Public Health

Reinventing health care

Print edition : September 29, 2017

The first Family Health Centre in Kerala inaugurated by Chief Minister Pinarayi Vijayan at Chemmaruthy village near Thiruvananthapuram on August 17. Photo: R. Krishnakumar

Pinarayi Vijayan (right) arriving for the inauguration of the FHC. Photo: R. Krishnakumar

In the new outpatient department at the Medical College Hospital in Thiruvananthapuram. Photo: R. Krishnakumar

At the General Hospital in Thiruvananthapuram, swamped by fever patients. Photo: S.Gopakumar

The Laboratory at a new FHC in Kadakampally near Thiruvananthapuram. Photo: R. Krishnakumar

The eHealth pharmacy counter at the Government Model Hospital in Peroorkada, Thiruvananthapuram. The eHealth project was launched by Pinarayi Vijayan in August last year. Photo: R. Krishnakumar

Kerala launches a major effort to transform its public health system.

ON normal days and when fever swamped the wards, anger, frustration or a tame resignation characterised the mood of patients and bystanders at most public health facilities in Kerala. With barely an exception, these institutions were badly maintained, understaffed and ill-equipped and, in the upper tiers, bursting at the seams with unmanageable patient numbers. Quality of care suffered as a result. At the lowest level, the primary health centres (PHCs) were worse off, being single-doctor units with inadequate infrastructure and staff who struggled to offer even the minimum level of early health counselling, care and outreach work.

Like anywhere else in India, only those who could not afford private hospitals would want to go to a government institution. Nearly 65 per cent of the population preferred the private sector, according to unofficial estimates. Still, on almost all days, government hospitals would fill up, and the demand for cheaper and better care remained high in the State. The number of outpatients even in the PHCs, which worked from 9 a.m. to 1 p.m, ranged between 100 and 450 a day.

In August this year, even as the State came under the grip of yet another fever epidemic, with over 25.5 lakh people seeking treatment in two months, the majority of them in crowded government hospitals, a report published by the Achutha Menon Centre for Health Science Studies, Thiruvananthapuram, made grim reading for Kerala’s health planners.

A State-wide study conducted by the centre found that on an average, nearly one out of three persons over 18 years of age had hypertension and one out of five such adults had diabetes. Two-thirds of the people in the State in the 45-69 age group are either diabetic or prediabetic. The latter is a condition that puts the person at high risk of developing Type 2 diabetes and also at increased risk of developing heart diseases. The report warned that the change from a prediabetic to a diabetic stage occurred much faster in Asian Indians compared with other ethnic populations.

But even among the better educated, awareness, treatment and control status of the two non-communicable diseases (NCDs) were “alarmingly low”. Only 13 per cent and 16 per cent of people with hypertension and diabetes respectively had adequate blood pressure and blood sugar control status.

The study also found what it termed a “reversal of social gradient for diabetics” for the first time in India, with higher prevalence of the disease in the “low educated group” compared with individuals with more than a high school level education.

“We have been hearing for quite a while that lifestyle diseases like these were on the rise in Kerala. But what is shocking is the finding that over two-thirds of the population in the 45-69 age group (67.7 per cent) is either diabetic or prediabetic,” Dr B. Ekbal, neurosurgeon, health activist and Planning Board member, told Frontline.

Coincidentally, it was soon after the report was published that Kerala launched a determined programme to restore its weakening public health care system, which should have ideally picked up warning signs of a population’s worsening health status much earlier.

Named “Aardram” after the Malayalam word for “compassion” or “solace”, the mission aims to reorient Kerala’s network of nearly 900 rural PHCs and to create a primary care system capable of addressing challenges of the current pattern of diseases in the State; provide quality treatment services at the secondary level hospitals that include taluk, district and general hospitals and to scale up those improvements at each level up to the medical college hospitals (MCHs); and to generate a patient-friendly environment in all government hospitals.

Another, more ambitious project, “eHealth”, which is still in its early stages and whose progress is being eagerly watched by the Centre and other States for “lessons from its success or failure”, was launched a year ago in August 2016. It is to work alongside Aardram with two important objectives: one, to ensure IT-enabled and more efficient service delivery to every individual and household; and two, to generate a centralised, dynamically updated health care, demographic and public health database of every one of them.

