Since the WHO’s Alma Ata Declaration on Primary Health Care (PHC) there has been debate about the advisability of adopting comprehensive or selective PHC. Proponents of the latter argue that a more selective approach will enable interim gains while proponents of a comprehensive approach argue that it is needed to address the underlying causes of ill health and improve health outcomes sustainably. Under the more comprehensive model, activities were along a continuum of promotive, preventive, rehabilitative and curative. Under the selective model, the focus moved to rehabilitative and curative with very little other activities. Government of India is aiming at providing comprehensive health care Via health and wellness centres.
Aardram Mission is one of the four missions under the ‘Nava Kerala Mission’ initiated by the government of Kerala, which aims at the same deliverables at the grass root level . It was launched with the objective to completely transform the public health sector in the backdrop of the Sustainable Development Goals (SDGs) 2030 of the United Nations (UN). Aardram Mission’s primary focus is on SDG 3, ‘Good Health and Well-being’. The health status of Kerala being different from the rest of the country, there was a need to redefine the SDGs in the context of the state as a part of which Mission Aardram was launched in February 2017. Kerala has set short-term goals to be achieved by 2020 and long-term goals to be achieved by 2030 as part of the SDGs. This was formulated by various expert committees who worked on health issues prevailing in Kerala.
The main objectives of Mission Aardram are:
1. People-friendly Outpatient Services
2. Re-engineering PHCs into FHCs
3. Access to comprehensive health services for the marginalised/vulnerable population
4. Standardization of services from primary care settings to tertiary settings.8
The main focus on the PHC to FHC transformation aspect of Mission Aardram, which
is a phased series of infrastructural and administrative changes. With the strong emergence ofthe profit-oriented private healthcare sector in Kerala that seemed to have been gaining increasing popularity among all sections of society, people began to lose faith in the public healthcare system (the PHCs in this context). A stronger curative focus gave the private hospitals an upper hand and forced PHCs across the state to compete along the same lines tomerely stay afloat. An overall shift in the direction of curative healthcare services drastically increased the out of pocket expenditure for patients, and combined with the epidemiologic anddemographic transition, government intervention through Mission Aardram eventually becamenecessary. In addition to playing the role of the street-level bureaucrat when it comes to SDG-3,the transformation envisions comprehensive healthcare provision inclusive of ‘preventive, promotive, curative, palliative and rehabilitative services.’The changes that accompanied the transformation can be categorised into those pertaining to strengthening primary care, improving the quality of services, addressing the social determinants of health and community participation. Strengthening primary care and improving the quality of service provision largely focuses on infrastructural improvements, human resource training, record management through the e-Health system, improved laboratory facilities and amore preventive rather than curative outlook towards healthcare service provision. The Panchayat Raj Act of 1994 that transferred institutions like to PHCs to the local self-governing bodies proved especially beneficial at the time of the transformation as it paved the way for increased convergence with other departments and national, state, or panchayat level programmes, thereby better positioning the transformed FHCs to address the social determinants of health. Community Participation is an important characteristic of a Family Health Centre, especially in the more rural FHCs as they bring the community together to work towards improving the quality of living in the area through its different forums, for which a notable mention in this context would be ‘Arogyasena.’
Observably, one of the most significant changes would be concerning how the patients are dealt with at the FHCs. There exists a pre-established chronological sequence of checkpoints that the patients are guided through, allowing better patient flow. This has a doubly positive effect on the functioning of the FHC as it not only allows better service provision at each step through specialisation, but also allows the centre to deal with higher volumes of patients.
Co-ordination and Community Involvement
The involvement and autonomy of operation of the local-self governments in the functioning of the FHCs proves beneficial because the LSGs are perfectly positioned to act as co-ordinator and involve other departments, organisations and Panchayaths. Involvement of such organisations is quintessential as it helps in addressing the social determinants of health in a more wholesome manner. Lack of good health in a community doesn’t imply that the Health Department and Panchayat aren’t carrying out their function, as there exists several non-health related social determinants of health, affiliated with other departments. The involvement of the LSGs provides the perfect platform for such a kind of inter-sectoral co-ordination Mission Aardram also ensures community participation for available services through ASHA,WHNSC, Kudumbashree health volunteers, and an initiative they have received much praise for, ‘Arogyasena.’
