Health, the sustainable development goals (SDG) and the role of UHC Session 7 : Improving frontline services : maintaining the momentum on health workforce strengthening Kerala s Experience Dr. K. Ellangovan MS(Ortho), PhD (IIT-M) Secretary to Government Department of Health & Family Welfare Government of Kerala, INDIA
A Snapshot of KERALA One of the smaller state, situated in the south west corner of the country. We are closer to Maldives and Srilanka. Has one of the best health indices in the country be ti IMR, MMR, Longevity etc.. Has 33 million people with one of the high sex ratio, in favor of female Relatively affluent, high female education, late marriage of girls Ruled generally by coalition government, vibrant democracy One of the de-centralized democracy Has large number of Non-Resident citizens ( huge remittance of foreign currency)
Issues in Frontline Health Services: Worker s Perspective Frontline service is not as attractive as tertiary care services. (The services of health department is seen more as a curative service and not as preventive or promotive) High attrition rate (migration both internal & external, members of the Panchayats and school teachers) Lack of clarity on role and responsibility (Changing morbidity profile has not brought about corresponding change in skills) Low motivation (poor monitoring, shifting controls and lack of adequate incentives) Working in silos (Poor coordination skills with other departments, poor field work)
Issues in Frontline Health Services: Through the prism of healthcare dimension Access Geographical inaccessibility tribals, coastal belt Service barriers (Incomplete range of services) Quality Knowledge gap (Soft skills included) Lack of standardization of services (indiscriminate Antibiotic usage) Administrative inefficiency (over burden) Cost High out of pocket expenditure (Medicines and Diagnostics)
What was our plan and how we did it? 1. Operationalize UHC in three districts (Two approaches) 2. Supply of free generic medicines 3. Rationalization of Anti-biotic usage 4. Created a forum for intersectoral coordination Public health protection Agency 5. Community based services palliative care programme, Cancer detection camps, school health & Comprehensive mental health programme
Strengthening frontline services Through Pilot project to operationalize UHC Implemented two pilots one with Public Health Foundation of India and other with University of East London University of East London standardizing the treatment protocol and skill upgradation. PHFI revamping the facilities and reengineering the patient care cycle Robert Kock s principle of 80:20 was adopted 20% of clinical cases leading to 80% of the morbidity in the population Primary care physicians were trained to manage 20 common ailments through A clinical care pathway prepared by professors in the medical college Facilities in the PHCs were spruced up with gadgets and equipments Availability of medicines for common clinical conditions ensured Clinical laboratories established in primary care centers
Results of UHC pilot in Kerala (in selected PHCs) FACILITY PRIMARY HEALTHCARE CENTER, CHEMMARUTHY COMMUNITY HEALTHCARE CENTER, VENPAKAL PRIMARY HEALTHCARE CENTER, KALLIKAD CONTROL: PRIMARY HEALTHCARE CENTER, VEERANAKKAVU REMARKS Time Frame 2013 2014 2013 2014 2013 2014 2013 2014 Outpatient Registration 60,497 62,287 85,270 85,611 44,884 34,680 71,528 74,400 No remarkable change in the number of total outpatients registered at the three pilot facilities. Range varies from a 0.3 percent to three percent increase Diabetes Mellitus 23% 26% 29% 31% 6.5% 8.5% 3.4% 4% Increase in percent of patients screened positive for diabetes mellitus are in the range of seven percent to thirty one percent from the total outpatient registrations. The control facility had a seventeen percent increase in diabetes mellitus screening. Hypertension 26% 29% 30.7% 32.8% 7.9% 9.3% 4.5% 5.32% Increase in outpatient screened with hypertension in the range of seven percent to eighteen percent.
