Down the memory lane

31 May,2009.It was a scorching aftternoon.After my lucnch at home, I hardly got into my chamber,when my Technical Assistant Dr.B.Rajesh showed me a circular from the Dept.of Revenue,Ministry of Finance calling for application for the post of Member(Administration),Adjudicating Authority. As usual, Government circulars calling for nominations/applications invariably land on the last day so that only chosen few get to apply for. I faxed an application duly filled in and called up the Department of Revenue to ascertain whether my application had reached the concerned. Once I got the answer in the affirmative, I switched of my mind about the application and carried on with my routine.

In early July, I was surprised to get a call for the interview at the Department of Revenue on 8July,2009. I appeared before the board chaired by the Secretary to Govt. of India, Ministry of Finanace and forgot about the whole thing. On November,11,2009 I got fax communication that I had been selected and that I should confirm or otherwise of my willingness to join ans Member. I communicated my willingness by a return fax on the same same day. On 12,November, I got a fax communication offering appoint but stipulating that I should take Voluntary Retirement from ServiceThe Board consisted of gto

Regional Resource Centre for Northeastern States (RRC-NE)

The North Eastern region of India is considered one among the most complex regions of the country in terms of its diverse culture, language, ethnicity, accessibility,development etc. Despite of many years of effort, the region remains under developed in terms of health care facilities, health indicators and many others.

The launch of Reproductive & Child Health II and National Rural Health Mission in April , 2005 brought in a paradigm shift in the planning process in the health sector in the country with significant rise in the investments in the health sector. These programmes entail upon the state governments to undertake participatory planning starting from the grass root level to strengthening of its managerial capacities so as to effectively plan interventions and execute the same.

Considerable amount of funds have already been released to all the 8 NE states. Over the last few years with the support of NRHM, these states have achieved many milestones but many more are to be achieved. In these states, efficient managerial functioning with sound technical back up is seen as an issue, which many a time results inadequate absorption of funds released to the state. That was the time, It was at his point of time, I joined the Ministry of Health & Family Welfare as Joint Secretary. I was mandated to set up the North East Division so that special attention and focus could be given to this region

Accordingly, the Ministry in association with the Development Partners like European Commission, UNFPA, DFID etc set up the Regional Resource Centre for Northeastern States (RRC -NE) at Guwahati in September,2005 in order to handhold the the region by augmenting the technical and managerial capacities of the NE states at all levels.

The main objective of the RRC is to provide technical assistance to the North Eastern States, help identify core areas to be focused in the short, medium and long run and plan for providing the missing technical and managerial capacities to these states. The major tasks of the RRC-NE included preparation of Situational Analysis on various aspects of the Health Sector and prepare policy proposals, re-structuring of the health system at the State, District and sub-district levels, institutionalization of integrated planning and management, taking stock of the financial resources available and the critical gaps and strengthening and streamlining of financial management systems, devolution of financial and administrative powers, strengthening and streamlining of procurement and logistics ,standardization of norms (services, staffing and infrastructure) at the primary and secondary levels, strengthening and streamlining of health management information systems (HMIS) , development of drug policy,advise on inter-sectoral convergence etc.,

In addition to the above, the Regional Resource Centre is also required to conduct workshops and

meetings on behalf of Government of India for effective operationalization of NRHM in the NE

Region.

The RRC-NE is organized as a ‘hub-and-spoke’ structure. The hub is headed by the Director (full time) with a Core Team of experts in Public Health,.Finance, Accounting and Audit, .Procurement and Logistics,Health Management and Information System,Community Mobilization and Civil Engineer-cum-Architect

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A BRIEF REPORT ON THE ACTIVITIES CARRIED OUT IN NE STATES DURING THE TENURE OF SHRI. K. RAMAMOORTHY, JS (NE), MOHFW, GOI

During my tenure (2005-2008) as Joint Secretary(NE) the northeastern states achieved many mile stones. One of the biggest challenges in any programme implementation the set up of institutional arrangements at the State level, District level and at Facility level.

It was mandated that for getting assistance under the National Rural Health Mission , the concerned state government should sign Memorandum of Understanding (MoU) with Government of India , followed by setting up of State and District Health Missions.The State NRHM has to be headed by a Mission Director. It was also mandated that all the existing vertical health programs are to be merged while forming the State Health Society. Periodical discussions and monthly video conferences led to the achievement of these basic goals.

