Universal Health Care Primary Care Pilot Project
The Report of the Steering Committee on Health for the 12th Five Year Plan published in February 2012 by the Health Division of the Planning Commission of India highlighted that the Government's 'foremost commitment was towards evolving Universal Access to Essential Health Care and Medicines, so that disparities in access to health care, particularly those faced by the disadvantaged and underserved segments of the population would be corrected'. Health system goals were defined by the Committee as including 'quality, efficiency, acceptability, equity and responsiveness'. It was also highlighted that a strong comprehensive primary care platform was critical to the development of a health delivery system which would be universally accessible, affordable, and would provide a clear basis for the national package of 'essential health services' to uniformly high standard.
In response to this vision, the Department of Health, Government of Kerala (GOK) developed a plan to pilot test a new model of primary care as a basis for Universal Health Care (UHC) in Trivandrum. The proposal for the UHC Primary Care Pilot Project was submitted under the National Health Mission (NHM) .The proposal also highlighted the need for a number of stakeholders such as Directorate of Health services, Directorate of Medical Education and others to offer leadership, guidance and practical support to the project. Furthermore, the National Health System resource Centre (NHSRC) was identified as an important knowledge partner to guide the study and disseminate the findings. Technical support for this endeavor has been obtained from a consortium of primary care and public health experts from University of East London (UEL). The NHM Programme Implementation Plan (PIP) for the year 2013-14 approved the project and three institutions, CHC Venpakal, PHC Kallikad and PHC Chemmaruthy has been selected as pilot institutions for the pilot. The State Health Systems Resource Centre Kerala (SHSRCK) is the nodal agency for implementing the project in three pilot institutions. The major aspects of the UHC Primary Care Pilot Project are detailed below.
Development of Protocols for Disease Conditions
In the initial phase of the project the protocols were formulated for 6 common conditions which include the following: diabetes, diabetes foot care pathway, hypertension, depression, and antenatal care. The fever protocol is adapted from DHS protocol. The key purpose of the pilot is to develop shared care pathways within the PHC and between the PHC and other levels of care and to have a standardized system of care guidelines in place for the primary care setting.
Developing of basic Electronic patient record
An important flagship of the pilot is the planning of an IT platform for the delivery of care. The record has been designed to be flexible so that it can be modified and expanded as staff becomes more confident in its use and links can be built between the basic patient record and disease management protocols. The basic patient record is now uploaded to the PHC system. The record at present allows basic registration data such as name and date of birth, health data such as BP and BMI, consultation information and prescription details to be recorded for each patient.
Training to PHC staff for the first 6 conditions
The training for the staff of three pilot institutions started is one of the most important components of UHC project and the training focused on the management of the six conditions which includes diabetes, hypertension, depression, antenatal care, immunization and fever management to all staff of the three institutions. The purpose of these sessions was to create a common understanding of UHC and the purpose of the project among PHC staff and higher level clinical experts, present a large body of material to PHC multi-disciplinary staff in the shortest time possible, establish an interaction among PHC staff and between PHC staff and secondary/tertiary care experts with the local system.
Development of infrastructure of Pilot PHCs to facilitate improved care
As part of the project one of the key components is infrastructure development of three pilot institutions which would contribute to achieving the overall objectives. The main basis for infrastructure improvements is to facilitate patient flows through the shared care pathway. For e.g. a smooth progression from the waiting area and patient registration desk to a point where BP and basic measurements can be recorded before the patient proceeds to the doctors room. The idea was to improve the patient experience in the waiting area and utilize the waiting space for health education through provision of health promotion messages.
To develop training resources to build community and LSG institutional capacity and to ensure that the care pathways are appropriately implemented
An important aspect of the pilot is to build on Kerala's existing formal links between the PHCs and LSGIs. Hence one dimension of the pilot development is to build community and LSGI capacity to make a formal and important contribution to primary care delivery.
Introduction of Diabetic complication screening services at primary care level
the pilot helps to introduce for the first time diabetic complication screening at primary care level which includes annual diabetic foot care screening services, referral for diabetic retinal screening and renal screening services at primary care centers (where lab is present). An annual diabetic foot care examination form is made to perform annual screening services. This intervention in the pilot is to address the diabetic challenge of the community and also for early detection of diabetic complications which helps to meet the economic constraints affected by families with diabetic complication.
Baseline Survey in the three pilot institution areas
Another key component of the project is to undertake a baseline survey in the three pilot institutions and this survey can help in assessing the effectiveness and scalability of the model in the initial phase of the project.