Since FHCs are geographically bound to a particular Panchayath, it is possible tointuitively derive quantitative indicators relating to reach or impact of certain outreachprogrammes. For instance, based on the population of a Panchayath, which is commonknowledge to all staff at the FHC, and considering the statistic that 20% of the populationis prone to develop diabetes28, an approximation can be drawn comparing recordedcases of diabetes in the area using eHealth to expected numbers of diabetic patients.While this requires no official documentation and can be carried out at very low costs, it’snot the best or most accurate measure there is. It does not account for the residents thatmight choose to visit private hospitals instead, and the very premise of the number ofcases on eHealth could it in itself be incorrect owing to its limited reach. The Floods that occurred in Kerala in 2018-19 severely deterred progress in Phase 2 ofMission Aardram. The Health Department and LSGs had to redirect their funding andfocus towards rescue and rehabilitation operations. Several of the newly established centres and ongoing construction sites were badly damaged. In this light, it is importantto set aside contingency reserves to lessen the blow that unforseen events like the secould have on implementation of a particular project. Outside of the compilation of the Health Status Report, other outcome documentation,measurement and evaluation methods aren’t uniform across FHCs in the State. Allcentres need to undergo the same treatment in order to conduct a fair comparisonbetween them. Analysing and understanding the gap and what caused it, and how itmany have been bridged at another centre is the first step towards solving it, and for thisvery reason, a uniform measurement that identifies certain KPIs as listed in the National Health Policy. Only the best performing FHCs areidentified for the NQAS (National Quality Assurance Standards), which are broadlyarranged under "Areas of Concern"– Service Provision, Patient Rights, Inputs, SupportServices, Clinical Care, Infection Control, Quality Management and Outcome. These standards are ISQUA accredited and meets global benchmarks in terms ofcomprehensiveness, objectivity, evidence and rigour of development. 29 NQAS ratings at FHC Poozhanad are 99%, with an LEIKERT score of 4.4 / 5, and it is the first centre togo completely paperless. The following points are of great importance while measuring and evaluating outcomes under Mission Aardram
While reviews and gap analyses are being conducted frequently, it was so evident that
- There is less focus on documenting and communicating the results to the large network of people involved in delivering the outcome of this project.
- The environment is enabling for doing population enumeration and perfect dissemination of preventive and promotive services.
- It is time that the society of Kerala should be made aware of Health seeking behaviour rather than Treatment seeking behaviour, leading to high out of pocket expenditure.
- Information education strategies should aim at all 826 public health institutions and their geographic area with LSG participation
Hence the state of Kerala is planning a Peoples Campaign with motto “OUR HEALTH OUR RESPONSIBILITY”. The annual plan has been prepared to give emphasis on
- Healthy food campaign
- Exercise and yoga promotion
- DE addiction and against drug abuse
- Cleanliness and sanitation
- Importance to Health seeking rather than treatmentseeking
OUTCOME- By conducting effective IEC/BCC activities in all the 826 panchayaths for preventive promotive areas of the above said 5 domains will be aiming at huge beneficiary improvement in the following areas:
- Population enumeration to happen in all operational Health and wellness centres (826)
- Population based screening
- Health promotion and NCD awareness activities
- Promotion of physical activities
- Diet modification
- Other lifestyle modifications
- Defaulter tracking and ensuring treatment
- Support groups for physical activity promotion, rehabilitation( counselling)
- Creating spaces for physical activity, Yoga, sports and outdoor games, exercise etc in association with LSGD/other agencies
- School and workplace interventions ( nurses outreach)Screening for mental illness using screening questionnaires as per “sampoornamanasikarogyam”/ “AASWAS”/ “Ammamanasu” guidelines and referran
- Ensuring treatment compliance and follow up of patients with mental disorders.
- Defaulter tracking
- Facilitate access to support groups.
