Can Kerala’s bold experiment to overhaul public health from bottom up succeed?

On Wednesday evening last week, 40-year-old Raghavan was pleasantly surprised to find that there was a doctor available to see him at his village’s government health facility. Raghavan, who had come down with fever, lives in Cheruthazham, a village in Kerala’s Kannur district, where the primary health centre had been converted to a larger family health centre with more facilities.

“I was surprised to meet a doctor at 5 pm in a primary health centre,” said Raghavan, as he collected his free medicines from the pharmacy.

The primary health centre used to be open only for six hours while the family health centre functions for nine hours with doctors available from 9 am to 6 pm.

“Doctors here used to work till 2 pm,” said Raghavan. “So labourers like me were never able to avail their services, as we had to work till noon to make a living. We depended upon private clinics paying half of our daily earning for consultation and medicines. Availability of doctors till 6 pm will reduce our medical expenditure.

The Cheruthazham centre is one of 35 primary health centres in Kerala that have been upgraded to family health centres. State health authorities want to improve infrastructure and quality of service at all 703 primary health centres converting them into family health centres by the end of 2018.

Each family health centre is supposed to have three doctors, four staff nurses, one dentist, one pharmacist, and one lab technician. Consultation and medicines are being made available free of cost while the laboratory services are at nominal rates. Each centre is to be equipped with multiple consultation rooms, a dental clinic, a laboratory, an outpatients’ waiting area, a children’s indoor playing area, a women’s waiting room with a sanitary napkin vending machine, a yoga hall, a gymnasium and an outdoor play area.

The Cheruthazham family health centre has all these facilities.

The need for revamp

This year’s dengue and swine flu outbreaks in Kerala that have affected more than 26 lakh people have exposed the weaknesses in the public health system. Most healthcare facilities with their inadequate infrastructure and staff shortages have struggled to handle patients.

In many hospitals, there was no place for patients to sit and bystanders had to hold intravenous fluid bags of patients lying hospital verandahs. Government facilities depended on private laboratories for basic tests to confirm fever. The situation was worse at the small primary health centres, each of which had only one medical practitioner.

The project to upgrade primary health centres is of the Kerala health department’s Ardram Mission, or Mission Compassion, that aims to improve all government health facilities – from primary health centres to medical college hospitals.

The first upgraded family health centre was inaugurated at Chemmaruthy panchayat in Thiruvananthapuram district on August 17, the first day of Malayalam festive month of Chingam. As many as 35 primary health centres have been revamped since then.

“By the end of 2017, 170 primary health centres will become family health centres, while 500 more will be upgraded next year,” said State Health Minister KK Shylaja. “We hope to reduce high out-of-pocket expenditure on health by strengthening the public health facilities. It will also minimise people’s dependence on private health care facilities.”

The family health centres also have gymnasiums as part of a plan to combat lifestyle diseases. A recent study has shown that as many as one in three adults over 18 years in the state suffer from hypertension, while one in five from diabetes. It also found that more than two-thirds of adults in the age group of 45-69 years are either diabetic or pre-diabetic.

“We want to inculcate a healthy living style among the youngsters,” said Saritha. “That is why we have decided to set up yoga and gymnasiums at all FHCs.”

Onus on local bodies

But how will family health centres overcome the infrastructure and manpower shortages that have plagues primary health centres? Dr RL Sarita, director of health services, said that the government is doing this by decentralising health management.

“The project puts the onus of local healthcare management also on gram panchayats,” she said.

Local administrative bodies in Kerala have supported the development of health centres ever since the government implemented democratic decentralisation in 1990. Local bodies get up to 30% of the State Plan Fund and these resources have been used to revamp primary health centres.

The state government has created posts for 961 doctors, nurses and paramedics at the new family health centres. Of the three doctors at each centre, the state government will appoint two while the local administration will appoint the third doctor on contract. The salaries of these medical workers will be paid from the State Plan Funds allotted to the local body.

The state health department has issued also guidelines stating that family health centres are healthcare delivery institutions of local self governments. According to the guidelines, “The FHCs should work with different social development sectors like social justice, education, agriculture, water supply, SC/ST development. FHC team has to create an environment conducive to health promotion and disease prevention.”

To set up the Cheruthazham family health centre, for example, Cheruthazham gram panchayat had to find sponsors to fund sprucing up the facility.

“Co-operative banks, youth clubs and social service organisations supported us to provide roof at the outpatients’ waiting area, buy chairs, build the indoor play area and paint the facility,” said PV Valsala, health and education standing committee chairperson of the gram panchayat.

The family health centre has three doctors at the moment and the panchayat is in the process of appointing one more doctor and a pharmacist.

Initial success

In the past month, the larger family health centres have already found more takers than the primary health centres. Dr Anwar Abbas, medical officer at the Chemmaruthy centre said that the number of daily outpatient consultations jumped from 250 to 400 after the upgrade. This is largely because the facilities are now accessible to workers like Raghavan.

“A majority of the patients are daily wage labourers,” he said. “They are finding it easy to come here after their work as we function till 6 pm now.”

Saritha hopes that the impact of FHCs will be reflected in Kerala’s health sector in the coming years. “FHCs ensure adequate facilities for patients, availability of qualified doctors, and free medicines,” she said.“So FHCs will help us combat any medical emergencies in future.”