs, x‐ray
images, audio, patient records,
videoconferences, etc.) from one
site to another via the Internet,
Intranets, satellites, or
videoconferencing telephone
equipment in order to improve access to health care. Real time telemedicine
could be a simple telephone call, video‐conferencing, remote monitoring or
consultation using tele‐otoscope, a tele‐stethoscope, Teleradiology, remote
microscope etc.
History
In 1906 Einthoven, inventor of electrocardiography first investigated on ECG
transmission over telephone lines. During 1920s, radios were used to link
physicians at shore stations to assist ships at sea that had medical
emergencies. First large‐scale telemedicine project, Space Technology
Applied to Rural Papago Advanced Health Care (STARPAHC), was developed
and demonstrated by NASA in 1973. NASA initially used telemedicine to
transmit basic physiological data from astronauts to understand the effects of
launch, spaceflight, and reentry on the human body. During 1960s Moon
programme accelerated telemedicine and telescience systems development.
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In developed countries constraints on time and resources will make
face to face consultation increasingly expensive, and telemedicine has the
potential to produce major efficiencies in the diagnostic process. In
developing countries telemedicine will help the rural people to access
specialty health care services.
Indian Space Research Organization, Department of Information
Technology, Centre for Development of Advanced Computing and National
Rural Health Mission Supporting the Telemedicine projects in India.
Telemedicine projects started in Kerala as early as 2002 to provide
follow‐up treatment to cancer patients. The success of the Cancernet leads to
development and deploy of many telemedicine projects in Kerala.
Coordination and inter liking of all
telemedicine projects in Kerala is
envisaged under NRHM. More over
the same network can be used for
patient care, follow‐up treatment,
diagnosis, continuing medical
education, teleconferencing, patient
education, behavioral change communication and communication and case
discussion.
56

Telemedicine Projects in Kerala
Sl. No Name of project Funding Agency Implementing
Agency
1
CANCERNET – later changed to
Onconet
DIT‐ Govt of India
2 ONCONET – Kerala
&
CDAC
ISRO
3
DIT‐Govt of India
Telemedicine and Tele‐
CDAC
&
Education Facilities in Kerala
Govt of Kerala
4
Tele Health and Medical EducationISRO &
Project Kerala
GoK
ISRO
5
Rural Health Care Delivery systemMedia Lab Asia
through Telemedicine
(DIT)
CDAC
6 Mobile Telemedicine
Media Lab Asia
(DIT)
CDAC
Revitalisation of existing
7
telemedicine centres and scaling up
NRHM
telemedicine facility to more
CDAC
primary care centres in Kerala.
1. Cancernet
Cancernet was the first endeavor in India in the area of tele‐oncology,
which was successfully commissioned in 2002. Cancernet was an oncology
network for providing telemedicine services in cancer detection, treatment,
pain‐relief, and patient follow up and continuity of care through peripheral
hospital. It provided great help to the cancer patients who needs continuous
follow up and treatment. Success of cancernet paved the way for the fullfledged
Telemedicine project Onconet.
Onconet
Cancernet later converted to Onconet, which consist of teleconsultation
clinics at Regional Cancer Centre (RCC) and its peripheral centers
at Kochi, Kannur, Palakkad, Kozhenchery and Chavara. High bandwidth
57

connectivity is available between RCC and peripheral centers through
satellite link. It includes tele‐pathology and radiology system at RCC and two
nodes for capture, storage, transmission and online sharing of images. There
is also an oncology resource centre, which provides cancer related
information to clinicians, researchers, health planners and administrators on
the telemedicine network and Intranet.
It is a web based telemedicine system with hospital information
system as the back end and telemedicine software tightly integrated with
Hospital Information System. It is a multi‐tier web application runs on Java
and J2EE Technologies, Oracle 10g database and an application server.
Connectivity is provided with 384 Kbps V‐SAT and 128 Kbps ISDN.
Main components of oncology telemedicine systems includes a video
conferencing system , connectivity between RCC with nodal centres and a
central server containing patient data, accessible through LAN within the RCC
as well as at nodal centres through a WAN.
Telemedicine provides a way for cancer patients to get follow‐up near
their home town.
2. Telemedicine And Tele Education Facilities In Kerala.
Four Taluk Hospitals, Mental Health Centre Trivandrum, Medical
College Hospital, Trivandrum, Sree Chithira Thirunal Institute, and RCC form
this telemedicine network. This network is functioning using the Mercury
Telemedicine software developed by C‐DAC.
3. Tele Health and Medical Education Project Kerala.
This project connects 6 Medical colleges, Regional Cancer Centre,
SCTIMST, all District Hospitals and one CHC. This project has been developed
and implemented by
ISRO, IIITMK, Govt. of Kerala and CDAC.
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4. Rural Health Care Delivery through Telemedicine
This project is being implemented in Kerala. Aim of the project is to
develop a resources sharing, integrated, rural healthcare delivery system
through Telemedicine using Information and Communication Technology
(ICT) at Tirur Taluk of Malappuram District, Kerala using available network
coverage provided by Akshaya Network. System study completed and
specialty and nodal centres are identified which included 9 CHC and one
THQH. Web based Telemedicine Software is under development in open
source.
5. Mobile Telemedicine
This project is being implemented, which includes development of
low cost mobile telemedicine facility and deploy the prototype in Cherthala,
Alappuzha district with the objectives of extending specialist care to the rural
areas for early detection of diseases like Tuberculosis, diabetes, hypertension
etc. It also includes follow up of patients with chronic diseases, early
detection of cancers, comprehensive care for the cancer patients, follow‐up
consultation and provision of maternal and child health services.
6. NRHM Telemedicine Proposal‐ Project for revitalisation of existing
telemedicine centres and scaling up telemedicine facility to more primary
care centres in Kerala.
Memorandum of Agreement has been signed between NRHM and
CDAC for the implementation of the project. Objectives of the project are to
make all the telemedicine centres set up under the different projects fully
operational, to promote the usage of the telemedicine centres for patient
care, to bring all the telemedicine centres in Kerala in a common frame work
and to establish more telemedicine centres in health care institutions. It is
also decided to start telemedicine centres at General Hospital Trivandrum
and Malabar Cancer Centre.
59

ASHA workers - Owning more
responsibilities
The ASHA was earlier planned to be implemented in the States
with poor Health Indicators. However, after a detailed assessment on the
special needs of the states Government of India approved ASHA scheme for
the whole population in the state of Kerala. Further, it was planned to deploy
32853 ASHA volunteers in fourteen districts by 2010. Around 20,000 ASHA
volunteers have been selected so far of which 10,000 have been deployed in
the state. First Phase of training has been completed for the selected ASHA
volunteers.
The roles and responsibilities envisaged for are as follows:
Identify pregnant women as a beneficiary of the Scheme and report /
facilitate registration at the sub centre for ANC.
Assist the pregnant woman to obtain necessary certifications where
necessary.
Provide and / or help the women in receiving at least 3 ANC, TT
injections, IFA tablets.
Identify a functional Government Health Centre for referral & delivery
and acquaint the women with
the details of the same.
Counsel for Institutional
delivery
Escort the beneficiary women
to the pre‐determined health
centre and stay with her till the
woman is discharged.
Arrange to immunize the
newborn till the age of 9
months
Register birth or death of the
child or mother.
Post natal visit within 7 days of delivery and track mothers health
Counsel for initiation of breastfeeding to the newborn within 1 hour
of delivery and its continuance till 3‐6 months
Roles and responsibilities: A paradigm shift
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Considering the health scenario in the state of Kerala where the
burden of non‐communicable diseases is on the rise, it has been decided to
extend the role of ASHA to the management of Communicable & Non‐
Communicable diseases. The areas where their services are planned to be
extended are Prevention & Control of Communicable diseases, Identification
& Control of NCD’s, Palliative care and Community based Mental Health
Programme.
Towards the Prevention and control of Communicable diseases ASHA
volunteers are made responsible for the following
‣ Reporting of outbreaks/ cases to Sub centre/PHC/CHC
‣ House to house campaigns and other IEC activities
‣ House visits with teams for Source Reduction activities and
chlorination and acted as volunteers for the same
‣ Lead Source Reduction activities by house visits
Improving Immunization through ASHA
As a part of strengthening immunization the field level activities need
to be strengthened using ASHA/link workers and also by making the use of
local level events like the Ward Health Nutrition Days (WHNDs). WHND,
which is organised every month in a ward, is the right platform to strengthen
immunization under the leadership of ASHA.
done by ASHA
As a part of social mobilization for WHND the following has to be
Visit all the household and get
to know all the families. Make
it a point to visit all the poor
households, especially SC/St
families
Make a list of infants who
need immunisation, were left
out or dropped out
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Find out the reason for dropouts or un immunized
Review and plan activities to mobilize the dropouts and un immunized
children
Make a list of children who need care for malnutrition
Make a list of children who were missed
Also ASHA workers should find out and note down the reasons for not
taking immunization or missing out immunization or dropping.
ASHA/JPHN should make a note on the people who did not attend the
session as per their list. This should be discussed in the monthly review
meetings at PHC and Special awareness/BCC drives should be launched based
on the nature of resistance of the population.
Special NCD Management Programme through ASHA
As a part of NCD management though ASHA, during the detailed
training given to ASHA volunteers, classes on prevention of Non‐
Communicable Disease are given. Along with this, it is also planned to give
necessary drugs / kits to ASHAs
At grassroots level they are expected to take up the following
activities
1. Initial Home Visit to all households
of there are & Collection of details
of all persons above 35 in the
prescribed format. For this she will
be paid Rs. 2/‐ per form. (500
persons out of the 1000 population for ASHA are expected to be
above 50)
2. Bring all those with suspicion of NCD to the Subcentre / PHC for initial
Checkup. (50% of the surveyed population i.e. 200 persons are
expected to be brought for initial Check up) For this she will be paid
Rs. 20/‐ per person.
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3. Of the persons brought for Checkup, those who are diagnosed to have
any NCD will need regular follow up. ASHA is expected to arrange for
a minimum of 2 follow up visits during 1 year for each of these cases.
(Almost all of the 100 persons brought by ASHA are expected to need
regular follow up visits) For this she will be paid Rs. 10/‐ per follow up.
63

Debit card scheme for ASHA Volunteers
The background
Like other states, Kerala too is deploying one ASHA volunteer for
every 1000 population. Around 20,000 volunteers have been selected and
half of them received the necessary training. In Thiruvananthapuram district
around 2000 ASHA volunteers are already deployed. The performance of
ASHA volunteers are monitored by Junior Public Health Nurse at field level
and report to PHC Medical Officer. PHC Medical Officer verifies this report
and effect payment to ASHA Volunteers.
The issue
Complaints regarding timely payment of incentives to ASHA volunteers,
owing to reasons enlisted below:
As the incentives are to the paid from different heads, based on the activities
of ASHA workers, the PHC Medical Officers find it difficult to debit the
amount from different heads. The fear of audit objection is also a reason,
which causes delay in releasing the payment in time.
This delay some times affects the motivation and achievement levels of ASHA
workers.
The solution - Debit card- a
revolutionary idea
To ward off delay in making payments to
ASHA volunteers, Thiruvananthapuram
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district designed and implemented a novel scheme for paying incentives to
ASHA Volunteers through a debit card system.
Through this system, the incentives are credited to the respective accounts of
AHSA volunteers from the district NRHM office. The performance report
verified by the PHC Medical Officer is sent to the districts, based on which
payment is made by way of crediting the amount to the respective ICICI bank
account of ASHA volunteers from the district headquarters. This not only
helps avoiding delay in payment but also helps in generating SOEs
immediately.
Features of the debit card
The ICICI Bank Pay Direct Card is a pre‐paid card with magnetic strips, which
can be loaded in rupees. The card does not have any minimum balance
requirement and it offers the flexibility of using it at all the VISA ATM outlets.
Bulk uploading and reloading facility
The Card holder can upload and reload any number of cards at any
time unlike with cheques, which need to be signed and distributed to
each employee separately.
Web‐based MIS
The Card owner can check all the transactions online, which gives the
advantage of better tracking of their accounts.
Instant SMS alerts on every upload
The Bank also provide a facility where the cardholder receives an SMS
alert on his mobile phone whenever money is uploaded onto the card.
24 x 7 Customer Care assistance
ICICI Bank has created a dedicated helpline number that remains
active 24x7. So let it be a balance inquiry, lost‐card reporting or
activating the replacement card, this number remains available for
help anytime.
65

Immunization Drive – October 2008
Background
Reviewing the present scenario of Vaccine Preventable Diseases
(VPDs) of the state and to save the future generation from the threats of
VPDs, it has been decided to strengthen immunization coverage through
intensification of IEC/BCC activities. The month of October shall be observed
as ‘Immunization Month’, every year from the year 2008 onwards. The
campaign will be a joint venture by the Health and Education department and
District Medical officer (Health) and District Programme Manager, will ensure
that all possible steps have been taken for smooth implementation of the
programme.
Planning and review
Inter‐sectoral Co‐ordination Committees will be constituted at District,
Education District, Sub district and School levels by involving officials from
related departments like Health, Education, Social Welfare and LSGIs and
representatives of Parent Teachers Association, IMA, IAP, Opinion leaders,
religious leaders, NGOs etc., and any person suitable for strengthening
immunization. District Collector will be the Chairperson. DMO(Health) will be
the Convener and RCH Officer will be the Joint Convener of the District level
Committee. The committee will plan and review the overall campaign.
State level Launch
The campaign was launched at the state level
by the Minister of Health and Social Welfare in
the presence of Minister for Education and
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other officials and Peoples' representatives on October 03, 2008.
Campaign methodology
It is proposed to hold the following IEC BCC Campaigning throughout the
month of October.
a. Pledge to read in School Assembly.
b. Special talk once in a week in the school assembly by MO
Supervisory Staff.
c. Since all Wednesdays are Immunization Days, a Key Message
on Immunization may be exhibited in the Notice Board of
every School on 1 st , 8 th , 15 th , 22 th and 29 th of October 2008
and the Class Teachers may be asked to copy the message and
to convey to students of the concerned classes.
d. Brochure depicting the message on immunization should be
distributed to all students. Brochure, Posters, Stickers, Flip
Chart and Pledge will be produced and supplied from HQ.
e. Students will be given
an opportunity to
clarify doubts on
Immunization. They
will be asked to write
their doubts on a piece
of paper and handed
over to the concerned class teachers before 25 th October
2008. The written doubts so collected should be handed over
to the Health Personnel through Health/Science Club of the
school. Health Personnel will prepare the answers to the
doubts raised by the students in consultation with the MO and
Supervisory staff. The answers thus written will be submitted
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to the Headmaster concerned with the questions before 29 th
October 2008 and a copy of the same should be kept in the
PHC, CHC etc. The Headmaster will be asked to take necessary
steps to gather all students who raised the doubts in a suitable
room and arrangements may be done to read the Answers to
the Questions on or before 31 st October 2008.
f. Most catching awareness programmes like Ventriloquism
(Monkey show)/ Magic show shall be conducted at school
level where immunization coverage is low.
g. Most suitable Cultural/ Folk Media Programme shall be
played for the general public where the immunization
coverage is low.
h. Press releases on VPDs.
i. Rally shall be arranged at school level and the consequences
of VPD’s may be highlighted among the general public where
immunization coverage is low.
j. Quiz/Elocution/Essay writing/Poster making/Slogan/Poem
writing competitions shall be conducted at school, sub‐district
and Education district levels and the winners should be
appreciated and Awards may be presented.
k. Half‐day Orientation Training shall be given to all
Headmasters at Sub‐district level and teachers. PTA members,
selected members from Health Science Club at school level. A
handbook Module may be prepared and issued to all
participants.
l. Efforts will be made to make Immunization as a point of
discussion in all conversations and meetings.
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m. A circular is prepared and circulated to all Health institutions
explaining the role and responsibilities of all levels of staff
during the Immunization Month.
n. Regular Press releases shall be given on the activities planned
and activities performed at District and Block levels.
o. Coverage through local TV channels will be ensured
69