· One major thrust under the NRHM was to form Rogi Kalyan Samiti( Hospital Management Society) at District Hospital, SDH, CHC, PHC etc. I still remember the days I used the chair the Hospital Development Society at the taluk level during my days as Assistant Collector/Sub Collector during 1980-82. It dawned on the Ministry of Health & FAmily welfare to have such set up in all the district,taluk and sub divisional levels. I also remember my step to give total financial autonomy to Hospital Development Societies meaning thereby that the income generated by the hospitals would be retained at the facility level and ploughed back into the system for repair of equipment, furniture,maintenance of building,water supply,electricity,telephone and purchase of medicines in case the stock gets exhausted. of course, I had a wage a war with the Finance Department of Kerala during 2006-07.

F The only addition here is that the Ministry of Heealth provided recurring financial support to the committee to carry out its own plan for the development of the hospital. In NE states also, the RKS was formed in different categories of hospitals, as mandated. Many of these committees have been doing many innovative works in NE states.

· A

Managing any show is always an art, which necessarily requires skills. Majority of the Medical Officers lack these skills. To support in this front, it was decided to engage staffs at State, District, Block with managerial background so that the programme can be managed efficiently and it can deliver goods. It was named as State Program Management Support Unit (SPMSU), District Program Management Support Unit (DPMSU) and Block Program Management Support Unit (BPMSU). Engagements were made as per the state’s requirements from State Program Manager, State MIS Manager, State IEC/BCC Expert, State Finance Manager etc. The same types of engagements were also made for the district. At Block level, Block Program Manager, Block Accounts Manager was engaged. In NE states also, for majority of the state the SPMSU, DPMSU, BPMSU staffs are in place.

· State Programme Management Support Unit and District Programme Management Support Unit were formed and all required personnel were placed.

The Government of India launched National Rural Health Mission (NRHM) to address the health needs of rural population, especially the vulnerable sections of society in April 2005. The Goal of the Mission is to improve the availability of and access to quality primary health care for the people, especially for the vulnerable groups focusing the women and children. To serve the rural community, the Sub-centre is the most peripheral level of contact with the community under the public health service delivery system. This caters to a population of around 5000, but is effectively serving much larger population. With less than 50% MPW (M) being available in the State, the ANM is heavily overworked, which compromise the quality of services & community aspects of services. The very nature of her job responsibilities makes it difficult for her to take up the responsibility of a ‘Change Agent’ on health in a village. Thus a new band of community based activists, named as Accredited Social Health Activist (ASHA) has been positioned to fill this void of community processes. 1 ASHA is engaged per 1000 population in plain areas, which was relaxed for hilly areas, like NE states.

.Because of the active persuasion of Sri Ramamoorthy, all the NE states could take initiatives for selection of ASHA and train them. A total of 49000 ASHAs were selected during 2007-08. Provision of drug kits for each of the trained ASHAs was made available.

The condition of the health infrastructure was in a very bad shape before NRHM, so it was mandated under NRHM to give major thrust to the infrastructure strengthening. 33% of the total fund is earmarked for the strengthening of infrastructure. To know the status of infrastructure of the different hospitals and to take up infrastructure strengthening on priority, massive drive was carried out for doing facility survey (as per IPHS) of District Hospitals and CHCs in NE states. The facility survey findings were also shared with the Ministry. Based on the facility survey findings, facilities were taken up for infrastructure improvement. Identified CHCs from NE states were given Rs. 20 lac for infrastructure strengthening. 56 District Hospitals (18 from Assam, 3 from Meghalaya, 14 from Arunachal Pradesh, 11 from Nagaland, 2 from Manipur, 2 from Sikkim, 6 from Mizoram) from NE states were given Rs. 1 crore each during March’07 for improving the existing status of the infrastructure. State like Assam has compiled a booklet on the findings of the facility survey. The District Program Management Support Unit staffs are taking lead role in getting the facility survey done of different health facilities. With the technical inputs given by the Engineer of the Department, work is executed with the support of Hospital Management Society.

