Access to healthcare services is a cause of major concern especially in public health institutions. Shortage of medical professionals, absence of facilities, lack of quality assurance and insufficient spending are few significant issues plaguing public health care. It is in this backdrop that the Performance Audit of Public Health Infrastructure and Management of Health Services in Karnataka has been carried out during 2021-22, covering the period 2016-17 to 2021-22. This report attempts to assess the quality of health services and patient care services provided by the public health care facilities in the State. SIGNIFICANT AUDIT FINDINGS The overall performance of the State in providing quality health care services, though satisfactory, had certain deficiencies. The observations noticed on the management of the services and health care infrastructure are summarized below:
Adequacy of Human Resources There was shortage of about 45 and 53 per cent in respect of doctors/specialists and nurse cadres respectively in Taluk Hospitals (THs) in comparison with the Indian Public Health Standards (IPHS), the shortage of specialists/doctors being significant in services such as General Surgery, Ophthalmology, Anaesthesia etc. There was asymmetric distribution of human resources in the test-checked hospitals. Policy framework for healthcare services The policy framework for hospital management in the State had gaps that need to be addressed. The State neither prepared its own norms/standards nor did it adopt those prescribed by the Government of India (GoI) in respect of outpatient and inpatient services, pathology investigations and human resources. This has and will continue to impact the availability of health care infrastructure and patient care services. The State did not have a documented procurement policy to ensure availability of essential drugs/medicines at all times, improve the existing system of procurement and supply of the drugs and quality assurance of drugs. Neither there was any policy and action plan for ensuring the proper assessment of the requirement of the medical equipment, timely procurement, distribution system and maintenance of equipment. Outpatient Services The availability of doctors was not proportionate to the outpatient load. This resulted in much higher OPD cases per doctor in the secondary HIs in comparison with other HIs. Non- availability of specialized doctors led to nonavailability of services like ENT, Pediatrician, etc., for substantial periods. Registration Counters available were not commensurate with the OPD load in test checked HIs. This could potentially lead to challenges in providing timely and appropriate medical care to patients seeking treatment. Inpatient Services IPD services such as ICUs beds were not adequate in most of the test checked health institutions as per IPHS guidelines. There was shortage of operation theatres in THs/CHCs and significant shortage of drugs and equipment in IPD and Emergency services. The absence of critical services and shortages in facilities and resources undermines patient well-being, compromise healthcare quality, and erode public trust in the healthcare system, exacerbating health disparities and economic burdens. Emergency Response and Health System Preparedness Drugs worth ₹17.79 crore required for preventing/curing of COVID-19 were yet to be supplied. The State incurred additional expenditure on procurement of PPE kits for COVID 19. There was significant delay in supply of the essential medical equipment and consumables at the time of emergency even after providing exemption under 4(a) of KTTP Act. Equipment worth ₹95.15 crore was yet to be supplied. MGPLS was not functional in few of the test checked HIs, fire safety audit was not conducted in the test checked HIs. These deficiencies collectively emphasize the critical need for a more streamlined and proactive approach. Maternity Services Maternity services lacked essential human resource, drugs and pathological investigation facilities. These deficiencies significantly hindered the hospitals' ability to effectively monitor the health of mothers and newborns, potentially impacting maternal and infant mortality rates. Newborns delivered through preterm labour remained at risk of serious postnatal complications and neonatal deaths. Support Services The provisioning of diagnostic services in the test checked hospitals was suboptimal, marred by inadequacy of prescribed equipment. Distinctive dietary requirements for different categories of patients were not ensured. Dietary services to the patients apart from the pregnant women were not provided in 10 test checked health institutions. These deficiencies could lead to delayed or inaccurate diagnoses, reduced emergency response effectiveness, compromised patient health due to improper nutrition, and overall lower quality of healthcare services provided by the hospitals. Auxiliary Services In the test checked health institutions, air and surface samples were not regularly taken for microbiological survey to check for infections. Cleaning and laundry