Behavioural Change Communication -
Innovations
Initiative 1: Compilation of Government Orders –
publishing a booklet on Arogyakeralam
Since the inception of Arogyakeralam in the state of
Kerala, various government orders have been issued
related to the implementation of the programme in the
state. Previous year’s orders were printed and circulated
as and when required and mostly the orders were in
English. This practice did not enable easy reference of
government orders. Thus to tide over this difficulty,
Arogyakeralam decided to translate all the orders
in local language, compile it and print together as a
booklet with a brief description on NRHM and the
activities. Thus a booklet named ‘Arogyakeralam‐ a
guideline’ was printed and circulated widely till the
ward level. This was appreciated by GoI, PRIs and
the health workers at all levels and is being used as
an easy reference manual for implementing NRHM activities in the state.
70

Initiative 2: Local specific health melas
Health Melas are envisaged under NRHM, towards sensitizing the public on
available health services and creating a demand on such health services.
Detailed guidelines were issued from GoI towards the conduct of this.
However, considering the local demand and its peculiarity, minor
modifications with necessary policy support was made, for the successful
implementation of such Health Melas.
Considering the popularity and impact of health melas it has been decided to
hold health melas in all Legislative Assembly Constituencies in the State for
which an amount of Rs. 1,00,000/ ‐
(Rupees One lakh Only) per
constituency, has been allotted
through NRHM. 114 out of 140
Melas have been organized in the
year 2007‐08. Almost all of the
health melas have been a grand success in terms of community participation,
organization and response from the common mass, who participated in
Melas. It is worth mentioning that Rs. one lakh, per constituency has been
devolved from NRHM towards the conduct of the mela, an equal amount or
more, has been raised through sponsorship. The ownership and involvement
shown by the Members of Legislative Assembly is commendable. Apart from
the amount allotted per constituency, the elected representatives were able
to raise more amounts making the Melas a grand success.
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Initiative 3: Local Specific IEC campaign: Bodhana Nauka
(Information Boat)
NRHM, Alappuzha and AIR, jointly organized a Bodhana Nauka or Information
Boat for conveying the health awareness among water logged Kuttanad
region in Alappuzha, which was really a grand success and caught the
attention of everyone.
The life of Kuttanadan folks are
mostly like fish, who take birth in
water and continue their life in
water. This has caused them to
be affected by water borne
diseases as well as vector borne
diseases like chikungunya,
Leptospirosis, diarrhea etc. The programme called 'Bodhana Nauka' was
focused to give more attention on creating health awareness especially on
preventive measures for different communicable diseases among the people
by joining hands with health professionals, people's representatives ,
community leaders, educational Institutions, religious institutions, ASHA
volunteers etc. The programme included street plays, awareness classes, quiz
competitions for public and school children, Special radio programmes etc.
Initiative 4: Promoting the brand Image of NRHM
The society registered for implementing NRHM in the state has been named
AROGYAKERALAM towards popularizing the brand image of NRHM. The
name AROGYAKERALAM was placed in NRHM logo and was used widely to
have maximum mileage. Moreover a slogan ‐ AROGYAKERALAM
AISWARYAKERALAMI‐ was also coined as a part of popularizing brand image.
72

Health messages placed through newspapers, journals, weeklies, souvenirs,
events, electronic media etc carried the logo and the slogan with
prominence.
Initiative 5: Caller ring tone
Title song with health message as the lyrics has been designed and
produced. This is now being used as caller ring tones in all corporate
mobile connections of NRHM. The song having a message is also
played during all functions/events of NRHM. This has helped in
popularizing the brand image of NRHM as well as increasing the
visibility of the programme.
73

Pain and Palliative Care under NRHM
CARE of the incurably ill, Dying and Chronically Bedridden
PATIENTS
Background
Most countries in the Developing world are experiencing health transitions
with a rapidly rising burden of chronic and incurable diseases, which are
currently, the major cause of death among adults.
In India, in 2005, 53 percent of deaths were due to chronic diseases 43 % of
disability adjusted life‐years ( DALY’s) lost. According to WHO estimates,
about 5.4 million of them would benefit from Palliative Care. Palliative care
is the active total care of patients
whose disease is not responsive to
curative treatments. Palliative
Care responds to physical,
psychological, social and spiritual
need of the patient and the family
and extends if necessary to
support in bereavement. It is
patient centered and not disease
focused. The goal of palliative care is the achievement of the best possible
quality of life for patients and their families.
Palliative care services, if implemented in a rational public health way
improves the quality of life for cancer suffers, patients dying of chronic
diseases, the elderly terminally ill and people suffering from AIDS.
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The Neighbourhood Network in Palliative Care (NNPC), a community owned
project in Kerala has exceptionally a good coverage. NNPC offers proof to the
theory that communication ownership can work wonders and the results of
the performance could be outstanding if the project is in collaboration with
the local government.
The basic concept behind NNPC is that networks provide social support, selfesteem,
identity and perceptions of control. This network of trained
community volunteers with the support of health care professionals brings
together individuals from diverse backgrounds. Such groups in the
community have shown better understanding and cooperation in response to
the challenges faced by the community.
The methodology of NNPC involves getting people from a region together,
discussing problems of chronic, incurable and bedridden patients in their area
enlisting the support of those who are willing to spend minimum of two
hours every week for helping these patients and giving the structured
trainings and encouraging them to plan and organize locally relevant services.
Groups of these trained volunteers are linked to the Palliative Care
professional and health care institutions in the area. Community groups and
health care professionals make an action plan which clearly defines individual
and institutional roles and responsibilities.
The funds necessary for the project are mobilized locally. The region where
NNPC is in place, local governments (Panchayaths) in Kerala’s three‐tier
decentralized governance have also been offering financial support for the
project
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In less than eight years, the NNPC initiatives has resulted in an estimated
coverage of more than 70 percent in Palliative Care and long term care in the
region as against a national average of around one percent in Palliative Care.
The result of NNPC has proved that the delivery of sustainable good quality
palliative care and long term care is possible with community participation
The new Palliative Care Policy declared by the Government of Kerala is
unique in many ways:‐
(i)
(ii)
(iii)
(iv)
It is the first time in Asia that any government has put forth a policy
for Palliative Care
This policy emphasizes the community based approach to palliative
care and considers home based care as the “Corner stone” of
palliative care services
It highlights the need for integrating palliative care with primary
health care and disease effective programme for effective coverage
Integrating the existing services with the main stream health care and
Local Self Government Institutions
The Policy envisages the guiding principle of home based care. It considers
palliative care as part of general health care and aims to ensure adequate
orientation of available man power and existing institutions in the health care
field to this area.
The Palliative care policy of Government of Kerala validates the NNPC
approach in palliative care and also endorses the WHOs recently formulated
policy of community participation in the area of Non‐ Communicable
diseases.
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NRHM pain and palliative care project
NRHM, Kerala has initiated the project aimed at the development of
community based care services for the bed ridden, elderly, chronically and
incurably ill people in the state. This unique initiative is expected to have
wide positive implications in the care of these marginalized groups of people
in the state and also nationally. With a budget of more than 4 crore rupees,
this is the largest palliative care project in India so far. This is also the only
palliative care project in NRHM in any state in India.
Then new NRHM project is exactly in the same lines as the government of
Kerala's palliative care policy and is expected to act as the main implementing
arm of this policy. The project aims at awareness and capacity building in the
general community, health care professionals in government and private
sector, local self government officials, the student community and grassroots
level political leaders. A series of demonstration projects in the background
of these awareness and training activities are expected to facilitate the
evolution of a social movement in the care of the incurably and terminally ill
patients in the state, well integrated to the existing health care system.
Preparation
As part of the preparation for
the project, networking with the
existing palliative care initiatives
in all the districts was
completed. First round of district
level meetings of stake holders
were finished in July 2008
Recruitment of field staff for the project has been finished and the list
of selected candidates published
The process of establishment of the coordinating unit and resource
centre at IPM is now on
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Training of the field coordinators is now on. The trained coordinators
will be reporting to the corresponding DPMs after training on 18 th
August.
Awareness / training programs in districts will start by the third week
of August
The doctors and nurses selected for the project will start their training
by end of August and report for work by mid October
Media support:
A major campaign by Malayala Manorama in association with IPM to build
awareness among various sections of the people is already on. The campaign
is for a period of one year and is expected to cover the whole period of the
project. Malayala Manorama has agreed on continued support for the
project.The news paper has promised that the new webpage launched by it
and linked to its online page (third largest in the world in terms of number of
hits) will have a definite space allotted for the Arogyakeralam –Palliative Care
Project. This space can in future be used to reach out to wider Malayalee
community all over the world.
Organisations:
Indian Association of Palliative Care, (IAPC) the umbrella organization of
palliative care initiatives has pledged unconditional support to the project.
Support from IAPC will ensure that all the existing groups in palliative care are
with the project
Other groups/ departments:
Involvement of students and youth have been ensured (see below)
Other government departments like Local Self Government Department,
Department of Youth welfare and the Home Department have expressed
interest in collaborating at the grass root level.
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Work done in so far:
We have already started moving ahead.
First state level workshop for trainers in palliative care in Kerala was
conducted on 8th and 10th August 2008, Calicut. More than 100
volunteer trainers from all over the state were briefed on the project.
This team expected to work as resource persons for the awareness /
training programs in the project
All the six centres offering training in palliative care in the state
brought on a common platform under the project.
o RCC, Trivandrum
o TIPS, Trivandrum
o Amrita, Cochin
o IPC, Trichur
o CRCPC, Manjeri
o IPM, Calicut
Background work for facilitating the involvement of the students in the
project is on
o All NSS (national Service Scheme) units under Calicut
University getting involved this year
o All NSS units under technical cell (Engineering Colleges and
Polytechnics) getting involved this year
o Selected units under Kerala University getting involved this
year
Groundwork for facilitating the involvement of the youth has also
been done.
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o Government of Kerala’s Youth Welfare Board has taken a
decision to collaborate with the activities
o Nehru Yuvak Kendras and affiliated youth clubs (more than 50
clubs in each district) will collaborate with the project
o This will mean awareness / training for more than 25,000
young men and women in the state
o Kerala Police getting involved
o 20 police stations with community policing will cooperate with
the project as pilot
o 4th Battalain of Kerala Armed Police (more than 800
personnel) in Kannur District getting palliative care training
under the project next month
80

RADIO HEALTH
Health Literacy and Community
participation have played a significant role
in the development of the famed Kerala
Health Model. Health care demands have
been increasing over the past 50 years due
to transitions in population structure
(increasing old age population) and disease pattern (increasing life style
diseases like Diabetes, Heart disease, hypertension, stroke, accidents and
traumatic and emerging infections). The attitude and behavior of general
population hence needs to be modified to maintain the public health gains.
The present situation demands a need of new and innovative health
communication strategies to communicate with the target audience, without
which assuring people’s participation will be difficult.
With the intention to have a healthy and well fit population, Radio
Health is such an innovative Community Health Education and
Communication model designed and produced by NRHM (National rural
Health Mission) and initiated by Thiruvananthapuram district team of NRHM
in collaboration with AIR
Radio Health aims (i) to build up an innovative and comprehensive
health literacy model through the medium of RADIO by assuring wider
community participation for mass appeal (ii) to create awareness among the
audience the importance of health and the need to lead the life as an healthy
individual;(iii) to create a friendly and open atmosphere for audience
interaction through innovative ideas; (iv) to create a positive change in the
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health habits and behavior of people (v) To ensure the idea/ message
conveyed, reach every nook and corner to gain targeted feedback.
Radio Health is the first ever concept
of its kind of where FM Radio works as
a medium for health literacy
campaign. It will be the best platform
to coordinate majority of Health
Practitioners ranging from Specialists
Doctors to the peripheral health
workers and Asha Workers. It will mainly focus on Primary Health Care and
Preventive aspects of health by giving importance to all Medical Systems
(AYUSH) and Alternate Health Practices. It is mission for solving health
problems both physical and mental through interactive programmes by cocoordinating
different agencies of Health Care System, NGO’s and Radio
Health Clubs.
Radio Health Clubs will be introduced in Schools, Colleges, Residential
Associations, Cultural Groups etc. Radio Health Club members can function as
RJs and Programme Producers. This concept will be an effective mode of
propaganda for Radio Health as a whole.
Radio Health has been launched on 25th September 2008. The
Frequency of Transmission is 101.9 MHz; Ananthapuri FM .The transmission
time is 3 to 3.30 pm, 4 days/week.
Contents of the Programme is prepared under the direct supervision
of Expert Doctors, Public Health Experts and executed by Creative persons
and Radio Health Club Members. An approval committee has been
constituted who will approve the programmes to be aired periodically.
82