“If you look at a graph of Kerala’s spending for health care over the years, you will see a spurt somewhere in the early 1970s, then the next one when the National Health Mission funds began to arrive. Otherwise you will see a plateau. Then the next spurt will be only during the current period,” Rajeev Sadanandan, Additional Chief Secretary in charge of Health, said.

On August 17, the first day of the Malayalam festive month of Chingam, at Chemmaruthy, a village 65 km from Thiruvananthapuram, Chief Minister Pinarayi Vijayan unveiled one of Aardram mission’s proud initiatives: a reinvented public health centre, named Family Health Centre (FHC). It had an attractive facade, freshly painted walls and a lot of breathing space all around. Inside it were a computerised registration facility; waiting areas with clean chairs and televisions; consultation rooms that ensured patient privacy; a hygienic laboratory; a well-stocked pharmacy that dispensed tests and drugs at affordable prices; immunisation, depression and fitness clinics; clean water and clean toilets.

Compact, tidy and finally more equipped than ever for primary care, it had for the first time in history three doctors and four nurses, fieldworkers and volunteers and an extended work schedule from nine in the morning to six in the evening. All FHCs that came after it were to offer “promotive, preventive, curative, rehabilitative and palliative services” to all, “irrespective of whether they came to the institution or not”. It was also meant to provide “outreach activities” for the various public health programmes and “other routine services”.

On an average, an FHC, one each in all the 978 panchayats of Kerala, was to serve a population of around 30,000. Chemmaruthy had about 37,000.

The government’s objective is to make the entire health sector and all tiers of hospitals “people friendly”, Pinarayi Vijayan said at the inaugural ceremony that was held with rustic verve on the grounds of a nearby temple. “Our ultimate aim is to provide a system of ‘family doctors’ catering to every individual in Kerala society. But for that to become a reality, it will take some more time. It cannot happen all of a sudden. For that, we will require a lot more doctors than we have today, for instance. But our aim definitely is to reach that target,” he said.

State Planning Board Vice-chairperson V.K. Ramachandran explained the work cut out for Aardram thus: “A function of Aardram would be people-friendliness in approaching and gaining access to the medical system; another would be converting the primary health centres into family health centres—it will not just be a health centre you go to only when you have an ailment but it will be a centre that will also monitor and track non-communicable diseases, the new scourge in Kerala. Apart from that, Aardram involves upgrading all government hospitals so that referrals are not always necessary and a lot can be done at lower-level hospitals.”

He said that the various types of NCDs that Kerala was facing now required that they be monitored, tracked and treated. “So, if you are registered at an FHC, and then you are above a certain age, you get an SMS saying that it is time that you get your BP checked, and so on. If you can actually track BP, cholesterol and blood glucose levels, that itself will help prevent a whole lot of avoidable diseases and avoid further complications. Given the trend of NCDs in the State, we must do it for the population above 18, not just those above 40.”

Preventive care and fighting epidemic diseases formed the focus of Kerala’s health strategy during the early part of its development. From the 1980s, the State began to be known the world over for its progress in respect of indicators such as life expectancy at birth, infant mortality, maternal mortality and the ratio of males to females in the population. In all such respects, the State began to achieve standards much beyond the Indian average and comparable with developed countries that were medium to high achievers.

But health care managers are increasingly squeamish about referring to these gains of the past, when the State is seeing a determined comeback of many of communicable diseases on a large scale and new threats in the form of NCDs such as cardiovascular diseases, diabetes, cancer and chronic obstructive pulmonary disease (COPD) that have become a major cause of death and disability and is finding itself inadequate to the task of dealing with the alarming increase in death and injury caused by road accidents, the numbers being among the highest in India.

Moreover, even when its achievements have been remarkable and still far ahead of other Indian States, women die in Kerala because of preventable causes relating to pregnancy and childbirth, such as post-partum haemorrhage, pre-eclampsia and sepsis, and young children below one year too die because of diseases of prematurity or congenital heart disease, for example. Also, many people still suffer from neglected tropical diseases such as lymphatic filariasis, leprosy and tuberculosis.

SDG targets

On the basis of the Sustainable Development Goals (SDG) announced by the United Nations “to promote healthy lives and to promote well-being for all at all ages”, Kerala has set its own ambitious targets to further reduce maternal mortality and child deaths even though it has already achieved several of the goals much before other regions. “We have declared our own SDG targets and we are opening ourselves to be measured against that. For instance, one is to reduce the maternal mortality rate from around 60 to less than 30 by 2020 and less than 20 by 2030,” Sadanandan said.