Along with the infrastructure strengthening, it is equally important to put qualified Human Resources (both medical and paramedical) at the facility so that ultimately, people who come seeking services get the desired services from the facility. So, provisions were made under NRHM for appointment of health professionals at different categories of hospitals starting from SC to District Hospitals. Accordingly, 2^nd ANM as per the mandate of NRHM was introduced at SCs of NE states. The provision of engaging 2^nd ANM at SC has not only reduced the work load of the existing ANM but also it has increased the overall performances of the SC. Also, a number of Specialist, Medical Officer (Allopathic), MO (AYUSH), Staff Nurses, Lab Technician and MPW (Female) were made available at the health facilities. While giving engagement of staffs at different health facilities, it has also been ensured that the staffs stays at their place of posting and deliver services. Many states in NE states have come up with their own innovative plan to ensure that the staffs engaged stay at the place of posting.

Most of the NE villages lie in remote areas,where it would be impossible to make available health care. So we decided to press into service Mobile Medical Units. Going by the past experience of the Ministry in supplying unwieldy Mobile Medical Vans, my division specially designed MMUs( nos) with essential equipment,medicines,manpower etc. for the NE states bearing in mind the hilly terrain. I was also responsible for assisting the Ne states particularly Assam to go in for Boat Clinics to reach out to its riverine pockets I also suggested that Union Territories like Andaman & Nicobar and Lakshadweep should get support for Boat Clinics.We found that they were popular among the people living in reverine belts of Brahmaputra.

ii. TakInitially, I was required to operationalise the North East Indira Gandhi Regional Institute of Medical Sciences (NEIGRIMS),Shillong for which the late Prime Minister Rajiv Gandhi laid the foundation stone way back in 1986. The construction phase of the institute at a cost of Rs.469 crores was progressing at snails pace. with a missionary zeal I took up the task, convened fortnightly review meetings with the agency Hindustan Construction Company ( a PSU under the Ministry), the Director and the others and speeded up the process.Then came the question of recruiting manpower( both teaching and non teaching) and procurement of high end equipment required for the 500 bedded multi specialty teaching hospital and institution. It was a Herculean Task to get suitable candidates for the faculty positions.However, with faculty recruited 300 beds were operationalised. Departments like ------------------------------------------------------------- were started. I also got the Nursing College Building completed and admitted the first batch of B.Sc Nursing students during the academic year 2007-08.Now, the first batch of B.SC Nursing students are passing out of the college this year. we also admitted the first batch of M.B.B.S students, who are in the third year now.

During one of the visits to Manipur in early 2007, the Hon'ble Prime Minister promised that the Regional Institute of Medical Sciences,Iphal, Manipur would be taken over by the Ministry of Health & Family Welfare. Making use of this assurance, the North Eastern Council prevailed upon the PMO to instruct our Ministry to take two of their institutions such as - Regional Institute of Paramedical & Nursing, (RIPANS) - Mizoram, Lok Nath Priya Mental Hospital -Tezpur, Assam. Reluctantly, we agreed to take them over and started working on their upgradation.We released Rs 85 crore for setting up a Super Specialty Hospital at the Gawhati Medical College,Assam.

Photographs:

My five year tenure as Secretary ( Health &Family Welfare) and then as Principal Secretary during 2001-2005 was varied , interesting and most challenging. It was an assignment that gave me immense satisfaction and enabled me to learn alot about health related issues and make rich contributions for the health sector of the state.

From the beginning of my stint, I started taking regular review meetings with Heads of Departments, Programme officers and my staff in the Department. In certain cases, I used join the Heads of Departments when they were taking monthly review meetings.It enabled me to have first hand knowledge as to what was happening in the field and what remained to be taken up on a priority basis. It enabled me to initiate advance action against monsoon - related and seasonal out -breaks of communicable diseases, ensure preparedness of the Departments concerned for any major casualty. It also enabled me to identify the missing crucial links in the system.

Dengue Outbreak & Control

In August 2005, the state was realing under a Dengue outbreak and deaths were mounting. Every death, even ordinary death was attributed to Dengue. We immediately called a meeting of the the Head of the Department of Community Medicine of the Trivandrum Medical College to understand the gravity of the situation and worked out a strategy to address the problem squarely. We launched an awareness campaign by giving talks over the television, Radio, Press and launched door to door campaign. We used the school choldren to carry home the messages relating to " Dos" and "Donts". All the hospitals were asked stack test kits and emergency medicines. The Medical Colleges were asked to adopt the most affected villages by this out- break. We requested all the local bodies to focus on cleaning up their clogged drains,waste dumps, backwaters- the source of dengue larvae breeding. These efforts and the commitment shown by the doctors and paramedics enabled us to bring the outbreak under control.