Standardizing Health Institutions:
Ensuring quality services
The background
The Hospitals existing in Kerala under govt. services is not having a uniform
pattern and the required minimum standards have not been clearly specified.
This has created various types of regional imbalances in the availability of
health care instituions, which invariably and adversely affects the availability
of services in the backward districts /areas. In the absence of clear‐cut
standardization criteria, systematic and uniform institutional development
strategies have not been followed in the state. Based on some of the
fundamental principles of Public Health Planning followed in the
standardization committee report, the recently developed Indian public
Health Standards (IPHS), giving due consideration to the special features of
the public health scenario and institutional development pattern of Kerala, it
has been decided to standardize health institutions coming under the Health
Services Department.
The process
As per the standardization process the institutions will be classified,
based on the bed strength. Accordingly the Institutions will be classified as
follows with the mentioned facilities and staff strength.
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i. Primary Health centers (PHC)
Primary Health Centers are basically Grama panchayat level health
Instituions intended for providing the basic promotive and preventive health
care services including the implementation of the national and state level
Public Health programmes along with minimum curative services. Though
observation beds are provided in these institutions but elaborate in‐ patient
care is not expected at this level.
However, at present there are many PHCs (i.e. Panchayath level Health
instituions) having in patient services, Lab Services, Vehicles with driver etc.
In these instituions existing pattern will be continued. But considering the
fact that, the efforts for making the inpatient facilities into real functioning
components in many of these institutions have repeatedly failed, if required
the nonfunctioning sanctioned bed strength and additional staff created in
some of these institutions may be transferred into other intuitions requiring
additional staff and bed strength.
Staff pattern.‐Minimum staff required
1. Medical Officers 2 (Preferably one male and one female ‐ increased from
existing one, the remaining 1 can be provided from NRHM till sanctioned
posts are created)
1. Pharmacist 1
2. Staff nurse 3
(increased from existing 1, the remaining 2 can be provided on contract basis
with NRHM funding till sanctioned posts are created)
3. Nursing Assistant 1
4. Hosp. Attendant 1
5. Part time sweeper 1
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Public Health wing
One Junior Public health Nurse & Junior Health Inspector each for one sub
Center (i.e. for 5000 Population in plains and for 3000 population in tribal and
hilly areas.)
One Health Inspector
One Lady Health Inspector
Office
One LD/ UD Clerk
One peon
ii. Primary Health Centers with 24 Hr on call service (24x 7 PHCs).
After upgrading the eligible Block PHCs into CHCs as per the
standardization criteria, the remaining block PHCs with functioning in patient
facilities along with other existing Mini PHCs with functioning IP facilities will
be categorized as 24 Hr PHCs as per Indian Public Health Standard. One
hospital in each block will be designated as 24 X 7 PHC and should have bed
strength of up to 30.
Staff strength:
1. Medical Officers 4
2. Pharmacist 2
3. Lab Technician 2
4. Staff nurse 9
5. Nursing Assistant 3
6. Hosp. Attendant 3
7. Part time sweeper 2
Preferably a vehicle, which can be taken by outsourcing
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Staff nurse and other category of staff is to be provided as per the existing
bed strength and other facilities.
The institution will have OPD services, emergency 24 X 7 services that
could be attended by nurses and one Medical Officer. Well functioning HDCs,
co‐location of AYUSH doctors, referral services, in‐patient services, minor
surgeries, management of would and fracture, MCH care including FP
services including facility for MTP, nutritional services, School Health
Programs, Monitoring & Supervision of National Health Programs including
ASHA. Full laboratory facilities shall be available and availability of drugs &
key diagnostic tests is to be ensured.
iii. Community Health Centers (CHC)
Community Health Centers are Block level Health care institutions
providing basic Secondary Care Health Care services along with the planning,
implementation and coordination of the public Health programmes at the
Block level. There will be one community Health center each in all the Health
Blocks in the State. All the existing Block PHCs and the prevailing CHCs shall
be renamed as Block CHCs. At present some of the CD blocks are not having a
CHC .In such cases one block PHC/ Govt. Hospitals will be upgraded into CHC
and with the support of GoI these centers along with presently existing CHCs
shall be upgraded to Indian Public Health Standards (IPHS). In case if any of
the CD blocks are currently having two CHCs, one of them shall be renamed
as 24 hr PHC. The CHCs will have bed strength of 30 to 100 with theater
facility, Laboratory, X‐ray, ECG, and Ultrasound
Staff required
Doctors –specialists (Junior Medical consultants) in General Medicine,
General Surgery, Obstetrics & Gynecology, pediatrics, Anesthesiology
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Other non specialists (general category) based on the total bed strength.
Paramedical staff and other staff based on the bed strength and other
facilities available.
Block level Public Health staff
Health Supervisors 1
Lady Health Supervisors 1
Staff Nurse 12
JPHN 2
Pharmacist 2
Lab Technician 2
Radiographer
Ophthalmic Assistant
1 security
Other ministerial posts as per norms
The institution shall have proper waste management system, laundry
facilities, full emergency services, shall have a minimum of 7 doctors and 1
Block Coordinator cum PRO. The institution shall provide 24 X 7 services, shall
have separate male and female wards, and shall provide emergency obstetric
care including surgical interventions like caesarian section, new born care,
emergency care of sick children, lapro services, MTP services, essential lab
services, blood storage services and transport services. Shall have ECG
facilities, X‐ray facility and preferably USS facility, shall have fully functional
OT with surgical items. Minimum of two vehicles one especially
administrative control over the PHCs and SCs, One statistical assistant as
block will be the first level of monitoring / MIS. Minimum one computer with
internet connection; shall have computerized pharmacy, training & skill
development of PRIs, ASHAs, JPHNs, Nurses etc., fully functional HDCs,
residential accommodation for the staff
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iv. Taluk Hospitals.
There will be one Taluk Hospital each in all the taluks. Taluks, which are not
having a Taluk Hospital, the biggest CHC/ Govt Hospital, will be upgraded as
Taluk Hospital. In some places Taluk hospitals, which were previously
designated as CHCs shall again be re‐designated as CHC, if that particular
Taluk has got two Hospitals of taluk level status.
Taluk Hospital will have minimum bed strength of 100. All the Taluk Head
Quarters Hospital having more than 100 bed strength will continue to have
the existing facilities and staff.
v. District Hospital/General hospital
There will be one District / General hospital in each district with
minimum bed strength of 250.
vi. Women & Children’s Hospital & specialty hospital.
The existing Women and children’s hospitals will continue as Women &
Children Hospital. The minimum bed strength of W&C will be 200, and the
bed strength of W&Cs with less than 200 bed strength will be increased
accordingly. Considering the fact that W &Cs are needed in every district for
providing quality Maternal and Child Health, W &Cs will be started in all
districts.
Specialty hospitals of Mental Health, Leprosy and Tuberculosis will
continue as specialty Hospitals. Strengthening and development of these
Hospitals will be taken up in due course separately.
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Effective utilization of untied funds and
Annual Maintenance Grants: with
special focus on Malappuram
Untied funds and Annual maintenance grants are a boon to many of
the institutions, which had been reeling under shortage of resources. Many
of the institutions are making the best use out of it Malappuram district has
become a model on this.
In terms of health indicators Malappuram is the backward district in
the state of Kerala. The 2004 DLHS survey puts the district at 180th place.
However visible changes are seen almost two years since the implementation
of NRHM in the district. Malappuram is the district where the highest number
of health institutions are there with 11 Community Health Centres, 88
Primary Health Centres, 589 Subcentres and 5 Taluk Head Quarters Hospital.
NRHM untied funds has become a boon to Malappuram as most of
the institutions that were in a bad shape are getting a facelift because of
NRHM funds. Innovative and patient friendly services were initiated using
untied funds and maintenance grants.
Some of the changes that were made using untied funds and annual
maintenance grants are enlisted below:
89

Token system in a PHC using untied funds
Token system was introduced
in a PHC called Chaliyar in
Malappuram district owing to
which a more systematic
delivery of services could be
put in place. This PHC situated
in the tribal area caters to
more than 250 patients every
Before token system was introduced
day. Seeing the success of this system the executive committee, district
health and family welfare society has decided to scale up this system to more
institutions.
Improving facilities in subcentres
Owing to improved facilities in subcentres, more
Public Health Nurses are staying at the centres
and giving services. Around 10% increase in the
numbers of JPHN staying in the centres is noted
Patients availing Token System
90

Improving facilities at Sub Centres
- Post Situation
JPHN Attending a patient at a
modified sub centre at Malappuram
Well dug using WHSC Funds - a
proud panchayat president
standing beside
IP Ward - Pre situation
IP Ward - Post situation
Water Purifier put in place
Visiting Room with TV & IEC
Materials
91

