An ongoing transformation of Nagpur’s urban primary health centres has made affordable medical care more accessible to people
The patients sitting in the freshly painted waiting room have Amitabh Bachchan for company, even if it’s only a video of the movie star — with a message on measles vaccination — playing out on a television screen behind the reception desk. Red signboards provide an attractive pop of colour amidst the off-white walls. The well-appointed space could be part of a private hospital … except that it is not. It is the new look of a government-run urban primary health centre (UPHC) in Nagpur that has undergone a radical upgrade.
The vastly improved centre is the outcome of a partnership between the Nagpur Municipal Corporation (NMC) and the Tata Trusts to overhaul 26 UPHCs across the city. Initiated in December 2017, the partnership targets a widely felt need in what is one of the fastest-growing urban centres in Maharashtra. And it is a need that resonates strongest with Nagpur’s poor, a huge number of whom live in slums.
The ‘model UPHC project’ demonstrates an ecosystem-based approach to providing better healthcare services to the urban poor and is aligned with the central government’s flagship National Urban Health Mission (NUHM). “The project supplements efforts undertaken by the municipal corporation and NUHM through the use of effective tools for public health care management, tools that can bridge the gap between policy and action,” says Amar Nawkar, a programme officer with the Trusts.
The transformation of Nagpur’s UPHCs began with a determining of service gaps in the existing facilities to understand why the centres were not much liked, to put it mildly, by those most dependent on them. The big factors were poor infrastructure, shortcomings in services and a lack of awareness of what was available at the centres.
These and other factors were worked on in the redesign of the model UPHCs, which are based on health system frameworks endorsed by the World Health Organisation and the central government. It was clear that essential components needed improvement to provide comprehensive health services to the public. The Trusts drew up a blueprint that laid out the issues plaguing the UPHCs, as well as what could be done to cure the system of its ills. The proposed partnership spelled out the roles of the partners and the areas of cooperation between different departments.
Six areas for attention were identified for a three-year programme that was divided into three phases, over which 26 UPHCs would be covered. A governing council was set up and this had members from NMC and the Trusts and an independent public health consultant as well. The council monitors the programme’s progress and steps in, when necessary, to eliminate bottlenecks.
An 11-member team from the Trusts was put together to work on the project. Being based in the NMC headquarters has helped the team — and the initiative — maximise operational efficiencies, as has become evident through the first and second phases of the project, which took in 17 UPHCs.
The 17 centres were repaired and repainted by the municipal corporation before the Trusts team began upgrading infrastructure. In order to improve patient experience, new furniture, air conditioners, televisions and CCTV cameras were installed. Staff rooms were built and furnished and the design of the interiors of the centres were standardised, from the colour schemes to the signage.
Bringing in new technology was a key element and this has enabled the UPHCs to follow globally recognised medical protocols. Computers and webcams were procured to have a system with electronic health records. “A patient’s medical record is captured when he or she registers at a UPHC,” explains Mr Nawkar. “This makes it easier to improve efficiency and the proficiency of treatment.”
Patient experience has been an important aspect of the makeover, the intent being to ensure that visits to the centre go as smoothly as possible. The resultant streamlining has simplified the process. Patients register, sit in the waiting area and then go for their consultation. The doctor provides a print of the prescription, which the patient can use to collect medicines from the UPHC pharmacy.
The changes have taken account of the staff, too. Clinical and non-clinical personnel at the centres have undergone training for capacity building. Along with technical skilling, experts were roped in from the Institute of Hotel Management in Aurangabad to conduct workshops on motivational training, soft skills and communication.
In essence, primary care is incomplete without adequate diagnostic competence. The city had three designated laboratories but using their services was a cumbersome task for patients. That explains why the provision of clinical and biochemistry diagnostics was made an integral part of the model, and in innovative ways.
“We found that people were spending money in private establishments for basic laboratory investigations,” says Mr Nawkar. “Since the municipal health system already had doctors who could suggest investigations, staff to collect samples and space to conduct tests, we decided to set up a state-of-the-art centralised laboratory where spending would be kept to a bare minimum.”
After plenty of hard work, the first phase of the model UPHC programme was completed in June 2018 (and the second in January 2019). Staff training was an issue but that has been ironed out. “We have provided support not just during the training phase but even after operations have begun,” says Mr Nawkar. “All UPHCs have our people handholding the staff and ensuring process compliance.”
Up until now some 38,000 patients have been registered under the project. The consultation process has become more organised. The soft skill training has helped change the way the staff interact with patients. And the availability of drugs is being regularly updated so that supply is not interrupted.
The centralised pathology centre offers 49 diagnostic tests at a nominal rate that can be done through the UPHCs. Blood samples are collected at the centre and unique codes are tagged with the patient’s name. The samples are tested at the centralised laboratory and the reports get dispatched to the UPHC, where the patient can collect it.
For the first time, the UPHCs are delivering crucial demographic data to the state health administration. “The electronic records help determine the footfalls at the UPHC, they indicate the gender and age of the patients, and the disease distribution,” says Mr Nawkar. “For example, if diarrhoea cases increase in a particular area, the administration will be alerted and they can take steps to control the situation. The digitisation of patient records is bringing in better data analytics and near real-time reports, leading to focused action plans and informed policy decisions.”
Staff at the UPHCs are upbeat about the new systems and processes. “The provision of diagnostic facilities and medicines has led to an increase in patients visiting our centre,” says Renuka Yawalkar, a doctor at the Futala UPHC. Sarika Mankar, a lab technician at the Indora UPHC, says, “The furniture provided by the Trusts has helped us organise our equipment and supplies more efficiently.”
NMC officials are highly appreciative of what the partnership with the Tata Trusts has delivered. “Collaborations such as these help raise the standard of medical health,” says additional municipal commissioner Ram Joshi. “We have technocrats and qualified medical staff, but the Trusts have management experts who can help with the scale of managing all these factors.” On its part, the corporation has stepped up efforts to create a more productive environment.
The Nagpur UPHC programme has secured many positives and it has admirers in the medical care ecosystem, but there is much left to be done. Work on the third phase of the project is set to commence and new facilities such as a tele-medicine unit are being planned.
The UPHCs will be linked to medical colleges so that the medical officer at the centre can, if and when required, consult an expert or specialist for advice. Another plan is to use a mobile medicine unit to connect doctors working in slum areas with those at the centres. “This unit will help provide people with specialist care at their doorstep,” adds Mr Nawkar. Meanwhile, nationally recognised medical institutions are extending their support by conducting regular clinical audits of the centres to ensure quality of service.
What all of this adds up to is a vital reality — the Nagpur Municipal Corporation has succeeded to a significant extent in its aim to provide high-quality primary healthcare to its populace especially those who cannot afford expensive private care.