Results of UHC pilot in Kerala (in selected PHCs) FACILITY PRIMARY HEALTHCARE CENTER, CHEMMARUTHY COMMUNITY HEALTHCARE CENTER, VENPAKAL PRIMARY HEALTHCARE CENTER, KALLIKAD CONTROL: PRIMARY HEALTHCARE CENTER, VEERANAKKAVU REMARKS Fever 1.78% 1.79% 14% 13% 2.2% 2% 12% 7.9% No remarkable change in the outpatients registered with fever cases. Depression and Psychiatric Disorders Immunization 0.01% 0.04% 11% 10% 0.9% 1.8% 2% 3% 93% 93% 100% 100% 88% 97% 83% 84% Detection of depression increased by three times at Chemmaruthy and doubled in Kallikad. Depression outpatient cases decreased nine percent at Venpakal. The control facility had a fifty percent increase in depression screening cases. Immunization registrations have been consistent at both Chemmaruthy and Venpakal, with a slight increase of ten percent in immunization registrations at Kallikad. The control facility immunization cases increase by 1.2 percent. Percent of Referrals From Outpatients 0.6% 0.2% 3% 3% 4% 3% 2% 3% Percent of Follow Up Cases After Outpatient Referrals 0.2% 0.1% 62% 71% 2% 3% 3% 4% Overall referrals to the higher level of care have remained same or decreased, in the range of twenty five percent to sixty seven percent. Referral cases increased by fifty percent at the control facility. Increase in follow up cases in the community ranged from fifteen percent to fifty percent at Venpakal and Kallikad. Follow up cases reduced by half at Chemmaruthy. The control facility follow up cases increased by 33.3 percent.
Supply of free generic drugs to reduce the out of pocket expenditure Kerala today supplies 495 free generic medicines in the primary care centers This includes 149 drugs for non-communicable diseases and 69 anti cancer drugs Karunya Community Pharmacies sell branded drugs at concessional rates This has resulted in reverse flow of patients from private hospitals to Public hospitals at a rate of 8% per on a year on year basis from 2011
Rationalizing use of Antibiotics To overcome Antimicrobial resistance A public private partnership forum was created to discuss and evolve a stewardship programme for rationalizing use of antibiotics 13 professional bodies prepared and vetted a list of antibiotics to be used A national symposia was conducted and a antibiogram was approved and Published. The same is under implementation. The cost of medicines will drastically reduce besides the chances of Developing resistance. The pilot survey is underway to find out the impact
Public Health Protection Agency to achieve intersectoral coordination A first of its kind in the country to address social determinants of health A Ministerial committee and a committee of secretaries in the department of Health, sanitation, local self governments, water supply, labor and education A statewide action plan to control and monitor epidemics in the state Plethora of schemes aiming to achieve financial protection Statewide survey for non-communicable diseases (detected new cases of Diabetes and Hypertension in young adults) A forum is today available to address social determinants of health
Workforce migration - issues Kerala has probably highest rate of migration to other states and abroad Better pay and living conditions Family compulsions (marriage etc..) Societal outlook (perception) Government granting long periods of leave To learn newer techniques Inconvenient posting On an average about 12% of the workforce in the government is on leave [shortage of specialists and experts in the state (Psychiatrist, Anesthetist etc..)] Remote areas and Tribal pockets have no sufficient workforce.
Initiatives to retain workforce in rural areas Government of Kerala has revised pay and allowance for doctors and other staffs New Primary Health centers Financial incentives (addition to pay) for those in tribal belts Non-financial incentives to help them secure Post graduate seats on priority Periodic review and declaring scare category to deny them long spells of leave Tenure restriction in difficult and remote areas Switching over to District recruitment boards instead of state level recruitments Local recruitments (tribal youths as peer educators) NCD training Periodic training (to include motivational courses, orientation courses) Cancer detection programmes Dis-incentivising ASHAs who have got elected as local government representatives
Lessons for a wider audience Align services to the morbidity profile Clarity on role responsibility of frontline workers Involvement of local community to achieve community participation Local recruitment of workforce Reposition primary care institutions as centers of comprehensive care Constant skill up-gradation & motivational courses (self esteem) Recognition for work beyond the call of duty Post graduate courses in medical education department to align with disease
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