Health Management Information System
for Kerala State
Events are taking place every day. Be it at Health or any department.
The events so happened is to be recorded for our study and future reference
, so that our planners can have a scientific and reliable study for formulating
and implementing plan to evolve remedial and suitable measures to make
our future safe. In olden days, the recording was only manual and there by a
huge data collection and its analysis was simply not easy. Now we are living in
a modern era and with most modern equipments in our hands. The
computers can be of very useful and big and long data can be stored and
analyzed so easily. This information will be the base in taking important
policy matters pertaining to that subject.
This is the background on which, health
department decided to implement certain
schemes and HISP is one among that. This
is basically meant to record child and
maternal activities, immunization,
communicable diseases and record its movement.
The Health Management
Information System for reporting of
Maternal and Child Health activities for
the State of Kerala is being scaled up
from Thiruvananthapuram district taken
for pilot implementation and extended to
remaining districts in the State. The scaling up will be effected in the HMIS
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formats customized to the
requirements of the State
adopting the HMIS Model and
Toolkit by NHSRC and the
project is rolled out in the State
from October ’08 with
technical support from NHSRC.
The scaling up of HMIS implementation in Kerala is also entrusted to
HISP, India, after the successful implementation of pilot by them for
Thiruvananthapuram district. Arogyakeralam (NRHM), under the Health Dept
will monitor the implementation.
The salient and unique features of the project are:-
The Health Information
Systems Programme (HISP) software
is developed on FOSS (Free & Open
Source Software) in accordance with
the State IT Policy was piloted in
Thiruvananthapuram district in
Kerala by HISP India who was
entrusted the task of setting up
computer supported HMIS in public health facilities – the District Health
Information Systems (DHIS) in 2005.
HISP is provided with facilities for Data Management on Maternal &
Child Health related activities, Immunization coverage, Communicable
Diseases monitoring etc., generation of reports on same and various
analyses. Provisions are also there in HISP to keep the collected data in order,
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in every respect, for future requirements. The data thus collected will be
analyzed and used for planning and decision‐making purposes in the Health
sector.
The HISP software has systematic provisions for organized entry,
access, retrieval and management of data also facilitating automatic data
consolidation and validation. Improved data quality coupled with enhanced
scope of raw data to be processed for accurate information promises to be
new and innovative for the State’s Health Sector.
Vizhinjam PHC Map
Antenatal, Delivery, Live Birth
Oct 05 - Oct 06
Vellar ANC= 45 :Delv=42 :Births=42
M angalathukonam ANC= 33 :Delv= 30 :Birt hs= 30
Katt ukulam ANC= 78 :Delv= 69 :Births= 69
Peringamala ANC= 35 :Delv=31 :Births=31
Muttakkad ANC= 25 :Delv= 24 :Births=20
Venniyur ANC= 85 :Delv=70 :Births=70
Kattachalkuzhi ANC= 60 :Delv=65 :Births=65
Main Centre ANC= 53 :Delv=39 :Births=39
Total Population
43
ANC
Del
LIBI
1. The State wide implementation will be Web based and approximately
1,215 health facilities in the State including all PHCs, CHCs, District Hospitals,
Government Hospitals, General Hospitals, W & C Hospitals, Medical Colleges,
Taluk Hospitals and Specialty hospitals will be uploaded to the web for data
entry and management in customized formats collecting and processing data
from all institutions up to peripheral Sub Centres and even Private health
facilities.
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The computers installed in all the Health Institutions over the State
will be connected to the Server proposed to collocate at the Data Centre of
the State through Kerala State Wide Area Network (KSWAN) / Broad band
Vizhinjam PHC Map
% Full Immunization
Oct 05 - Oct 06
Vellar 105%
Kattukulam 94%
M angalat hukonam 100%
Peringamala 106%
Muttakkad 170%
Venniyur 89%
Kattachalkuzhi 98%
Main Centre 110%
Total Population
fullimm
89
90 - 94
95 - 100
101 - 110
111 - 170
connection of BSNL. The data will be collected to the Central Server on‐line.
Capacity building of the Staff at different levels of Health Dept will be
a by product of HISP implementation. The programme mainly focuses on
equipping all levels of Health staff to enter and manage the application
through intensive trainings across the State. Nearly 12,000 staff belonging to
Health department will be trained under the programme.
Serving as an effective MIS tool, HISP proposes to collect vital inputs
from a variety of health units reporting for Maternal and Child Health
activities and IDSP to present raw data and mainly covert the same into
processed formats for information.
HISP is set to change the face of data reporting in State’s Health
Sector as we switch to digital reporting and management of Health related
data for better information. Getting equipped the Health facilities and
personnel for managing the data as web application through large scale
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trainings covering a spectrum of resources is also a matter of pride to the
State. Ultimately, making use of the same for better monitoring, planning and
decision make will prove vital for development of the State.
The project is expected to finish by 2010.
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School Health Programme
Kerala is the most literate state in India there by the emphasis on
school health is immense since
most of the children attend
school till 12th standard unlike
other states. These students
carry lot of information to their
home and families situated even
in the far‐flung areas. Now,
NRHM has taken a step ahead in
bringing these children under one
net: that is “School Health
Programme”. It is known to all
that today’s children are
tomorrow’s citizen and their
health is paramount concern of
any welfare State. The selected schools will be tested with the first doze of
this scheme by this year and in the coming years; entire schools of the state
will be brought under this umbrella.
There are 14000 government and Aided schools in Kerala including
higher secondary and VHSS with around 50lakh students. No doubt, it is a
massive programme, by which these huge populations get hands on
information on health and hygiene and its necessity. This will reflect in the
future years and they will easily cooperate in building up a better and healthy
NATION. The students spend, twelve years in schools and a continuous
pouring of information on Health and Hygiene is going to reflect in their way
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of life. And this is definitely a good media rather than spending much on
other media. Similarly focus on the health of the students’ at school will
finally yield a healthy, well‐informed and productive generation. The
academic performance of the
children, which is the main focus of
the school authorities, will also
improve and show considerable
changes when the both physical
and mental health of the students
and their coping up skills during
stress is enhanced.
Keeping the above
objective in mind the National
Rural Health Mission Under the
Health Department has joined
hands with the Education
Department in chalking out a School health Programme aiming at the
comprehensive growth and well being of students for a better, well informed
and healthy generation. The stepping‐stone for achieving this goal was on
December 1st 2007 at the Cotton Hill Girls Higher Secondary School
Thiruvananthapuram.
The school health clinic, the first of its kind, was set up at one of the
largest girls’ school in Asia namely Cotton Hill Girls Higher Secondary school
on the 1st of December 2007 and is functioning extremely well with a full
time Doctor and a staff nurse. There has been a tremendous positive
response from the students, teachers and the PTA of the school since a lot of
time and energy and manpower were being wasted for taking children who
are ill to the nearest medical institution.
The main objectives of the School Health Programme are
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Clinical examination: The
primary, preventive and
minor clinical problems are
dealt and referred as per
need by a full time
dedicated JPHN (ANM)
appointed for 5 schools
each. A Health Calendar
with a chart will be set up
in each class to know at a
glance the absenteeism
due to illness.
Counseling: The services of a clinical psychologist/ MSW are present
at regular intervals in a month for general and specific counseling
according to the need. Both Individual and Group counseling would be
conducted. The children needing counseling at individual level will be
decided on voluntary basis and through the recommendation of the
Class Teacher or JPHN.
Health education to the students is conveyed by setting up of health
information charts, placing an anonymous question box and health
messages placed and rotated per class. Frequently asked questions
would be compiled at the end of one year to prepare a booklet so that
it will be useful for the other students. Students deliver a health
message daily after the prayer in the school assembly as “Health
thought of the day”. Taking into consideration an average of 35 weeks
of school 35 health messages will be printed and hung at the class
room. One message per week to be circulated in each class on a
rotation basis so that it is most cost effective. A question box will be
placed in all schools for children to clear their doubts on any topics
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without mentioning their name. The box will be opened once a week
and the answers to the questions will be compiled and put up on the
notice board. The box will be placed in the school Health Club.
Involvement of the parents and teachers: Classes on parenting,
support during academic backwardness in children, organizing
interactive sessions in the class with parents of the students from
different professions during which they will not only tell about their
professions but will also highlight the health risks they face due to
their profession and what steps can be taken to prevent them. This
has a three fold advantage like the students get an orientation about
that profession i.e. career guidance, and to know the health problems
related to a profession and how to prevent it. In addition, a sense of
ownership develops among the parents when they address their own
children’s class. The parents and teachers will also benefit during the
Medical Camps held in the schools twice a year.
Comprehensive health database of students: Formulating a health
database of each and every student of the school with updated
information on their comprehensive health. The new and innovative
“School‐ TC & Health Record” is introduced by the “Arogyakeralam”
(NRHM), Department of Health, Government of Kerala, for the overall
physical, mental and social health development of school children.
Information regarding the comprehensive health of the student is
noted in this Record. The programme is named ‘‐2 to +2’ as it is meant
for children from Pre‐Primary (LKG) to the Higher Secondary levels
(Plus Two). This is also an authentic Transfer Certificate (TC) because
the TC is a part of the Health Record. The Conduct Certificate is also
included in the ““School‐ TC & Health Record.”
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This Record is an authentic and comprehensive one covering general
information, health details of the child and members of his/her family, details
of fitness program, TC & conduct certificate, extracurricular achievements
and List of free text books. This Health record is jointly brought out by the
Departments of Health and NRHM, Education, Local Self Government and
Sports & Youth Affairs with the active participation and support of Parent‐
Teachers’ organizations. As ‘Prevention is better than cure,’ it is best, if
children are made to imbibe healthy habits and attitudes at an early age,
which would help them later in their lives as well. Many of the diseases can
be cured completely if they are diagnosed and treated in the initial stages.
This may prevent its spread& progress, minimizing treatment expenditure
and reducing absenteeism of the students from schools and parents from
their offices.
This Health Record is filled and maintained in schools. Every child will
undergo a Primary Health examination and screening once a year and those
who require further medical treatment will be referred to specialized doctors
in the special medical camps. The details of students who require further
investigations and treatment is promptly entered in the Health Record and
sent for specialized treatment to referral hospitals along with their parents
through a referral card.
The introduction of “School ‐TC & Health Record” is a very significant
step by the State’s Health sector and first of its kind in the country. This
programme is initially introduced in selected Government and Aided schools
in the State and will be scaled up in the coming years.
Monthly reports will be compiled by the JPHN and submitted to DPM
with copy to head office. This data may be used for research.
Frequently asked questions of the students would be compiled every
6months ‐1yr as small booklets “FAQs of students in schools”. Health
education classes and messages circulated can also be compiled at the
year‐end as a school health booklet for students, teachers and
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parents. The database from each district will be compiled centrally
and maintained as a comprehensive health profile of all Government
school going children in the State. The district school health
programme would be jointly monitored by the District Programme
manager, Block medical Officer in charge and District medical Officer.
Keeping the above objectives in mind the school health programme
has been chalked out for all districts covering 1 school per
panchayath/municipality/corporation. In this phase, covering 1100schools in
the first pilot phase option to the local self‐government to fund the same
program in another school in the same panchayath.
The school health Team is planned under the Medical Officer of the
Block CHC or PHC or Taluk Hospital nearest to the school and the team
includes
Health Supervisor
Lady Health Supervisor
Health Inspector
Lady Health Inspector
Junior Health Inspector
Junior Public Health Nurse
Block Arogya coordinator
Ophthalmic Assistant
Teacher Coordinator / Teacher counselor (Male/Female)
PTA representative
ASHA/AWW
Dental Hygienist
Fitness coordinator
The school health team will visit the selected schools at regular intervals and
would assist the JPHN and school authorities in conducting the Health
education Classes, Observance of health Days and Medical Camps. The School
health Team will assist in promoting immunization program, facilitate blood
group checking, measure height, weight, BMI and physical & psychological
health status, re‐organization of school health clubs, conduct referral services
and propagation of health message. Health Education classes in the schools
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and data analysis and compiling with monthly reports to the block
coordinator/CHC Medical Officer In‐charge/DPM.
A full time dedicated JPHN will be appointed for 5schools to facilitate
all the school health activities namely planned health check‐up one day per
week of the selected school, promotion of immunization program, facilitating
blood group checking, measuring height, weight, BMI and physical &
psychological health status using screening questionnaire to be filled by
respective class‐teachers, re‐organization of school health clubs, referral
services and propagation of health message in the schools. One JPHN in
charge of 5 schools in an area and will visit each school once per week.
Medical Camps
One screening camp by the JPHN and a lady Doctor in July followed by a
special medical camp in December/ January including specialist doctors will
be conducted in each selected school. Organizations like Indian academy of
Paediatrics, Indian Medical Association, Indian Dental Association and
Federation of Obstetrics and Gynecologic Society of India have partnered in
the program for health education and health check up of the students free of
cost. Counseling services will be made available according to the need by
hiring a counsellor and also making use of the counselors being hired under
the education department. The disability‐trained teachers of Sarva Siksha
Abhayaan will also be trained in this programme for their contribution in
screening the students. The Block Resource Centre of SSA will be utilized for
further follow up of students with problems along with their parents. Referral
services from the school to the local health facility and follow up counseling
when needed will be provided.
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Activities planned for 2008-09
Printing of School – TC & Health Card
Printing of health education posters and calendars
Appointment of JPHNs (1JPHN/5 schools, 220 JPHNs for 1100 schools)
Identification of schools 1per panchayath/nagarasabha totally to 1100
schools and list of selected schools from Education Department.
GO from education department to the schools for cooperation with
the programme.
Joint meeting of the Health and Education departments.
Formal inauguration of the programme with launching of the Health
Card
Signing of letters with IAP, IMA, IDA and FOGSI.
Development of training modules.
Identification of school health MOs and formation of school health
team.
Training of JPHNs, Teachers, School health team, ASHAs, Block Arogya
Coordinators based on modules developed.
Development of annual schedule of weekly visits, screening and
health education classes in consultation with the school authorities.
Distribution of Health Cards/Calendars/Health messages to the
selected schools and monitoring to see that all cards are filled
according to the guidelines
Revival of the Health clubs of the schools
Regular and timely health education classes in schools selected
initiated by the JPHN/School health Team with involvement of parents
& teachers
Regular monitoring by Block Arogya Coordinators and quarterly field
visits by the DPMs/RCH Officers/ State officers
The cooperation from the Education Department is:
Government Order from Education departments issued to all
schools
o Assign one period per week for health Education Classes
o Conduct 2 camps‐ 1 screening and 1 special medical camp in school
in one academic year
o Have the active cooperation of the PTA and management
o Revive the health Clubs in schools
o Provide space for counseling and to conduct health education
classes
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o Provide all support and cooperation to the JPHN assigned and the
school health Team
o Make provision for the JPHN and Medical Officer to sign
attendance in a special attendance register maintained at the
Principal’s office
o Allow JPHN the use of the computer at school for maintaining data
and records and reporting.
Maintenance of health cards and other IEC materials provided to
the school
The disability trained teachers to be trained in School Health
Programme
To approve the utilization of the Block Resource Centre for
programmes under the School health programme
Cooperation from DPI & DHSE in owning the programme along with
Health Department
This School Health Programme is a unique programme and first of its
kind focusing on inculcating healthy attitudes and habits in the future
generation “Catching Them Young” by making health a part of their
curriculum. The schools are a medium to reach the whole society through the
students and their families. School Health programme not only encompasses
the comprehensive health and academic growth of the students but also
focuses on public health issues like environmental sanitation, source
reduction activities and in general a healthy lifestyle for the general
population. We look forward to a healthier and vibrant Kerala through this
programme.
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Geospatial Rural Health Information
System for Kerala State (G-RHIS)
Geospatial Rural Health Information System (G‐RHIS) is being developed for
Health & Family Welfare Department and Arogyakeralam with a view to
enhance efficiency in health services delivery at various levels especially
peripheral areas to enable monitoring of services, identification of gaps and
decision making.
The G‐RHIS is developed in a Geographic Information Systems platform with
Spatial Information on all government Health Institutions in the State. The
web enabled query G‐RHIS will provide spatial information on the locations of
1,274 Health Institutions including PHCs, BPHCs, CHCs, District hospitals,
Government hospitals, General hospitals, Specialty hospitals, W and C
hospitals, Medical Colleges, and others and also approx. 5,500 Sub Centres in
Kerala.
Spatial themes on Administrative Boundaries, road and drainage networks,
places developed in GIS will be provided in the software.
Advantages of G-RHIS
• The software will facilitate query and identification to provide spatial
and non spatial information of the basic details of Health Institution,
availability of medical, paramedical and other staff, hospital facilities,
