KERALA

World Bank team to work out second generation reforms

THIRUVANANTHAPURAM Sept. 21. A three-member delegation of the World Bank is scheduled to visit the State later this month to evaluate the critical requirements of the secondary-level healthcare infrastructure in the State as part of implementing a Rs. 810-crore package of second generation reforms over a five-year period.

The major objective of the team, which is due to arrive on September 29, will be to discuss threadbare a draft paper that outlines the contemporary and future requirements of the State's secondary-level health infrastructure and to format an `aide memoire' on the `Kerala Secondary Health System Development Project'.

The concept paper on the secondary health system, drafted by a multi-disciplinary task force, essentially highlights the State's infrastructure inadequacies to deliver quality care in a rapidly changing epidemiological-demographic scenario.

The World Bank team, headed by Hnin Hnin Pyne, Senior Public Health Specialist in South Asian Human Development, will comprise Peter Heywood, health specialist and World Bank's Country Office representative in New Delhi, and Paolo Belli, Washington-based health economist.

The visit is being perceived as a positive response from the World Bank, which had previously indicated its keenness to work closely with the Government on reviewing and agreeing on guidelines for reforms, formulating the rules of engagements for bank support for the health sector and identifying key health outcomes to be achieved through cost-effective strategies to prevent and manage non-communicable diseases.

In fact, the State Government had submitted the Project Implementation Plan of the Kerala Secondary Health System Project to the World Bank in March, 2003, through the Government of India, seeking financial aid to fill up the critical gaps in terms of personnel, infrastructure, equipment and capacity building.

According to sources, the World Bank team would, during the course of its six-day-long deliberations with a cross-section of Government officials, be provided with ``a close-up view of the ground realities'' in a State which faces challenges, old and new, on the health front.

In spite of the commendable gains in several parameters of health, the shifting emphasis on ensuring a continuum of consolidation of these achievements had turned out to be an impossible mandate for the State to fulfil on its own.

The discussions will take place against the grim backdrop of the re-emergence of communicable diseases like malaria and leptospirosis, adding to the growing burden of non-communicable ailments such as diabetes, hypertension, cardio-vascular diseases, renal disorders and various cancers.

It is pointed out that the burden of non-communicable diseases, which warrant expensive and long-term treatment, has to be viewed in the context of the rapid rate at which the State is `greying'. According to current calculations, an estimated 11 per cent of the State's three crore population belongs to the elderly category.

The resource-starved State is also grappling with an increase in HIV/AIDS cases besides growing instances of substance abuse, suicides and mental illnesses following the virtual collapse of family support systems.

Also at the core of the State's concerns are the poor health awareness and access to health services among the over 78 lakh Scheduled Caste and Scheduled Tribe population and a slum population of 45,337 (2001 Census).

The proposed initiatives to be taken up with the delegation include standardisation of service provision, facilities, manpower and equipment across as many as 236 health care institutions at the district/taluk/CHC (community health centre) levels, which would constitute the hub of the second generation of reforms.

Besides seeking to transfer more powers to local self- governments wherever necessary, the initiatives propose to determine the allocation of funds on the basis of the size of hospital.

However, broad sectoral allocation would have to be retained at the State level to ensure that sufficient funds are infused into sectors like women's component plan and public health, and that decentralisation does not result in financial independence for individual institutions or areas. The thrust is on evolving optimal infrastructural and service standards for better and cost effective health planning at a health institution.

A standard operating manual to be adopted uniformly across medical, pharmacy, paramedical, nursing and laboratory, a disaster management protocol to tackle natural calamities and setting up trauma care facility at district hospitals are among the proposals.

In the current scenario, there is an emphasis on a more balanced public-private mix in the State, where nearly 70 per cent of demands for health care are delivered by the private sector. Increased involvement of private hospitals in national and public health programmes is another important component of the reforms package.

Improving inter-sectoral coordination, performance audit for the secondary health system, replication of telemedicine models introduced by existing tie-ups with tertiary care institutions and fine-tuning the State Drug Formulary (1999) to rationalise prescriptions are also likely to figure in the discussions.

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