By Zeena Johar, President – ICTPH
A health system needs to provide for the requirements of an individual through various stages of life and states of health, offering promotive, health-maintenance, preventive interventions for the entire population and disease management capability addressing the tail-end of population-health distribution. Primary prevention targets prevention of disease and disability at the level of the community (immunisation and water and sanitation efforts for example need to be managed at the community level), while higher order preventive efforts at the secondary or tertiary level focus more on the individual. For accurate disease management, appropriate diagnostic capability, aided by evidence based administration of medicines and follow-up ensuring compliance, is crucial to ensure effective curative interventions. IKP Centre for Technologies in Public Health (ICTPH) a not-for-profit research organisation with its mission to design inclusive health-systems for remote rural populations, is anchoring a pilot with a Thanjavur (Tamil Nadu) based partner organisation: SughaVazhvu Healthcare. The objective of this pilot is to design an inclusive health-system ensuring accessibility and affordability for all the members of the rural community in the remote rural parts of Thanjavur.
The way I understand it there are four parts to your Health Systems Design:
1. Infrastructure (Clinic, Hand-helds, EHR, Diagnostics, etc.)
2. Human Resources (Nurses, Guides, Doctors, Administrators)
3. Financing (Insurance, Fee for Service, etc.)
4. Interventions and Protocols (Clinic based, Community Based, Referral pathways)
I feel that in the interventions space it may be useful to add a page in this note on all the ideas that you and your team are working on, referencing the relevant blog entry for each one.
One of our key roles, particularly in Tamil Nadu, once we have examined the patient in the RMHC would be give the patient:
1. Good information about their health status — including a printed report.
2. Good information about healthcare providers — particularly the government.
3. While the patient could certainly choose to purchase medicines and diagnostic services at the RMHC, I feel that it would be appropriate for us to make her aware of what is available / supposed to be available at the PHC and the ICDS Centre (perhaps obtain a booklet from the Government on this). And if indeed she chooses to go there it would be also be important for us to give her a formal letter of diagnosis and referral (perhaps just for medicines or diagnosis) — the resident doctor there is free to ignore our guidance or to use it as additional information while making her decision on the treatment to be offerred to the patient.
This link (http://www.hrhindia.org/assets/images/HRH%20Policy%20Note6.pdf) provides an interesting insight into the career preferences of medical students and nurses in Uttar Pradesh. While the study was very limited in its scope and strictly qualitative in nature it does support the proposition that building an empowerd-nurse-centric primary health system may be a more feasible alternative than trying to force MBBS Doctors to serve in rural locations.
Some of the hypothesis being tested in this note include:
1.Quality of manpower as defined by an MBBS degree is less important in a primary care setting and may even be a hindrance in the delivery of routine protocolised care in the primary care setting – they are very quickly bored with the routine and are not comfortable following strict protocols for treatment.
2.The development of clearly defined protocols for the treatment of routine illnesses and the training of personnel (ideally nurses or AYUSH providers – both of whom have some basic training in medicine but may be more comfortable with following protocols and not get bored with routine) on these protocols maybe the most important step. The ICTPH has developed these protocols and will be sharing them online soon.
3.Development of supportive tools such as an EHR which allows primary care providers to record each and every interaction with the patient can help with integration with higher levels of care as well in auditing the quality of care being provided to the patient – in finance we have been able to successfully train even 10th standard pass people operating in very remote geographies of rural Uttarakhand to do this successfully. The ICTPH team has indeed developed such an EHR as a public good for general use.
4.Development of SOAP or other standard practice protocols for screening (i.e., every patient gets a routine check on temperature, BP, BMI and Waist-Hip Circumference, for example; every female visitor gets a VIA exam for cervical cancer) maybe very important for early diagnosis and management of chronic illnesses. The ICTPH team has developed these protocols and will be putting them online soon.
5.Development of a integrated package of primary care interventions (including for iron-deficiency, IMCI, CVD, vision, hearing loss and Cancer) which are a part of the standard work of the primary health care system would be essential as well. The ICTPH team is in the process of taking each disease specific or condition specific intervention and integrating it into something that a well-trained lay health worker would be able to implement under the supervision of a well trained nurse.
6.Bringing basic diagnostic equipment close to the population may be a very important step forward in improving the quality and timeliness of care being provided in primary care settings. The machines of today are much-much cheaper that they were earlier and are much more automated so require far less training to use correctly. Once again the hypothesis being researched is that a Nurse will be ideally placed to managed these primary care centres entirely on his / her own.
Thanks for sharing – very interesting. Have you seen any results for the pilot yet? The elements that the pilot aims to design very much resonate with the overarching gaps seen in healthcare delivery and specifically innovative or entrepreneurial new models. The only additional challenge that is seen within this space is around regulation; though typically is only more of an issue when you take the pilot you’ve got outside of the region of Karambayam into new areas.
Richard
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