equipments and various services.
• Facilitate spatial information on the allocation and availability of
Community Functionaries under NRHM viz Accredited Social Health
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Activist (ASHA), Junior Public Health Nurse (JPHN) and Anganwadi
workers (AWW) along with the names, addresses and phone.
• It will also enable Spatial monitoring of the performance of various
State and National Health Programmes (National Blindness Control
Programme, National Leprosy Eradication Programme, RNTCP, Iodine
Deficiency Diseases Control Programme, FW Programme, NVBDCP,
Universal Immunization Programme, Malaria Control Programme) at
Institutional and area levels with respect to area, population and
time.
• Provide spatial query and information on trends in occurrence of
Communicable diseases with respect to area, population and time.
• Facilitate spatial information on generation of Panchayat Health
Plans, District Action Plans, Ward Health and Sanitation Committees,
Hospital Management Committees.
• Facilitate spatial information on Fund allocation to Sub centres and
expenditure with respect to time and purpose.
• Facilitate spatial information on JSY, amount handed over by hospitals
to various categories of beneficiaries.
• Provide Routing information to Health Institutions.
• The GRHIS software will also provide analytical information in
graphical format besides spatial and non spatial reports all of which
can be printed for use.
• The software is also provided with Zoom‐in, Zoom‐out, Pan, Identify
functions.
Plan for Uploading And Data Entry
All health institutions in the State except Sub centres will be uploaded to
access the G‐RHIS software and data entry will be done at institutional level.
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Present Status
• 5,250 Health Institutions covering eleven districts in the State are
mapped using GPS. Palakkad, Kasargode and Wayanad districts are
being mapped.
• Data structure designing of GRHIS software is completed.
• Data coding is in progress.
• First version of Software to be ready by December 2008
The implementation of G‐RHIS in the State will revolutionize planning and
decision making in Health Sector using Geospatial Technology through
effective performance monitoring of all Health institutions and Health
programmes, facilitating allocation of resources and personnel and various
Epidemiological analysis.
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Information Technology
More than a dozen Scheme/ Programme/ Projects in Health and Family
Welfare Dept in Kerala are backed with Information Technology. They are
HISP, SPARK, MESSAGE, IDEAS, Video Conference, IHMS, School Health,
RSBY, Tele Medicines,
Keralam Website ,etc
Video Conference, Geo‐ spatial Rural HIS, Aarogya
The innovative programmes under the H&FW Dept are explained below
1. Arogyakeralam Website
This Exclusive website is developed for publishing information about the
health and social welfare activities of Govt of Kerala. The website developed
by M/S National Informatic Center(NIC) was recently converted to FOSS (Free
Open Source Software) as per State’ IT Policy. In order to have a
decentralized content Generation, NRHM opted CMD (Content Management
Frame work). This enables content generation at any levels of scheme/
project implementation. The content after its approval can be uploaded to
the site by the generated staff itself, but with access permission of the
administrator. A state owned IT organization, C‐DIT is the agency identified
for the training and support the website
2. SPARK (Service and Payroll Administrative
Repository for Kerala)
SPARK is a web based application software developed by NIC under IT Dept
for the whole State for the Management of Payroll, Human Resources and
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Other payments, of government employees. The monthly routine work, the
salary bill preparation is made simple through SPARK.
Digitization of Service book is the first phase of SPARK
implementation. This is done with help of the Govt Organisation, Keltron, in
Health and Family welfare dept.
In H& FW, 23000 out of the 45000 service books have been digitized.
Implementation work is progressing in association with State IT Dept &
expected to finish before December 2008
Infrastructure development, such as installation of Computers,
Printers, Connectivity, Network & power wiring in about 2000 health
institution is the biggest task connected to implementation of SPARK. Giving
training to all the Self Drawing Officers and staffs in establishment section is
the next biggest task.
SPARK is integrated with TIS (Treasury Information Software) aiming to e‐
transaction of salary and other payments.
3. MESSAGE (Modern Electronic Systems and Services
Agility & Governance in Enterprises)
MESSAGE is a web based application developed by NIC for state IT Dept , for
Less‐ paper, Electronic file flow management for Govt Offices. This
Transparent file management , as it is web based broaden access to the
office work. Any time /anywhere file processing results fast file movement.
Searching for the file usually result time loss. The file search and Monitoring
made simple in MESSAGE. Public search is also possible which support Right
to Information rules.
Training to staff is over, and NRHM is waiting for the action of IT Mission for
implementation of MESSAGE.
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4. IDEAS (Information and Data Exchange Advanced
System)
IDEAS aims the Service Delivery to Citizen. This Web based application
gives information about the file status to staff and public through web
search. It contains modules such as tapal entry, file transit, meeting
management etc.
IDEAS is implemented in Health and Family Welfare Dept in Govt
Secretariat and running in full swing. As it runs in other Govt Depts also the
file follow up became easy. Provision to register the file no enables delivery
of file status through e‐mail and SMS at free of cost.
5. IHMS (Internal Hospital Management System)
IHMS is an application software for management of information within the
Hospital like OP& IP management, generating history of treatment,
communicable diseases, etc. It is implemented and running successfully in
Trivandrum Medical College and will be replicated in all other Medical
Colleges and major hospitals, subject to approval of Govt.
6.RSBY (Rashtriya Swastic Bima Yojana)
The Scheme envisages better health coverage to the public, especially the
BPL citizen. It enable freedom to patient to approach any empanelled
Hospitals, including Govt Hospital, for better treatment. Cashless treatment,
Smart Card based operation, etc are envisaged in the scheme.
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Software package for managing the insurance part, at Hospital level is under
Development . Bonus of the scheme is that Govt Hospital facility needs to be
upgraded to bring them to IPHS Standard for empanelment.
5. AASTHI
It is a Web based inventory management information system, which target to
maintain the statewide IT inventories. Hardware and OS (Operating Software)
protection is the added advantage of the programme. Preparation of
installation and commissioning certificate, fault reporting , etc are the
modules available with the software. Health dept will implement it in
association with the IT Dept.
6. Video Conference facility
Conferences and meetings are necessity of the department like H&FW,
handling sensitive areas related to Health services. In order to minimize the
strain and cost in participating and conducting the meetings/ conferences,
Video Conference Facility is a solution. NRHM took the initiatives to connect
all the District Centres through Video Conference Facility. Equipments are
ISDN based also so that worldwide conference will be possible.
One Centre set up at ' XANADU ' Trivandrum and another Centre is under
set up at Kerala NRHM HQ. Centres under NRHM will be linked with the
existing state facility under IT Dept
The VC Facility could support Tele Medicine also.
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Three Dimensional Interactive Digital
Anatomy: 3 D INDIANA – An NRHM Initiative
Background
Towards making MBBS studies more interactive and practical oriented
NRHM is now contemplating on putting into use three dimensional
interactive digital anatomy model software which has been developed by a
doctor at an Alappuzha clinic, Jerome Kalister, has with the help of a 15
member team. This software has been approved by Anatomical Society of
India. This software has been submitted before Medical Council of India.
3 D Indiana, an interactive digital anatomy model of the human body,
could help Medical students. 3D Indiana is an anatomy aid to medicos not a
substitute for a cadaver. Indiana, an acronym for
interactive digital anatomy, will help the user
navigate the inside of the virtual human body and
study internal organs, their location,
interconnection, size and texture.
Headed by Kalister, a team of medical
experts, software engineers and structural
engineers has been working on the project for
years, using 10 computer systems. Presently
students get to see a cadaver in the first year of
MBBS only. Second and third year, there’s only a
fleeting glance because the specimen would have
been dismembered in the first year itself. So
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medicos spend hours with diagrams and pictures instead of a cadaver. 3D
Indiana is a replica of the human with every organ, bone, muscle, nerve and
blood vessel. 3D Indiana will really help medical students, doctors, surgeons,
medical researchers.
Specialties of 3D Indiana
In this software each and every structure in the human body is
digitally sculpted and deployed in its true anatomical
positions, based on CTs, MRIs, real time dissections
and authentic text books. As per the brochure of the
software, 3 D Indiana is a fully navigable and
delightfully user‐friendly 3D environment lets the user
cruise amongst the rich details of the body. Every
structure is constructed with its ultimate details and
can be rotated, hidden, zoomed, made transparent,
grouped and viewed in either their systemic or
regional
orientations.
To begin with, this virtual interactive medium of the human body is
one of a kind in the arena of modern day, medical teaching aids marked by its
sophisticated and state of art character.
It offers a multidimensional view of the remotest of areas of the
human anatomical framework, equipped to zoom in on the smallest of
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structure with precision and clarity. Richly detailed, visually resplendent,
anatomically precise and spatially accurate, it affords the most
comprehensive insight into the human body.
At the undergraduate level, emphasis is on dissecting on real cadavers
considering that the sight, smell, touch and feel of real bodies, their various
organs, bones, cartilages and other structure is very much integral and
fundamental to the learning of the human body. This software would be
useful as a complementary learning tool for undergraduates considering the
visual impact & possibilities of the software.
As the software presupposes that the user should have a prior
thorough understanding of human anatomy, which in fact can only be
accrued through meticulous real time dissections on the cadaver, it could
serve as an excellent aid for research and advanced learning.
3 D INDIANA in its basic form is an ultimate reference in anatomy. It is
a powerful tool in teaching and leaning anatomy. It presents itself as a
fully navigable full body where each and every structure in the body is
oriented in its true anatomical position.
Virtual surgical with a game engine added it can be used to stimulate
and give training on any surgical procedure.
With a little programming normal body responses could be elicited
from the virtual body hopefully enabling clinical trials of drugs and
chemicals in it.
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The evolution of pathological process and body response to it can be
programme into 3 D Indiana.
Animated surgeries – hundreds of surgical procedures may be
simulated by animation on the 3d Indiana.
Combined with volumetric anatomy (a new concept in anatomy,
proposed by 3dindiana team, that gives a mathematical system of
location of each and every point in the 3d volume of the body‐refer
www.volumetricanatomy.com) it becomes an extremely accurate
virtual body from which measurements could be taken and be used
for multitudes of research purposes including planning of new surgical
access etc., etc.
3D Interactive Digital Anatomy is a scientifically accurate and
artistically perfect 3D rendition of the human body in its ultimate
detail. It is the most detailed and delightfully user friendly software
designed for assisting the study, teaching and research on human
anatomy. Every named structure in the body is digitally sculpted in its
richest details and deployed in their true anatomical positions in the
body based on CTs, MRIs real time dissections and authentic text
books.
Touch any structure with the mouse, its name is displayed then and
there. It can be isolated, zoomed, rotated so as to peruse it from any
angle. It can be grouped with any number of structures to view their
inter‐relations. Any one of them may be made transparent so that the
structures underneath is visible through.
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It lets you take any number of sections in any plane of your fancy. Any
piece can be disarticulated and put back fro any number of times. And
of course it is a fat free; yielding itself to a clutter less, clear view of
even the smallest structure.
The programmed index and annotations are quite cool. A user may
cruise amongst the various structures in the fully navigable body or
may follow a dissection mode that guides him through the minute
details
Putting the software into effective use
Sensing the importance of concept, after detailed deliberations with
the team who developed this, NRHM suggested the introduction of the
software in the Government Medical Colleges which could be introduced as a
trial in a medical college before the Medical Council of India approves it for
use in colleges throughout the country. A demonstration of the software has
been held at Medical College, Alappuzha. The field study of 3D Indiana Digital
interactive software, a unique creation by Dr. Jerome Kalister was held in the
presence of experts from the discipline of Anatomy. The NRHM has
constituted a committee which is now contemplating on distributing the
software to all Medical Colleges based on the field study report. The
committee will negotiate with the software company for supplying it at a
subsidized rate for the Government medical colleges.
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COMPULSORY RURAL SERVICE:
BRIDGING CRITICAL GAP IN
MANPOWER: DIFFICULT RURAL
AREA ALLOWANCES
Background
From the year 1998 onwards, a provision has been incorporated in
the prospectus for admission to the MBBS course to the effect that those
students who successfully complete MBBS course from Govt. Medical
Colleges in Kerala are liable to serve in rural areas for a period of 3 years, if
required by the govt. In the prospectus it is further stipulated that out of the
3 years, one year service should be in Difficult Rural Areas. Likewise, from
the year 2004 onwards the prospectus for admission to the Medical PG
course specifies that those students who successfully complete PG course
from Government Medical Colleges other than the All India Quota and
Government service doctors are liable to serve Health Services / Medical
Education Services for a period of 2 years, if required by the Government.
Clause XII (c) provision of prospectus for Admission to Medical PG Degree/
DNB/ Diploma courses 2004 stipulates that the applicants selected to PG
course will have to execute a bond at the time of joining the course to the
effect that they will serve the Government for 2 years after completion of the
course, if the Government requires so.
Towards bridging the critical gap
While the availability of medical personnel was an easy process in
some districts, the same was a laborious one in some backward districts.
Consequently, the Government decided to invoke the clause of compulsory
rural services from the year 2007 onwards for doctors studying the various
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government Medical Colleges in the State. They were appointed in various
health care institutions in the state with priority to backward districts. MBBS
doctors have to serve in health care institutions for a period of 1 year, PG
diploma doctors to serve for 1 year and PG Degree doctors for two years.
Even though objections were raised from several quarters on the compulsory
rural service, the government was assertive in providing medical care to the
rural poor especially backward districts. Government ensured that all the
doctors worked in the health institutions for the prescribed period.
Later, government based on various orders decided to extend the
conditions of compulsory rural services to doctors who passed out from self
financing colleges and cooperative medical colleges in government seats, All
India Quota candidates etc.
Outcome
The best possible outcomes as a result of appointment of doctors are
summarized as follows.
v. More institutions provided with 24 X 7
services
vi. OP increased
400000
350000
300000
Increase in O.P
vii.
OP time in selected institutions extended
from 8 AM to 8 PM.
250000
200000
150000
No:s.
viii.
Increase of deliveries as a result of increase
of patients from private to Government
health care institutions
100000
50000
0
2005-06 2006-07 2007-08
In addition, very few specialists are working in
Medical Colleges on bonded obligation under NRHM.
Increased O.P in Peripheral hospitals owing to increased manpower
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This scheme not only bridged the critical gap but also ensured that all
the MBBS students are given a chance to work in the Government Hospitals
to test and experienced their knowledge acquired from the colleges. NRHM
is offering a pay package of Rs. 15000/‐ for compulsory rural service and Rs.
20,000/‐ to those who are posted to Difficult to Rural Areas.
Call allowance
Apart from this Government specialists will be eligible for call allowance
between 8 PM to 8 AM (subject to certain terms and conditions) for
rendering additional work during night hours while NOT on call duty as
detailed below.
For each call Rs.100
For Gynecologist Rs.200 – Normal delivery
Rs.500 – Assisted delivery
Rs.1000 – Cesarean section / Emergency
hysterotomy/hysterctomy
For Surgeon / Ophthalmic / ENT / Ortho
Rs.200 – minor surgeries
Rs.500 – Major surgeries
For Anesthetist Rs.1000 per case for general & spinal anaesthesia and
long procedures
Rs.500 for minor procedures under block anaesthesia
However, Government Doctors can be appointed on additional shift duty
(3 PM to 8 PM and 8 PM to 8 AM) if there is absolute necessity. This is to be
decided by a committee consisting of District Medical Officer (Health), RCH
Officer and District Program Manager based on request from the local
Panchayat.
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The details of doctors working in health institutions under CRS as on October
01, 2008 are as follows.
Sl.
Compulsory rural Bonded PG Diploma /
District
No
service‐MBBS
Degree
1 Trivandrum 27 4
2 Kollam 27 5
3 Pathanamthitta 13 1
4 Alappuzha 42 0
5 Kottayam 17 1
6 Idukki 17 0
7 Ernakulam 49 2
8 Thrissur 40 4
9 Palakkad 28 6
10 Malappuram 27 2
11 Kozhikode 13 6
12 Wayanad 22 0
13 Kannur 43 3
14 Kasaragod 27 0
Total 392 34
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Initiatives on Infection Control at
Medical College Hospital, Trivandrum
The context
A hospital is a place where sick people come mainly for treatment
and investigation owing to which infectious diseases are constantly in
transition; new diseases are emerging and older diseases are re‐emerging. It
had been noted that in Medical Colleges, over the past few years, there have
been increased outbreaks of diseases that were earlier controlled. The
reasons for these outbreaks are multiple and complex‐some of them being
rapid population growth, expansion of population in to the remote areas,
environmental degradation, improved transportation leading to easier spread
of diseases, climate change, inadequate or deteriorating public health
infrastructure, and poor infection‐control& infection prevention practices.
In general, infections that occur more than 48‐72 hours after
admission and within 10 days after discharge are considered to be hospital
acquired infections or nosocomial infections. Hospitalized patients are more
vulnerable to infection than other healthy individuals, since the host is
immuno suppressed and the environment is conducive to growth of resistant
bacteria. Moreover the transmission of these bacteria is very much facilitated
by the activities of the healthcare workers and other patients. Some times
there is a large increase in the commonly occurring types of infections or
appearance of a new infection for e.g., Methicill‐ in resistant staphylococcus
aureus (MRSA) in the Surgery/Orthopedics ward
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The need to control
Approximately10% of hospitalized patients develops infection every
year. In developing countries this may go up to 25%. One third of these
infections are preventable. Diagnosing and treating there infections puts