But over several years, the changing disease profile has been calling attention to the need to restructure the public health care system, which was bogged down by the funds crunch of successive State governments.

However, from the late 1990s, with decentralisation becoming a reality in Kerala and funds of local bodies becoming available for local needs, many health care institutions under local governments had also begun to improve, Ekbal said. Until then, institutions like district and taluk hospitals and PHCs were a picture of neglect in terms of funding and manpower. Medical college hospitals were somewhat better off. But then local bodies began to receive 25 to 30 per cent of the Plan funds, and planning and resource mobilisation began to happen at the local level, and all grass-roots-level hospitals benefited from it. This was an important change that happened in Kerala, he said.

“Wherever doctors, health workers, panchayats and people’s representatives, bureaucrats and the people came together, there it worked: there was local resource mobilisation and reallocation of funds. Today at least 30 per cent of Kerala’s public hospitals are functioning remarkably well, including district hospitals such as those in Palakkad and Ernakulam, some of which have got NABH [National Accreditation for Hospitals & Healthcare Providers] accreditation. Even some of the PHCs and taluk hospitals are functioning well, the taluk hospital at Punalur being an oft-quoted example. Such stray instances showed that it was possible to do it in the public sector,” Ekbal said.

During the rule of the previous Left Democratic Front (LDF) government, there was a lot of improvement in the MCHs of the State too. As a result of all this, while a 1995 study showed that 23 per cent of the people used public hospitals, now the number has increased to about 35 per cent, Ekbal said. “In truth, of all the public institutions in Kerala, what did not go down or collapse was the health sector. Education did not benefit that much. But the health sector survived.”

According to Ekbal, it is important to understand that the changes in Kerala are taking place at a time when the world over the concept that prevention (of diseases) and promotion (of health care) are more important or equally important than curative care is coming to the fore once again and a second primary health care revolution is taking place. In the past decades, with the emergence of NCDs as a major threat, Kerala too had succumbed to the tendency of giving importance to specialty facilities in government hospitals.

Dialysis units, transplantation facilities, cath labs, and so on were established, for example, in all district hospitals. Medical colleges today provide state-of-the-art facilities and professional services. Angioplasty, bypass surgery and transplantation services are now provided at cheap rates, and medicines are heavily subsidised. These measures are necessary and must be made available to all, but because of them, the focus shifted away from prevention and primary care.

Aiming high

After the one at Chemmaruthy, only a handful of PHCs have been converted into FHCs at the time of writing this report. “By the end of September, 35 PHCs from all districts of Kerala are scheduled to be upgraded. The year-end target is 170 PHCs. Next year, 500 more would join the ranks of the FHCs in the State,” Keshvendra Kumar, State Director, National Health Mission, said.

On the other hand, the eHealth project, a more ambitious one that ideally should run along with Aardram, is likely to roll out only more slowly. In the first phase, it is to be implemented only in seven of the 14 districts of Kerala and in all new FHCs of the State. It is to provide the digital framework needed to create a patient-friendly interface for all of Kerala’s public hospitals. The concept is simple, explained eHealth technology officer Vinod Raj: “One individual, one EMR” (electronic medical record).

It meant a unique health ID for every citizen that would be linked to a centralised, dynamically updated health care information system that would function simultaneously as an integrated hospital management system, a disease surveillance mechanism, a management information system and a health care planning instrument for the government.

But developing the software for the unimaginable variety of uses the system needs to support is proving to be a frustrating one. So are the nitty-gritty of installing the required hardware in a variety of hospital settings and tailoring them to specific requirements. Vinod Raj said: “The ground rule is this: the business should go on without any failure. When it is that critical, connectivity, power, hardware, software, anything can go wrong. We have to maintain the needs of institutions from the smallest of the PHCs to the huge medical college complexes, and the mobile devices of FHC field staff who go door to door and dynamically update people’s records, among other things. It is a very complex thing. It will take two to three years to stabilise.”

