Hand in healthy hand

Collaboration with state governments, training and technology are pillars of the ‘health systems strengthening’ spread

W hen 40-year-old Pramila Irudhundi (name changed) sat down for a health screening in the town of Mancherial in Telangana, she thought it would be a routine checkup. What the nurse discovered was an advanced case of breast cancer. The detection led to Ms Irudhundi getting timely care and treatment at the MNJ Cancer Hospital in Hyderabad.

Catching the disease was the key for Ms Irudhundi, one of about 8.8 million people screened through the pan-India noncommunicable disease (NCD) application that the Telangana government has rolled out across the state. The numbers — with 5 million-plus awaiting their turn — highlight the gargantuan nature of the screening exercise, which is being undertaken by the state government in partnership with the Tata Trusts.

This pilot project is one of several under the ‘health systems strengthening’ (HSS) rubric of the Trusts, an area where effort is to enhance various aspects of the public healthcare structure of different state governments. The methodology for this involves training, technology and the use of models that can be scaled up.

Training tack

Training is a standout feature in the Telangana portion of the programme. More than 9,000 people, among them nurses and medical officers, have been trained to screen citizens and digitise records. The digitisation part is vital. “Digitising health data enables better evaluation, followups and a continuum of care for patients,” says M Venkat Rao, the HSS programme officer for Telangana.

Telangana is also the stage for another large-scale pilot in the HSS portfolio, a telemedicine centre that employs a hub-and-spoke model. The hub, called the care and coordination centre, is staffed by 18 doctors. These doctors use videoconferencing to consult with patients at 95 health centres in four districts. Treatment is suggested on the call or the cases are referred to hospitals.

The centre, which handles about 2,300 calls a month and does everything from fixing appointments to tracking treatment, is a joint venture with the Telangana government, which provides funding, infrastructure and specialist doctors. The Trusts contribute with hardware and software and a team of doctors, field managers and call coordinators.

Mr Rao says the care centre prototype offers more than just telemedicine. “It can take about 40% of the load off the overburdened public healthcare system. Tier-three hospitals in urban areas are unmanageably crowded and even critical cases get sidelined. Patients from remote areas are referred there but they have to spend money on travel, sometimes just to show a report.”

The government is planning to extend the model to more districts and connect around 1,000 urban and rural facilities. As and when that happens, the benefits will flow in to an ever-greater extent. “Such centres save people time and money while also improving accessibility, since patients get quality consulting closer to their homes,” adds Mr Rao.

In Maharashtra the Trusts’ HSS engagement involves improving healthcare services for the urban poor. The project emerged on the back of a 2014 survey which showed that the urban poor faced almost the same issues as their rural counterparts in getting quality healthcare. Although municipal corporations were allocating funds to run urban primary health centres (UPHC), as much as 60% of this was not utilised properly.

Striking results

In 2018, the Trusts partnered the state government to create model UPHCs in Nagpur city. Over the last two years, 22 out of 26 centres have been upgraded and the results are striking. “These facilities would see about 20 walk-ins a day; today, they attract five times that number,” says Dr Amar Nawkar, the HSS programme officer in Nagpur.

What has convinced Nagpur’s citizenry to trust public healthcare is the change they see and experience at the model centres. Computer and internet connectivity, essential drugs and equipment, a hi-tech lab that offers free diagnostics and testing, not to mention an attractive layout and furniture — these centres have been designed with patients in mind.

Bringing the centres up to scratch has been an intensive exercise, the biggest challenge being to change attitudes. “We realised that change called for all the actors — doctors, medical officers and UPHC staffers — to be aligned,” says Dr Nawkar. Team-building exercises were conducted and space was made for things like empathy training (making patients comfortable by greeting them with a smile and compassion).

What keeps the model sustainable is the ‘governance council’, comprising representatives from the government and the Trusts, which provides oversight. And the overall approach itself was crafted to ensure that personnel changes — frequent at the government level — don’t affect the functioning of the centres.

The Nagpur model has drawn the attention of other states and the Trusts are now carrying out a similar intervention in Raipur in Chhattisgarh. A team of 10 doctors and nurses were sent from Nagpur to participate in the initial training in Raipur. “Hearing their experiences has helped the Raipur participants come on board faster,” says Dr Nawkar.

Besides Telangana and Maharashtra, the Trusts have an HSS project running in Kerala through a partnership with the state government to build a trauma and emergency learning centre (ATELC) at the Government Medical College in Thiruvananthapuram. The logic for it is strong.

“Kerala records 40,000-plus road accidents and 50,000-plus related casualties every year,” says Dr Pratibha Nagtilak, the programme officer for ATELC. “The Kerala government wanted to upskill doctors and nurses to handle trauma and accident cases more efficiently.”

Time control

The centre focuses on training medical personnel to handle the golden hour, that critical period which is often the deciding factor in whether an accident victim lives or dies. The training is conducted by the Hyderabad-based Care Institute of Health Sciences and there are courses for doctors, nurses and attenders on specific techniques to keep the neck and spine supported, airway management, defibrillation and life support, etc.

“The Kerala centre is a unique project because of the Kerala government’s desire that this healthcare system attain global standards,” says Dr Nagtilak. The training, which started in January 2020, will cover more than 9,000 medical personnel.

The HSS projects in Telangana, Maharashtra, Chhattisgarh and Kerala are diverse in terms of geographies, methodologies and impact on beneficiaries, but they have one factor in common — they aim to permanently up the quality quotient of the healthcare systems in the respective states.