intense pressure on the health care service and health budget. In short,
healthcare facilities can be potential setting for transmission of diseases‐The
reasons being,
large no of persons with infections come to the healthcare
setting for services
services are provided in limited physical space
Providers of health care services are exposed to various
types of infections.
Availability of limited number of
instruments/equipments/essentials.
Hence proper precautions in the health care facilities are pertinent for
the prevention of nosocomical infections.
Persons at risk
All personnel in the healthcare setup who come in contact with
patients or their investigative procedures are at potential risk of developing
nosocomial infections. This includes
o Doctors
o Nurses
o Lab Technicians
o Attenders
o Nursing assistants
o Other paramedical
staff,
o Patients
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o Bystanders &the community.
Measures initiated to prevent infection in Medical College Hospital,
Thiruvananthapuram
Medical College Hospital, Thiruvananthapuram is a premier tertiary care
teaching institution with 1600 in –patients and 22 different specialties. On an
average the referral O.P comes to about 450 new cases and 1000 review
cases per day. New O.P in causality comes to 600 per day and review cases 70
per day.
Following an outbreak of infections in early 2007, the Infection
Control Committee of Medical College Hospital, Thiruvananthapuram
decided to implement a slew of measures to control the infection which
included mainly the training component and continued awareness and
ensuring adherence to standard protocol on Infection Prevention Practices
Training to all level of staff Infection prevention was organized with the
following objectives:
Prevention of infection within and outside the hospital
To bring about a positive change in the attitude and behaviour
of health care providers with regard to infection prevention
practices.
A Handbook for the participants was prepared in the vernacular
language by the State PEID Cell based on the WHO guidelines. The
participants were trained in:
1. Hand wash& use of gloves
2. Surgical hand scrub& use of protective attires.
3. Processing of instruments &their storage
4. House keeping and maintaining a sterile field.
5. Use & disposal of Sharps
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6. Waste Disposal.
Eminent faculties from various hospitals handled the sessions and around
1650 participants were trained in different batches covering 56 days
The State PEID Cell is now in the process of preparing posters for
wards and theatre on standard Precautions and developing a Protocol on
Infection Prevention Practices for Medical College Hospital, Trivandrum
based on WHO guidelines 2003.
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Ensuring quality supply of medicines in
a transparent and efficient way- the
KMSCL initiative
The beginning
In order to make available quality medicines, supplies, equipments &
diagnoistic services to the poorest of poor of the population in the state,
Government of Kerala has constituted Kerala Medical Services Corporation
Ltd. (KMSCL) as a fully Government owned company with authorized share
capital of Rs. Ten Crore with its headquarters in Thiruvananthapuram. The
company got registered on 28.12.2007 with the Health Secretary has its
Chairman and Special Secretary (Health), State Mission Director (NRHM),
Director of Health Services, Director of Medical Education, Addl. Secretary
(Finance), an expert in Pharmaceutical Sciences nominated by Government
and the Managing Director, KMSCL are as Directors.
Objectives of the Corporation
The main objectives of the Corporation are the following.
1. To implement a transparent system for
procurement, storage and distribution of
quality drugs, supplies, equipments etc.
required for the hospitals at reasonable
competitive price.
2. To ensure adequate savings in the drug
budget by efficient forecasting system.
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3. To avoid loss due to expiry of drugs and medical items and to optimize
accountability at all levels.
4. To achieve constant quality control monitoring of drugs and medical
items by establishing adequate quality assurance measures.
5. To adopt a streamlined procedure for procurement, storage and
distribution through IT enabled services.
6. To improve infrastructure of the existing Drug Warehouse in District.
7. To provide diagnostic and other miscellaneous services to Government
health care institutions.
8. To enhance Public Health Care Service delivery by providing excellent
management control and constant vigil.
The Corporation started functioning with effect from 1st April, 2008
by establishing District Drug Warehouses in all 14 districts in the State to
cater the needs of 1316 Health Care Institutions under the State Health
Services Department and 16 institutions under six Government Medical
Colleges in the State.
Procurement of Medicines for Hospitals
Government have constituted a Technical Committee (Expert
Committee) in the Corporation consisting of Director of Health Services,
Director of Medical Education, State Mission Director (NRHM), Drugs
Controller, Senior Doctors nominated by DHS & DME and an expert in
Pharmaceutical Sciences to prepare the list of medicines to be procured by
Corporation. On the basis of the recommendations of the Technical
Committee, Corporation has finalized the List of Essential Drug which consist
of 527 items of generic medicines, sutures, surgical and other items. Based
on the annual requirement of medicines & supplies furnished by the DHS
and DME, Corporation floated its first tender on 30.01.2008 in which a record
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number of 173 reputed companies from all over the country participated.
The tender processing were done in a transparent manner by publishing all
details in its official web site www.arogyakeralam.gov.in in due course
giving no chance of complaints from the bidders as well as the general public.
Factory facilities of 20 new firms, who had participated in the tender
for the first time in the state, were inspected by the team of inspectors
appointed by the Corporation and six firms were rejected as they were not
complying Good Manufacturing Practices (GMP) stipulated under the Drugs
and Cosmetic Rules, 1945.
Corporation finalized tenders with 103 firms, including State owned
Kerala State Drugs and Pharmaceuticals Ltd. (KSDPL), for supply of medicines
for the year 2008‐09 at a competitive rate. So far Corporation has issued
purchase orders for procurement of medicines worth Rs.97.08 lakhs to
ensure uninterrupted supply of all essential items.
Ensuring Quality
Each and every batch of Drug procured by the Corporation is being
tested through Empanelled Analytical Laboratories to ensure the prescribed
standards before release to hospitals. Corporation has empanelled Eleven
(11) approved laboratories from all over India for testing the samples
collected from the delivery received in the various District Drug Warehouses
of the Corporation. Government Drug Testing Laboratory,
Thiruvananthapuram is the appellate authority in the case of disputes
regarding quality testing.
Samples of supplies in each batch are chosen at the point of supply or
distribution/ storage points for testing. Payment to the suppliers is released
only upon receipt of quality analysis report from laboratories. Samples which
do not meet quality requirements are rejected, treating them as Not Of
Standard quality. So far Corporation has sent 2,809 samples of medicines for
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analysis and obtained results for 2,023 samples. Sixteen samples have been
declared as Not Of Standard quality.
Distribution to Hospitals
The medicines received from the suppliers are collected in the District
Drug Warehouses of the Corporation for delivery to hospital as per their
requirements. The delivery schedule for various categories of hospitals has
been designed as follows.
Medical College Institutions ‐ Thrice in a
month
District /General Hospital ‐ Twice in a month
Taluk Hospitals ‐ Once in a month
BPHC/ CHC/ PHC ‐ Once in 2 months
Mini PHC ‐ Once in 3 months
In addition to this emergency supplies are also given to hospitals as
per necessity. For each hospital budget allotment is provided for purchase
of medicines from the Corporation and a Pass book is also maintained to
record the transactions.
All the District Drug Warehouses and Head Office of the Corporation
are connected through online network by a data processing system named as
Drug Distribution Management System (DDMS) for monitoring the stock
position, details of samples collected for testing and to watch the
performance of suppliers, etc.
Other Projects under processing
Apart from supplying medicines, surgical and supplies to hospitals,
Corporation has initiated action for supply of coats, beds, bed sheets etc. for
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the hospitals. Action has also taken for fixing rate contract for supply of
consumables and disposables, Reagents and Chemicals, X‐ray items, Linen,
Medical gases, Glass wares, Dental Materials and specialized surgical and
sutures required for the hospitals.
Corporation is supplying medicines to
hospitals which are availing funds provided by
the Local Self Governments for purchase of
medicines.
Corporation has start action for supply of
32,200 ICDS kits consisting of 10 items of
medicines as per the requirement of the Sate
Social Welfare Department as per the Central Sector Scheme.
Negotiations are on with the State Animal Husbandry Department for
the procurement and supply of around 100 items of veterinary medicines.
Corporation is also supplying certain medicines to the Kerala State
AIDS Control Society and the State ESI Department.
Advantages
Disadvantages of earlier system
Lack of inventorisation of the
entire system.
No centralised computer
network system to monitor and
coordinate the procurement and
distribution functions.
Unscientific indenting, and
lack of proper quality check
Non‐adherence of First expiry
First out (FEFO) system.
Excess administration costs,
Advantages of the present
system
Procure and stock quality
drugs and supplies
Follow essential drug
guideline of WHO
Ensure ready availability of all
essential drugs and supplies
throughout the state, in proper
quality.
Ensure adequate savings in
Drug Budget by efficient
forecasting system.
Avoid loss of drugs owing to
expiry.
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no market standing of products.
Chances of duplication of
invoices.
Manipulation of quantity,
higher procurement costs.
Agents acting as cartel,
bargaining for higher prices, &
dictating terms.
Poor delivery system to the
peripheral hospitals
Constant quality control
monitoring of drugs.
Enhance public service by
providing
excellent
management control.
Adopt a streamlined procedure
for procurement, storage and
distribution
Medicines and Supplies are procured at a reasonable and competitive rate
much lower than the market rate. The following are some of the examples.
Sl. No. Name of the Drug KMSCL
Rate*
Market
Rate*
1 Isosorbide Dinetrate Tab 6.90 89.00
2 Nifedipine Tab 6.60 40.00
3 Atenalol Tab 12.25 40.00
4 Ciprofloxacin Tab 83.00 120.00
5 Amoxycillin Dispersible Tab 34.99 60.00
6 Amoxycillin Cap 74.05 120.00
7 Ampicillin Cap 68.34 122.00
8 Ranitidine Tab 19.60 32.00
9 Insulin Human Rapid Acting 55.85 120.00
10 Anti‐Snake venom 140.04 333.00
11 Anti‐Rabies Vaccine 205.70 316.00
12 Paracetamol Tab 13.68 24.00
*Rate for 100 tablets
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Ensures timely and uninterrupted supply of quality medicines,
surgicals, sutures etc. to hospitals.
Significant reductions in procurement cost of medicines and there by
savings in budgetary allotment.
Better inventory control.
Pre‐decided delivery schedule to hospitals ensures regular supply of
medicines and reduces rush in District Drug Warehouses.
Computerized Drug Distribution Management System (DDMS) enables
stock monitoring, re‐ordering and order placing of items easier.
Batch wise quality testing of medicines at the point of delivery
ensures quality assurance of medicines supplied to hospitals.
Suppliers’ bill passing and payments become prompt and regular.
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Improving efficiency of Hospitals- the
decentralized way
The context
People’s representatives and common population having a stake on
the development of their health institutions is of great significance in this era
of community led planning and monitoring. The true essence of this concept
was captured through a public contact programme (Janasamparkaparipadi)
organised at the districts led by the Minister for Health and Social Welfare
and Coordinated by NRHM. The initiative titled ‘janasamparkaparipadi‐2008’
covered the districts of Wayanad, Kannur and Kasaragode districts of the
state on 23 rd , 24 th and 25 th of October 2008. The rest of the districts will be
covered the end of December 2008. The aim of the programme is to get
suggestions and opinions from the peoples’ representatives, NGOs and the
general public towards improving the functioning of the hospitals and to
chart out a concrete plan of action based on the suggestions. The
stakeholders were asked to submit suggestions/grievances to their nearest
health institutions till two days before the programme day.
The process
The programme had a preparatory and an action phase. A slew of
preparatory activities were done as detailed below:
• Financial review of the districts was done the following heads
were reviewed:
• Expenditure against funds given under RCH‐II/Mission Flexible
Pool and Immunization
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• Expenditure against funds devolved for HMS/AMG/Untied funds.
• Expediting utilization of funds for HMS/AMG/Untied funds.
• JSY Funds utilization
• Progress of CHC up‐gradation
Detailed report on the progress of the civil works in institutions and layout
plans were prepared.
The public were informed about the campaign through:
• Public Address system
• Road show
• Bit notices to be distributed through ASHA volunteers
• Through TV as scroll messages
• Spot news through FM/Radio
• Press releases/news through Print and electronic media
• Banners/posters to be placed at major public places/offices/health
institutions
• Notice inviting grievances exhibited in all Primary Level Health
Institutions
• SMS to mobiles through a special news portal and major mobile
service providers in the state
Publicity was given for 5 days prior to the programme date and the
grievances received were consolidated, classified based on the nature.
The needs for the requested equipment from the Institutions were analyzed
with regard to:
• The availability of space for all the big (physically) equipment.
• The availability of specialist to operate sophisticated equipments.
• The input electrical supply for high load equipments.
• the patient load
• availability of existing similar equipments and its condition
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• range and capacity of machine suitable to the institution
On the Programme day
Public relations activities
• ASHA volunteers and the health staff guided the gathering
• Kiosk on NRHM was put up at the entrance
• Banners put up at different locations at the campaign site
• Leaflets on various health topics and NRHM distributed
• Ventriloquism/monkey shows/puppet shows organized at different
locations of the venue
• Wide Media coverage was given
• Media publicity through PIB and dept. of field publicity
• Reporting and documenting the event
• Awareness films/video spots through Plasma TV
• A big balloon with message 'jana samparka paripadi' flown at the
campaign site towards distant visibility of the venue
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The outcome
The sorted out suggestions and
grievances were sorted out discussed
and solutions suggested with a definite
action plan for implementation. Later in
the day review of NRHM implementation
in the districts was carried out. A press
conference was organized wherein the
action plan was detailed out.
Feedback from the participants (25 samples) were collected and analysed. As
shown in the graph below majority who participated
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State Disease Control and Monitoring
Cell (SDCMC): an innovative initiative
towards the control of communicable
diseases
The background
Emergence and resurgence of vector borne diseases, including Chikungunya,
has become a serious threat to Kerala – to the people and to the health care
management system. Since May‐June 2006, Kerala has reported outbreaks of
Chikungunya in many localities of Alappuzha, Kozhikode, and Trivandrum,
Ernakulam, Kottayam and Pathanamthitta districts. This has resulted not only
in health cost but also economic loss due to the number of man days lost.
NRHM Kerala has been working on possible options to prevent Chikungunya
and other vector borne diseases, on a war footing basis and has formed the
State Disease Control and Monitoring Cell (SDCMC) to coordinate various
interventions in disease control and management.
Role of SDCMC
SDCMC will be actively involved in the disease surveillance, monitoring and
control activities and at the same time coordinating the efforts of a wide
variety of stakeholders towards the prevention of outbreaks in the State. In
addition to collaborating with these stakeholders for the successful
implementation of the programme, SDCMC is also supporting various
projects being implemented to strengthen the disease control activities all
through the State. An action plan has already been prepared for the year
2008. A multifaceted approach with active participation from all the
stakeholders will help in preventing the catastrophic effects of the outbreak.
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The primary function of SDCMC is to act as the coordinating body between
these different stakeholders and to play a central role in the development
and implementation of disease control and monitoring activities in the state.
Standard Management Protocol developed
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Stakeholders of SDCMC
NRHM
KGMOA
IMA
KGMCT
HLFPPT
NICD
SDCMC
NIV
KERALA
UNIT
DHS
KSIVID
DME
Addl. DHS (PH)
Entomology teams
IDSP
NVBDCP
14 Districts
DMO (H)
District Malaria Officer
DPMS
District Level VC teams
State PEID cell
Regional PEID cell
Medical colleges
Government
Private
Cooperative
KGMOA ‐ Kerala Government Medical Officers Associations
KGMCT ‐ Kerala Government Medical College Teachers Association
NICD ‐ National Institute of Communicable Diseases
KSIVD ‐ Kerala State Institute of Virology Diseases
HLFPPT ‐ Hindustan Latex Family Planning Promotion Trust
DHS‐ Directorate of Health Services
DME ‐ Directorate of Medical Education
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The core strategies in addressing vector borne diseases, as specified by the
State Disease Control and Monitoring Cell (SDCMC) are
Strengthening of the surveillance system.
Integrated vector management.
Enhanced monitoring and supervision
Key supporting interventions planned for disease control and monitoring are
1. Capacity building
2. Behaviour change communication
3. Intersectoral collaboration
Activities of SDCMC at a glance
Daily Communicable Disease Reporting From All District
Headquarters/ Medical Colleges and consolidation
Daily report of Communicable Diseases in the state sent to Health
Minister, Secretary (H), Mission Director, DHS, DME via email and SMS
by 6 pm
Strengthening Of Surveillance System through Medical Colleges With
the Support Of State & Regional PEID Cells
Local Media Scanning
Visual Media
Print Media
24 X 7 Reporting & Monitoring
Lab Surveillance through NIV Field Unit, Alappuzha
Students engaging in source reduction activities
KSIVD (Kerala State Institute of Infectious and Viral Diseases),
Alappuzha, Microbiology Depts, Medical Colleges
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Developed and Implemented State and Block Level Action Plan for
the Control Of Chikungunya/ Dengue.
Developed Standard Management Protocol for Suspected
Chikungunya
Organizing Workshops on Monitoring And Supervision Strategies for
Prevention & Control Of Chikungunya, Dengue in Kerala
Integrated Vector Management: Developed Handbook on Integrated
Vector Management for Health Workers.
Pre‐monsoon Aedes Survey in the State
Intersectoral Coordintation With LSGIs
ToT Of ASHA Workers and volunteers on Source Reduction Activities
and and Observation of Dry Days.
Undertaking Research/studies
Feepok Study‐ Chikungunya Sequlae Study.
Situational Analysis of Chikungunya Epidemic In Kasargode District.
Study On Increasing Number Of Hepatitis B Cases From
Pathanamthitta District.
Source reduction activities
Epidemic Response
Started 24 X 7 Epidemic Control Cell and field stations in Kasargode to
control the outbreak
Held interstate Meeting‐ Kerala, Karnataka, Tamilnadu.
Held Inter district Meeting‐ Kasargode, Kannur, Dakshin Kannada,
Kudagu
Started Border Fever Depots
Organised Medical Camps‐ Allopathy, Ayurveda And Homoeo
Intensified Source Reduction By Arogyarakshak (Volunteers)
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BCC Initiatives
Focused Campaign using a slogan and campaign colour: Nithantha
Jagratha Veeduthorum
Nodal Agency: Hindustan Latex Family Planning Promotion Trust
Campaign initiated In Northern Districts
Set of IEC tools developed
Target specific leaflets for awareness generation amongst the public and students
Posters developed for awareness creation
142