services, despite outsourcing, were not satisfactory in most of the hospitals. Similarly, bio-medical waste management was inadequate. Most of the health institutions did not have SOPs/checklist for hygiene and infection control. The impact of inadequate hygiene and infection control practices in health institutions could be far-reaching, affecting patient outcomes such as well-being of the patients, health care workers. Management of Drugs and Equipment The drugs provided to the hospitals were short of their requirements as supplies were not commensurate with the indents by the hospitals. The system was unsuccessful in providing an unbroken supply of essential drugs to the patients in public health facilities as per its own prescribed Essential Drug List. Quality assurance of the drugs procured was compromised as the bulk of the drug supplies were accepted without the intimation of the quality test reports. There were delays in sending samples for testing and in communicating the test results rendering the quality mechanism ineffective. There were six instances where the results of the Drug Controller (certified as Not of Standard Quality) varied with the results of the empaneled laboratories. In these cases, 59 per cent of the drugs were consumed before receipt of test results. The quality mechanism was thus ineffective. The norms and parameters prescribed for storage of medicine were not adhered to. Due to non-availability of adequate storage facility, drugs/medicines were kept on the floors and without rack system. Improper assessment of requirement of medical equipment led to redistribution to the other health institutions, expiry of the warranty period even before the equipment could be put to use and the equipment lying idle. Health Care Infrastructure There was regional disparity in distribution of health care facilities in the State. The departments failed to operationalise the completed infrastructure which aggravated the problems of inadequate access to quality health care. Patient safety in the hospital premises was compromised on account of non-compliance with the disaster management guidelines and lack of proper fire safety arrangements in the test checked health institutions. The building and operational areas in the test checked health institutions were distributed as per the infrastructure available rather than prescribed plan and area. Due to delay in completion/non-handing over of buildings built at a cost of ₹228.36 crore, activities in the test checked health institutions were not commenced. The initiation of critical health care activities was hindered due to above factors and contributed to inadequate access to quality healthcare. Inadequate spending on the health care sector The average budget allocation for the period under review was 4.28 per cent, which was less than the percentage prescribed by the National Health Policy (NHP). The State’s expenditure on the health sector ranged between 0.60 to 0.77 per cent of GSDP during the period. The departments concerned failed to utilise the funds released, which affects the quality and accessibility of healthcare services across the State. Implementation of Centrally Sponsored Schemes There was a delay in release of matching share by the State Government towards NHM programme. The utilisation was around 94 per cent of the funds available under the scheme. The utilisation of funds was not consistent due to limited implementation of various activities under the Quality Assurance Programme. Under Kayakalpa Scheme, the number of Health Institutions which received the award increased from 103 to 900 during 2016-21. Under LaQshya programme, as of October 2022, only 73 HIs have obtained State Certification and 46 HIs have obtained National Certification. Only 76 per cent of the claims received under PMJAY scheme were settled during the audit period and the funds provided under the scheme could not be utilised by the test checked units. Adequacy and effectiveness of regulatory mechanism Varying levels of deficiencies were observed in compliance/adherence of existing regulatory mechanisms. The functioning of regulatory bodies and implementation of norms and regulations was ineffective. Shortage of staff in the Drug Control Department hampered drug testing and reporting. Bio-Medical Waste management continues to remain a major challenge. Significant number of HIs were functioning without valid licenses/authorisation. The cumulative effects of these deficiencies could lead to long-term consequences, including chronic health issues, environmental degradation, and weakening of health institutions. Sustainable Development Goal - 3 The department established Monitoring and Coordination Committees, including a State-level Steering Committee, to formulate action plans for achieving SDGs. However, there was no dedicated fund allocation to address gaps in achieving SDG 3 targets. Despite performing relatively well compared to other states under SDG 3, Karnataka failed to meet its own targets. Concerns persist regarding the incidence of TB and the prevalence of tobacco use.