At the Government Model Hospital at Peroorkada, where the eHealth pilot project was launched by the Chief Minister in August last year, a lot of infrastructure improvements and new facilities have come about. But the eHealth facilities are still in limbo. The electronic token system, the self-service kiosks, the computer terminals for doctors and various departments have been established and the networking has been complete. But software developers have not yet come to grips with the requirements of the nearly 30 different specialities. Many young doctors have taken to electronic prescribing, but most of their older colleagues or those handling crowded outpatient (OP) departments such as General Medicine mostly stick to handwritten prescriptions. At the clinical laboratory and the pharmacy, where electronic records have tremendous potential to ease workflow and optimise inventory management and ensure timely availability of medicines and equipment, there was a sense of ownership of the programme, but the staff were reluctant to talk about their experiences.

“Once the project starts functioning in a full-fledged manner, there is no doubt that it is going to revolutionise the public health scene in Kerala. But the development of the software [undertaken by a consortium led by HP] is not yet complete. The stabilisation will take some time. It is a very complex undertaking. There are a lot of bugs,” Dr N. Sreedharan, Additional Director of the eHealth project, said. The staff-short team that runs eHealth is, however, ready to launch the programme in the FHCs, where the requirements, including those of the fieldworkers using dedicated mobile devices, are comparatively not so complex. The main constraint at the FHCs is perhaps providing connectivity with the government’s dedicated Kerala State Wide Area Network (KSWAN), Sreedharan said.

A surprising facet of the Aardram mission is that all the PHCs in the urban areas of Kerala are out of its ambit (see interview with Rajeev Sadanandan). “By a quirk of history, the health centres in urban areas are manned by staff belonging to the Local Bodies Department, not the Health Department. Their focus is more on office work that includes registration of births and deaths, inspecting hotels and factories, sanitation issues, and so on. They are not trained to do immunisation work or fieldwork relating to public health. This is a reason why communicable diseases invariably spread from corporation and municipality areas, not rural areas,” Dr P.K. Jameela, State Consultant, Aardram Mission, told Frontline.

Jameela, who had earlier served as the Director of Health Services, also said she believed that the mission would introduce a paradigm shift in the functioning of the primary care system. “But the success of the mission will depend on how well the doctors and other staff adopt and accept the progressive changes that are envisaged. That is the most important challenge.”

Raising concerns

The Kerala Government Medical Officers’ Association (KGMOA) feels that the government has launched the Aardram programme without enough preparation and has expressed the concern that the interest and enthusiasm among people about it would lead to tensions if sufficient staff and facilities are not in place. “People will flock to the primary care centres and start making demands that we may not be able to meet,” Dr A.K. Raoof, general secretary of the association, said. “As of now, we feel that the extension of the OP timings alone is the only ‘improvement’ in the new FHCs,” he said.

However, association members had wholeheartedly participated in the training programmes and in the preparation of treatment protocols. “The concept is sound and we are very positive about it, but we are worried.” The KGMOA’s demand is that at least five doctors should be appointed in each FHC if it is to run well, given the additional role such centres are required to play in rural society.

“It is true that when services improve, the demand goes up. When I was working as neurosurgeon in 1992 at the Kottayam MCH, there was just a single ventilator in that entire hospital until 2000 when I left. Today, that hospital has 41 ventilators. At the Thiruvananthapuram MCH, there are 71, but even these are not sufficient,” Ekbal said. “So there will be problems, but we have to start somewhere. It is true that after the LDF government came to power, the largest number of posts created was in the health service. Nearly 6,000 posts have been created, the maximum after 1962. But it is still not enough. When we took a count recently at the Thiruvananthapuram MCH, that hospital alone required 1,000 additional posts. We are still sticking to the old doctor-patient ratio. But the population and demand for services have increased manifold. Because even in the medical college hospitals, patients are not admitted as per bed strength as the authorities cannot deny admission to any person in a government facility.”

V.K. Ramachandran told Frontline: “It has been Kerala’s tradition to keep the public sector as a countervailing force, to strengthen the public health system and public control and public access to it. Sufficient funds would be available from the Plan as well as KIIFB [the Kerala Infrastructure Investment Fund Board, the State government’s special purpose vehicle for mobilising resources for social and physical infrastructure projects]. If we can get these things together—ease of access, friendliness, expansion of primary health centres into family health centres, which also handle non-communicable diseases, and then the selective upgrading of facilities at different levels of the public sector hospital hierarchy, underlying all of which is an actually dynamic health record of the population—that will be a great transformation. I mean, we should aim for that. It is doable, and we should aim for that. I think there is a certain preciseness in the mission plan, it is amenable to timetables, and so on. It has a clear programme and a scheme of action that makes it doable.”