Platforms for Sharing and learning‐ Organizing workshops
A. National Workshop on Emerging Fevers with Focus on Chikungunya
The need
India witnessed a massive outbreak of Chikungunya in 2006 and 2007.
Kerala is reported to be one of the worst affected states in India during the
2007 epidemic. Though the health care community could address the
epidemic to an extent, this called for an effective action strategy to contain
the outbreak. The National Workshop on Emerging Fevers with Focus on
Chikungunya is an offspring of such a conscious and responsible thought.
Objectives of the workshop
To act as a forum for sharing
National/ International
experiences in containing
emerging fevers.
To provide opportunities for
deliberations of studies done
through oral and poster
presentations
Presentation and finalization of an action plan for the state in the
areas of
a. Prevention and control
b. Management
c. Follow‐up
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Major stakeholders of the workshop
Govt. of Kerala
National Rural Health Mission, Kerala
Directorate of Health Services
Directorate of Medical Education
Kerala Govt. Medical College Teachers Association
Kerala Govt. Medical Officers Association
Indian Medical Association
AYUSH Departments
Two pre workshop meetings were held to sensitize major stakeholders about
the forthcoming national workshop and ensure their participation in the
workshop, mobilize maximum number of research papers on Chikungunya
and emerging fevers and to prepare a draft action plan for the state. The
meetings focused on the limitations and gaps in the current practice and
threw light into strategies to strengthen the efforts to contain emerging
fevers.
The process and outcome
The national workshop was attended by 450 delegates from across the
country. Scientific sessions deliberated on the national scenario on the
Chikungunya epidemic and measures taken to contain the epidemic;
experiences of various states in the country; preventive and management
strategies were discussed in detail. The key aspects of preventive strategies
of the Kerala; state action plan for containing emerging fevers evolved in the
pre workshop meetings and the time bound strategic plan for the prevention
of Chikungunya and other emerging fevers; the management strategies. The
workshop concluded with the finalization of an action plan for the state in the
areas of prevention, management and follow‐up.
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B. Workshop on Intra Dermal Rabies Vaccination
The need
Rabies is a major public health issue in many parts of the world
causing an estimated 55,000 deaths every year. India suffers a casualty of
about 22,000 deaths per year due to rabies and in Kerala Rabies claims about
30‐40 lives per year. Timely and appropriate post exposure prophylaxis can
prevent deaths in this one hundred percent fatal disease. Approximately 3
million people receive post exposure prophylaxis in India. Nervous Tissue
Vaccine (NTV) has been replaced by more safe and effective Cell Culture
Vaccines (CCVs) in India since December 2004. WHO estimates that a full
course of Post Exposure Prophylaxis (PEP) requires 31 days of wages for an
Asian citizen thereby making it unaffordable to many. Intradermal post
exposure regimen has been approved by WHO as early as in 1992 and has
now undergone extensive evaluations in India. It is found to be equally
effective and at the same time cost effective (60‐70% cost reduction). This
regimen has been approved by the Govt. of India in 2006. NICD, Delhi has
formulated and published guidelines for intradermal vaccination for Govt. of
India and is already being implemented in states like Uttar Pradesh, Orissa,
Andhra Pradesh, Karnataka, West Bengal, Tamilnadu and Uttaranchal.
Proceedings of the workshop
In this context a workshop on
developing guidelines for IDRV
(Intra Dermal Rabies Vaccine)
in Kerala was held during the
month of September 2008. The
workshop was enriched by the
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presence of experts of International and National repute from within and
outside the state. Faculties from 8 states, who had already implemented the
IDRV regimen in their states, shared their experiences in the workshop. The
workshop was attended by key stakeholders from all over the state. There
were representatives from Health Services Department, Medical Education
Department and also Service Unions in Health Services. More than 320
delegates attended the workshop during which the faculties shared their
experiences regarding IDRV implementation in their states. The workshop
was followed by a core group meeting on the next day during which the
National Guidelines put forward by NICD in 2007 was discussed in detail and
was adopted to suit Kerala scenario. The core group had the presence of
nearly 50 experts from within and outside the state.
Outcome
There were 3 post workshop core group meetings as a result of which the
draft guidelines for implementation of IDRV and draft operational guidelines
have been prepared. It was decided to implement IDRV in a planned phase in
the state with the support of Kerala Medical Services Corporation Ltd
(KMSCL). As the first step IDRV will be implemented in the Anti Rabies Clinics
attached to the 5 Govt. Medical Colleges in the state and also General
Hospital, Thiruvananthapuram. It is also planned to impart training to the
stakeholders at three levels‐ National level training from Hyderabad, State
level training and District level training.
At present Kerala is following the IM regimen for Anti rabies vaccination and
only the bite victims belonging to BPL category are given the costly IM
treatment free of cost that too subject to availability. With the adoption of ID
regimen we will be able to cater to almost five times the patient load with
the present quantity of vaccine. This will surely help in improving the
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acceptability of the more cost effective IDRV regimen thereby increasing the
accessibility of the common man for treatment against this deadly disease.
The workshop IDRV KERALA 2008 is believed to be the first step in the
direction of a crucial policy change by Govt. of Kerala.
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COMPREHENSIVE HEALTH
INSURANCE SCHEME (CHIS)
1. Rashtriya Swasthya Bima Yojana
1.1. The Rashtriya Swasthya Bima Yojana scheme of Government of India
announced by Prime Minister, Manmohan Singh on Aug 15th 2007, is
introduced in the State alongwith Comprehensive Health Insurance
Scheme for (CHIS).
1.2. The objective of RSBY is to protect below poverty line (BPL) households
from major health shocks that involve hospitalization. Specifically, BPL
families are entitled to more than 700 in‐patient procedures with a cost
of up to 30,000 rupees per annum for a nominal registration fee of 30
rupees.
2. Comprehensive Health Insurance Scheme for (CHIS)
2.1. Provision of effective and free healthcare to the poorest 30 % families is
taken up in the Eleventh 5 year Plan of the State by way of strengthening the
Public Health System. As per the estimates of Planning Commission, there
are 11.79 lakhs BPL (absolute poor) families in Kerala and all of whom will be
covered under RSBY. In addition, the State government has estimated
another 10 lakhs BPL (poor) families in Kerala. According to the recent
enumeration there are 12,66,207 “absolute poor” and 11.01,206 “poor”
families in the State.
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2.2. In this scenario the Government of Kerala has extended the benefits of
Insurance scheme to the ‘Poor’ BPL population and All others included under
“Above Poverty Line” by introducing alongside the CHIS with slight variation
in premium. Hon’ble Minister for Finance, Dr. T.M.Thomas Issac in his Budget
Speech for 2008‐09, announced the implementation of the Comprehensive
Health Insurance Scheme for (CHIS) to all the families other than those
covered under the RSBY.
2.3. Thus the non –RSBY population covering more than 3/4 th families of the
State are divided into two categories (a) those belonging to BPL (poor) list of
the State Government but do not to the list of Central Planning Commission
and (b) the APL families belonging neither to list of State Govt nor prepared
as per guidelines of Planning Commission.
Accordingly the State Govt. issued orders on 4 th July 2008 for implementing
CHIS in the State. The scheme was launched on 2 nd October 2008 and
Alappuzha district was taken up as the first district. The RSBY and CHIS is
introduced in all the 14 districts of the State.
3. Premium and Registration fees for CHIS
In RSBY, 75% of the premium is met by the Central Government and 25% by
State Government while under CHIS (BPL poor), the State Government bears
100% premium. The beneficiary pays Rs 30/‐ towards registration fees/
family in both cases. In case of APL, the beneficiary bears the premium
amount as well as registration fees. The competitive premium per family
quoted is Rs.506/‐ inclusive of service tax and cost of smart card for all 13
districts except Palakkad where it is Rs.498/‐
3. Implementation of the Schemes in Kerala
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3.1. The Scheme is jointly implemented by departments of Labour &
Rehabilitation, Health & Family Welfare, Rural Development, and Local Self
Govt. The Labour Department is the Nodal dept. for implementation of CHIS.
3.2. A separate agency “Comprehensive Health Insurance Agency of Kerala”
(CHIAK) is created for implementation of the scheme.
3.3. “United India Insurance Company Limited” is the insurance provider for
all 14 districts.
4. Benefits of the scheme
First, the scheme provides the beneficiary a choice between public and
private hospitals and makes him a potential client worth attracting and
keeping due to the significant revenues that hospitals stand to earn through
the scheme.
‣ Cashless medical treatment up to Rs.30,000/‐ per annum
‣ Coverage of existing diseases
‣ No age limit
‣ Coverage extends to the head of household, spouse three dependants
(Children/Parents)
Second and related to this point, the overall design of the scheme involves
incentives that are conducive both to the expansion of the scheme as well as
long run sustainability. In the case of enrolment, the insurer is compensated
for each household enrolled and issued a smart card.
Other benefits to beneficiaries
‣ Free OPD consultation (No OP treatment)
‣ Accident death benefit of Rs.25000/‐ for head of family and spouse
(extra benefit offered free by the insurance company)
‣ Transport expenses up to Rs. 100/‐ trip with a maximum of Rs.1000/‐
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Apart from this Incentives would be granted to Hospital staff attending to the
patient @ 15% of claim amount received, Field Key Officers @Rs.2/‐ per card
and District Key Managers @ Rs.1000/‐ per month for 3 months
5. Empanelment of Hospitals
5.1. Criteria
‣ At least 10 inpatient medical beds for primary inpatient health care
‣ Should have an operational pharmacy and diagnostic service, or
should be able to link with the same. (Testing of clinical specimens, X‐
rays and ECG etc.)
‣ Fully equipped Operation theatre
‣ Fully qualified doctors and nursing staff under its employment round
the clock
‣ Maintenance and providing of necessary records
‣ Registration with Income Tax Department
‣ Telephone/Fax, 64KBPS connectivity, Personal Computer with 2 smart
card readers and a finger print verification machine or a stand‐alone
machine
‣ Agree to the cost of packages for each identified
intervention/procedure as approved under the Scheme.
‣ Bed charges (General Ward), Nursing and Boarding charges, Surgeons,
Anesthetists, Medical Practitioner, Consultants fees, Anesthesia,
Blood, Oxygen, O.T. Charges, Cost of Surgical Appliances, Medicines
and drugs, X‐rays, food to patient etc.
‣ Expenses incurred for diagnostic test and medicine up to 1 day before
the admission of the patient and cost of
medicine up to 5 days after the discharge
‣ Offer free OPD consultation
diagnostic tests and
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‣ Provide fixed discounts on diagnostic and medical treatment required
for beneficiaries
‣ Agree to display the CHIS status at their reception / admission
counter
‣ Agree to provide a separate help desk and have a dedicated officer in
the administration dept.
5.2. Indicative list of day care treatments
Due to the advances in the treatment techniques the following health
services will be treated on a day care basis
Haemo – Dialysis
Parenteral Chemotherapy
Radiotherapy
Eye surgery
Lithotripsy (Kidney stone removal)
Tonsillectomy
D&C
Dental surgery following an accident
Surgery of Hydrocele
Surgery of prostrate
Few gastrointestinal Surgery
Genital Surgery
Surgery of Nose
Surgery of Throat
Surgery of Ear
Surgery of Urinary System
Treatment of fractures/dislocation (excluding hair line fracture),
Contracture releases and minor reconstructive procedures of limbs
which otherwise require hospitalization
Laparoscopic therapeutic surgeries that can be done in day care
Identified surgeries under General anesthesia
Any disease/ procedure mutually agreed upon
5.3. Common exclusions
(Conditions that do not require hospitalisation)
Congenital external diseases
Drug and Alcohol induced illnesses
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Sterilisation and Fertility related procedures
Vaccination
War, nuclear invasion
Suicide
Naturopathy, Unani, Sidha, Ayurveda
6. Transaction at hospitals
Beneficiaries are entitled to a list of pre‐specified in‐patient services from the
second month following enrollment. Upon discharge, the pre‐specified cost
of the procedure is deducted from Rs. 30,000/‐. A receipt is printed and
provided to the beneficiary Actual travel cost up to a maximum of Rs.100/‐
per visit would be given to the beneficiary at the time of discharge.
7. Operation of the System
Enrollment
The List of eligible BPL households is provided to the insurer in RSBY format.
The list is posted in each village prior to the enrollment. The date and
location of enrollment booths is publicized in advance and stations equipped
with the hardware for the issue of smart cards. The smart card along with an
information pamphlet describing the scheme and the list of empanelled
hospitals is provided on the spot and the beneficiary has to pay Rs.30 as
registration fee. The Schemes operates through a biometric Smart Card with
Provision to split the card to more than one among the beneficiaries. On loss
of card, a new card can be issued but beneficiary will have to bear the cost of
the duplicate card.
153