Facility Survey

In order to fill up the critical gaps in any instituion, a "Facility Study" ( of infrastructure,man power, equipment, drugs,beds & furniture,water,drainage etc) is essential. With this in mind, facility surveys were conducted on a war footing against a blue print prepared by experts.This was published as a book titled "Instituion Analysis".

Essential Drug Lists & Drug Procurement Policy

When I joined the Department, almost all Malayalam dailies flashed news repeatedly that there were no essential drugs and even dressing materials. I went into the issue and realised that the Directorate of Health Services had not settled biils for the supply of drugs supplied during the last two years and that amount had mounted to Rs.35 crore. On top of it , the DHS required allocation to the extent of Rs.65 crores for every year. I took it up as a priority item and moved the Finance Department, which released funds in 3 instalments. Once, we got over the pending bills, we thought of ensuring availabilty of Essential Drugs in all the hospitals, for which we had to come out with Essential Drug Lists for Primary, Secondary and Tertiary Hospitals. An expert committee was constituted and Essential Drug lists were prepared and after getting Cabinet approval circulated to all the instituions.

PHOTO OF ESSENTIAL DRUGS

In order to ensure transparency and quality in the procurement of drugs, a Procurement Policy was prepared and Cabinet approval was obtained. This became handy for the DHS officials concerned with procurement of drugs and supplies to ward off complaints.

Rural Service & abolition of Liquidity Damages

Kerala is known for 100% literacy but was poor in public health facilities for want of adequate resources and lack of technical manpower. Most of the doctors and paramedics, who gained their degrees/diplomas at the cost of exchequer flew out of India for better pasture and as a result there were many vacancies across the state. There was a ban on recruitment as well. It affected health delivery. There were only two options before us - one, to deny leave for taking up jobs outside the state and two, to make rural service compulsory for those,who pass out of the Colleges with an MBBS degree. This move resulted in a lot of furore amongst the staff; but we put our foot down and said no. Moreover, the question of "Liquidity Damages" was done away with.

Private participation in Medical Education

At the time of assuming office as Secretary ,Health, there were only 5 Govt Medical Colleges, two Dental Colleges and few Nursing Colleges in the State. The number of MBBS seats totalled upto 900 and there was heavy competiton amongst students to get into anyone of the Medical Colleges in the state. Kerala parents would not mind selling their properties to educate their children. When their wards could not make it into the local Medical Colleges , they admitted them in the colleges in the neighbouring states paying hefty capitation fee. During one of my trips to the Ministry of Health , I discussed with Mr.Rao, Director in charge of Mediccal Education and asked him the way to go about to set up Medical Colleges in the private sector in Kerala. Of course, Kerala politicians would detest anything that is private . Of course, there have been lot private management run colleges of Arts & Sciences. On return from Delhi, I initiated a put up a note to the Chief Minister for orders. The initial response was "No". However, my logic was appreciated when I circulated the second note. We, therefore, issued a press release calling for applications for setting up Medical Colleges in the state.We got about 42 applications and on scrutiny with reference to the Medical Council Regulations, it was found that only 7 of them had the where withall to start a medical college the same year ie 2002.


When the issue came up before the Cabinet for consideratuion, I was called in to explain the logic and I did to the satisfaction of the Cabinet. It gave its not for consideration of all the 42 applications and issue Essentially certificate. I though it was a wrong move. Only subsequently, I realised that the Cabinet, in its collective wisdom took a practical decision. They knew pretty well that if only few were given and the others were denied, the decision of Govt. would be stalled by filing Writ Petitions. The same year, Amrita Institute of Medical Sciences,Kochi opened the first ever Medical Ciollege in the private sector. Now, few batches MBBS students have come out of this institution and it has also started offering P.G Courses. In the next few years , another 8 colleges sprang up making available 800 seats.This has provided lot of relief to the parents of chidren,who are intelligent but could not go out of the state for education .Of course, commercialisation by all these instituitions belied our hope and instructions. The plus points of this opening up of Medical ducation for private participation are that specialty care is available to all those who could afford, lot of infrastructure came up besides commercial establishments . It also provided for lot of employment opportunities for both skilled and semi skilled labour.