154

8. Gearing up for the scheme by NRHM
8.1. A technical committee headed by Superintendent with RMO, 2 to 3 Unit
heads / HODs, Nursing officer, Nursing Superintendent as members and PRO
as convener would be formed in all institutions. This committee will be
responsible for sorting out issues if in connection with incentives of doctors
and other staffs.
8.2. The Medical Officer in Charge is arranged to submit Insurance claims for
all the patients for the procedure services covered to the Insurance company,
with all required documents and the money received against the claim would
be utilized by the hospital with approval of Hospital Management Committee
155

(HMC)/ Hospital Development Society (HDS). The Medical Officer‐incharge/Superintendents
of the respective hospitals would be responsible to
provide the additional requirement if any in equipping the critical
components for implementing the CHIS Scheme through the Hospital
Management Committee/Hospital Development Society. The Medical Officerin
charge/Superintendents would ensure that proper records are maintained
for all the OP/IP cases handled in the hospitals to ensure timely submission of
insurance claims to the insurance company and realization of reimbursement.
8.3. Insurance money received from Insurance company will be deposited in
separate bank account started by HMC/HDS. All payments from this account
would be paid through bank cheques except transportation allowance to
patients upto Rs 100/‐ at a time. Payments of incentives to doctors to
Doctors and other staff will be through cheques. Only generic drugs would
be prescribed by Doctors as far as possible. And Kerala Medical Services Corp.
Ltd. (KMSCL) will make all efforts to ensure regular supply of the same.
8.4. 85% of the insurance amount flowing into the account would be
earmarked as HMC/HDS share and remaining 15% as incentive share. 85% of
the insurance amount earmarked as HMC/HDS share would be utilized for
filling critical gaps in providing quality medical care in various service delivery
areas of hospital namely OP, IP sections, OT for providing various drugs and
consumables, for essential lab investigations hiring manpower especially
doctors like anesthetist/ surgeon etc. Remuneration for Computer operator/
Data entry operator would be also met through this.
8.5. Utilization of the staff incentive : 15% of the Insurance money share
earmarked as the staff incentive share would be distributed as per the
following general guidelines.
Incentive break up as percentage of total incentive amount per case.
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1. Surgeon / main physician / doctor treating the case.
30%
2. Surgeon assisting the surgery / other physician / doctors involved
in treating the case
10%
3. Anesthetist / doctors of other departments actively involved in
case management of medical cases
20%
4. Consultations / call duty etc
5%
5. Staff Nurses
12%
6. Nursing Assistants / Hospital Attendant Gr.1 &2
8%
7. Lab Technician
2%
8. X‐ray / Ultra Sound CT Scan Technician
2%
9. Record Keeping / system management
1%
10. Others if any
10%
Staff Nurses /hospital Attendants Gr.1 &2 of IP Wards, OT, Post
Operator Wards, and Observation wards would be eligible for incentive as
per no. of cases managed. Lab technicians would be eligible for incentives if
lab investigations are done in hospital lab for these cases. Doctors involved in
the Ultra sound CT Scan would be covered as consultation component of
incentive.
8.6. One Computer each has already been procured and allotted to 1,033
Hospitals under Health Services, including the hospitals selected for the
scheme. These computers would be utilized for the implementation of this
scheme. A telephone with 64 Kbps connectivity is to be provided in the
hospital if not available already.
System Administrator and State Data Manager of NRHM will take care of the
connectivity aspect of this component.
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8.7. Rs. 15,000/‐ (Rupees Fifteen thousand only) each would be given through
HMC/HDS for all the selected institutions for the procurement of additional
of facilities/equipment. The Untied fund Maintenance Grant and the fund
provided to the HMCs through NRHM would be utilized for meeting the
additional requirement if any.
8.8. The procurement procedure of the finial print reader, smart card reader
etc. would be done by NRHM through the insurance company in centralized
manner after rate negotiations. The payment of the same woulld be made by
the HMC/HDS, at the local level after successful installation of the same.
8.9. In Medical College Hospitals, General Hospitals and Specially/District
Hospitals. CHIS counters will be functioning round the clock specifically to
take care of the CHIS patients. In other major Hospitals and smaller hospitals,
after the routine working hours, registration of casually patients will be done
by the staff nurse in charge/other designated staff in charge of the casualty.
They would also be eligible for incentive from the category of "others"
earmarked in the incentive guidelines ordered separately.
8.10. One Public Relation Officer (PRO) preferably with MBA qualification will
be posted through NRHM in selected institutions identified, and they will be
made responsible for looking after the implementation of the scheme (ie.
institutional level nodal officer) under the supervision and guidance of the
Superintendent/Medical Officer‐in‐charge of the institution.
8.11. A Computer Operator would be posted through NRHM for taking care
of the routine functioning of the CHIS scheme. In bigger institutions which
require additional staff to run the CHIS counter data entry operators if
required, would be engaged on contract basis through Kudumbasree units
with the approval of the HMC/HDS.
8.12. For the first 3 months the payment of the Public Relation Officer and
Computer Operator will be met by the NRHM. Thereafter it will be the
responsibility of the HMC/HDS to pay the remuneration of these staff.
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8.13. Facility Survey based filling of Critical Gaps: Facility Survey would be
completed immediate in the selected hospitals, for filling the Critical Gaps of
infrastructure, equipments and staff of all these institutions based on the
survey report should be completed through NRHM/immediately.
8.14. Facilities of remaining Hospitals selected: The facilities available under
plan fund, TRP, ACA, LSGI fund HMC fund etc would be utilized as per IPH
standard/standardization guidelines in time bound manner.
8.15. Strengthening the Lab facilities. The Lab facilities of the selected
institutions including Medical College Hospitals will be assessed and to fill up
based on IPGS/standardization Committee report in time bound manner.
The QCI norms and procedures will be followed in this regard.
9. Database Management Software
Software is proposed to be developed by C‐DAC for regular record keeping
generation of weekly and monthly reports and tabulation of incentive for
individual staff members. An additional RSBY / CHIS incentive recording
format will be designed and attached to all case sheets. Individual doctors
and other staffs attending CHIS cases would be putting the date wise
signature and staff nurse / head nurse in charge would be responsible for
record maintenance counter signed by unit chief every day.
Latest progress from field‐ Report by CHIAK
Field Key Officers issue 5,000 smart cards in Alappuzha under the two
schemes after the launch on 2 nd October 2008. Remaining districts to
be taken up in November.
Private hospitals are being consulted by Insurer and District Collectors
are monitoring the progress.
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District level workshops for 9 districts completed. Remaining being
taken up.
Meetings of Panchayat Presidents and other Panchayat
representatives in progress.
Kudumbasree is validating the BPL list of all districts other than
Alappuzha and the data will be handed over to CHIAK. C‐Dit would be
entrusted with the task of converting the same to RSBY format for
forwarding to Government of India’s approval.
One Hospital in each district will be called a Model Hospital and these
hospitals will have facilities equivalent to that of Medical Colleges in the
State. Facility surveys have been completed for major institutions
(District/General/Speciality/Taluk Hospitals) towards identifying the critical
infrastructure/manpower gaps which can be filled immediately as short term
plan and over a period of two years as long term plan. The up gradation of
119 CHCs in the state are on and nearly 50 will get upgraded by December
2008 and the remaining by March 2009. The empanelled hospitals for
implementing insurance scheme will be upgraded in a shortest time
regarding infrastructure, equipments, diagnostic and other facilities through
empanelled agencies. An amount of Rs. 18 crores (10 crores from Maternal
Health Rs. 5 crores from Child Health and Rs. 3 crores from Urban Health)
from RCH‐II and Rs. 22 crores (Rs. 10 crores from upgradation works and 12
crores from EMRI) from Additional ties has been set apart for upgradation of
selected hospitals in the state for implementing the insurance scheme.
List of Hospitals where the insurance scheme will be implemented is annexed
160

Annexure‐1
LIST OF INSTITUTIONS
TRIVANDRUM
1. General Hospital, Trivandrum
2. W & C Hospital, Thycaud
3. Government Hospital, Peroorkada
4. THQH Nedumangad
5. THQH Chirayinkil
6. THQH Neyyattinkara
7. Government Hospital, Fort
8. Govt. hospital, Parassala
9. CHC Kanyakulangara
10. CHC Kesavapuram
11. CHC Vithura
12. GH Varkala
13. ICD Pulayanarkotah
14. CHC Poovar
15. CHC Vizhinjam
KOLLAM
1. District Hospital, Kollam
2. W & C Hospital, Kollam (Victoria Hospital)
3. THQH Sasthamkotta
4. THQH Karunagapally
5. THQH Punalur
6. THQH Kottarakara
7. CHC Neendakara
8. CHC Kadakkal
9. CHC Nedumgolam
10. GH Nedumpana
11. Chest Hospital, Karunagappally
PATHANAMTHITTA
1. General Hospital, Pathanamthitta
2. District Hospital, Kozhencherry
3. Specialty Hospital, Adoor
4. THQH Tiruvalla
5. THQH Ranni
6. THQH Mallappally
ALAPUZHA
1. General Hospital, Alapuzha
2. W & C Hospital, Alapuzha
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3. THQH Cherthala
4. THQH Haripad
5. THQH Mavelikkara
6. CHC Chengannur
7. GH Kayamkulam
KOTTAYAM
1. District Hospital, Kottayam
2. General Hospital, Pala
3. THQH Kanjirapally
4. THQH Changanassery
5. CHC Vaikom
6. THQH Pampady
IDUKKI
1. District Hospital, Idukki
2. THQH Peerumedu
3. THQH Thodupuzha
4. CHC Adimali
5. CHC Nedumkantam
6. PHC Marayoor
7. PHC Devikulam
ERNAKULAM
1. General Hospital, Ernakulam
2. W & C Hospital, Mattancherry
3. THQH Fort Kochi
4. THQH Aluva
5. THQH Perumbavoor
6. THQH N.Paravoor
7. THQH Tripunithura
8. THQH Moovattupuzha
9. CHC Kothamangalam
10. GH Karuvelipady
11. CHC Piravam
12. CHC Kalady
THRISSUR
1. District Hospital, Thrissur
2. THQH Kodungalloor
3. THQH Irinjalakuda
4. THQH Chavakkad
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5. THQH Vadakkanchery
6. THQH Chalakkudy
7. Govt. hospital, Kunnamkulam
8. GH Mala
9. CHC Cherppu ( to be upgraded)
10. CHC Valappad
PALAKKAD
1. District Hospital, Palakkad
2. THQH Chitoor
3. CHC Alathur
4. THQH Mannarkkad
5. THQH Ottapalam
6. Tribal Specialty Hospital, Kottathara, Attapady
7. CHC Nenmara
MALAPPURAM
1. District Hospital, Manjeri
2. THQH Nilambur
3. THQH Tirurangadi
4. THQH Perinthalmanna
5. THQH Tirur
6. THQH Ponnani
7. CHC Malappuram
8. CHC Purathur
9. CHC Areecode
10. CHC Kondotty
11. CHC Vandoor
12. CHC Tanur ( to be upgraded)
13. Block PHC Melattur
14. PHC Edappal
KOZHIKODE
1. General Hospital, Kozhikode
2. W & C Hospital, Kozhikode
3. THQH Koilandi
4. THQH Vadakara
5. CHC Thamarassery
6. GH Nadapuram
7. CHC Kuttiyadi
8. CHC Balusserry
WAYANAD
1. General Hospital, Kalpetta
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2. District Hospital, Mananthavady
3. THQH Sultan Bathery
4. THQH Vythiri
5. CHC Meenangady
6. CHC Pulpally
KANNUR
1. General Hospital, Thalassery
2. District Hospital, Kannur
3. THQH Thaliparamba
4. GH Payyannoor
5. GH Kuthuparambu
6. CHC Peravoor
7. CHC Pappinisserry
8. CHC Panoor
KASARAGODE
1. District Hospital, Kanhangad
2. THQH Kasaragod
3. CHC Panathady
4. CHC Nileswar
5. GH Manjeswar
6. PHC Kumbala
7. CHC Cheruvathoor ( to be upgraded)
8. CHC Trikkarippur
164