Setting up of Paramedical Council


The services of Paramedical Staff is inevitable for health care delivery. But, unfortunately, the instituions that impart paramedical courses are not regulated and the personnel who come out of sizeable number of instituions are poorly trained and they play havoc with the lives of patients. Kerala was the first state to set up the Paramedical Council in India. I provided leadership in setting up this council to regulate paramedical instituion.

Telemedicine & CArdiac Emergency Hospital at Pmapa

Sabarimala is a pilgrim centre in Pathanamthitta district of Kerala. Located amidst forests, it has no medical facility worth mentioning for the lakhs of pilgrims, who throng the hills for darshan of Lord Ayyappa. I had the fortune of serving as Special Officer,Pmpa during my Adoor Sub Collector days. As Secretary, Dept.of Health & Family Welfare, I arranged for first aid posts, a Govt. run Hospital at Pampa and presssed into service lot of doctors and paramedics. In addition, I approached the Director of ISRO Dr.Madhavan Nair and appealed to him to station a telemedicine unit at Pampa so as to get tele consultation with specialists from Super Specialty hospitals in other parts of the state. He readily obliged. I also approached Amrita Institute of Medical Sciences,Kochi and also the Apollo Group of Hospitals, Chennai for their support. Amrita Institute of Medical Sciences responded the same year by establishing a 10 bedded cardiac emergency hospital and Apollo Group followed their steps next year. Since then, bith these institutions run cardiac emergency hospitals at Pampa, which are beneficial for the devotees.

Tsunami and the relief Operations

ON 25 December,2004 Tsunami struck the coastal belt of Tamil Nadu Kerala. The coastal belt from Trivandrum to Alleppy was the worst hit. We set up a round the clock Control Room and monitored the situation. I had instructed the DHS And the DME to press into service their doctors and paramedics and render relief on a war footing. The Medical Colleges were asked to send teams of specialists and paramedical staff to the affected areas well within their district. District Medical Officers and the Principals of Medical College were asked to draw medicine from their stores and buy from the open market in case of need. The local private hospitals were requested to offer medical services to those who were affected and Govt. undertook to settle the bills. Ambulances carrying doctors, paramedics and emergency medicines and equipment were asked to patrol the area and render services. The Secretary of the State Mental Health Authoriyu was asked to send Psychiatrists to the relief camps and asked to offer counselling. As suggested by me the Cabinet despatched senior Secretaries, who had workedd in those disricts to oversee relief operations and take on the spot decisions and help the District Collectors in carrying out effective relief operations.


A Fight Against Stigma

The Govt in general and the Health department in particular was shocked, when the news broke out that Benson and Bency , HIV-infected siblings of Chathannoor Village had been thrown out of the local Kaithakuzhy Lower Primary School and were forced to confine themselves to their home because of their HIV status . The efforts of the state machinary consisting of the Secretary , School Education, Director, Kerala AIDS Control Society and the District Collector,Quilon to allay the fears of the parents of the children studying in the school and the local panchayat did not yield results. These two children were virtually ostracized by the entire village community which also trampled upon their fundamental right to education.

Parents did not to want their children to share the classroom with Benson And Bency and the Parent Teachers Association voiced exaggerated fears of a risk of HIV transmission from these siblings. Exposing the deep-seated stigma that hounds HIV-infected victims, belligerent parents threatened to withdraw their children from the school if Benson and Bency were in.Eventually, the school gates slamed shut on the children.

Deprived of their fundamental right to education, the orphans, who are under the care of their grandparents, were forced to remain at home. Having found that my colleagues could not succeed in their attempt,I entered into the frey even though AIDS Control was the subject handled by Secretary ( Family Welfare). I made it a point to spend weekends with the children, invariably taking them for a stroll on the streets. My efforts to erase the stigma that surrounded them paid dividends. The following unpublished article written " Walking With +Vesby me would throw some light on my efforts to fight the stigma.

WALKING WITH +ves




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