- Vulnerability mapping, identification, mobilisation, treatment compliance follow up and referral of COPD/Asthma cases to FHC
- Tobacco cessation activities and COTPA
- IEC/BCC activities at community and schools level for primary and secondary prevention
- Identify and inform symptomatic cases to nearest health worker and facilitate medical care
- Active case search/ survey during an outbreak.
- Suchitwa mapping and hot spots identification
- Linkage with WHSNC, LSG, other line departments, NGOs and Harithakeralammission to address social determinants of health.
- Awareness on airborne infections, cough hygiene and hand washing, need for isolation.
- High risk screening,
- Sanitary survey of drinking water sources and ensuring chlorination
- Periodic water quality monitoring.
- Maintaining ORS Depot
- Activities in connection with enforcement of public health and food safety laws
- Integrated Vector Management activities
- Migrant screening
- Active blood smear collection for detection of Malaria &Filaria.
- Mass and contact survey of malaria cases.
- Morbidity management of lymphatic filariasis
- MDA -TAS activities
- Doxy prophylaxis for high risk groups (handling domestic animals, fishing, farming etc)
- Rodent control activities
- Identification, mobilisation and screening of individuals with hypo/erythematous patches and other symptoms suggestive of leprosy ( Aswamedham )
- Periodic screening of school children and migrants
- Mobilisation of close contacts of leprosy patients for screening
- Ensuring treatment compliance in leprosy
- Vulnerable population mapping
- Identification of cases with cough more than two weeks/weight loss/ prolonged unexplained fever and referral to FHC for Sputum AFB
- Identify and train DOTS provider
- Promote HIV and diabetes screening in TB cases
- Ensure treatment compliance, identify adverse drug reactions and refer in TB treatment
- Identifying high risk pregnancies and follow up
- Planning and implementation of activities at community level
- Premarital counselling of eligible couples and Support for planning of pregnancy
- Pre-conception supply of folic acid to prevent NTD
- Early detection, registration of pregnancy and issuing of ID number and MCP Card
- Antenatal check-up including screening of Hypertension, Diabetes, Anaemia etc
- Immunization for pregnant woman-TD
- IFA and Calcium supplementation
- Transport entitlements
- Follow-up of Gestational Diabetes Mellitus and Pregnancy Induced Hypertension.
- Registration in RCH portal and MCP card.
- Initiation and management of ARI/Diarrhoea and other common illnesses and referral
- Screening, referral (DIEC/FHC) and follow up/tracking for disabilities, developmental delays and behavioural abnormalities.
- Ensuring full immunization coverage
- Vitamin A supplementation
- Reporting of Adverse Events
- Following Immunization (AEFI)
- Follow up to ensure prophylactic and therapeutic compliance of IFA/WIFS
- Regular Post- partum care visits
- Home based new-born care through 7 visits in case of home delivery and 6 visits in case of institutional delivery
- Educating mother and family on new born danger signals.
- Identification and care of high risk new-born - low birth weight, preterm and sick new-born (with referral as required)
- Counselling and support for early and exclusive breast feeding complimentary feeding practices
- Identification of congenital anomalies and appropriate referral to DEIC/FHC
- Mobilization and follow up for immunization services
- Reporting of neonatal death
- Awareness about programs like Hridyam, New born screening (SalabhamJatakseva), SruthiTarangam, RBSK, Arogyakiranam and follow-up of beneficiaries
- Growth Monitoring, IYCF and food supplementation linked to ICDS
- Identification of acute malnutrition referral and follow up care for SAM
- Prevention of Anaemia - Iron supplementation and Deworming
- Prevention of Diarrhoea/ ARI
- Promotion of Home Available Fluids (HAF) and ORS
- Pre-school and School level Child Health activities - Biannual screening, School health records, Eye care, De-worming etc
- Screening of children as per national and state programs to cover 4’D’s Viz. Defect at birth, Deficiencies, Diseases, Development delay including disability (RBSK and Arogyakiranam)
- Awareness creation on proper use of electronic gadgets like mobile phone, tab, TV etc
- Promotion of physical activity and healthy food habits like reduced salt and sugar intake and increasing consumption of fruits and vegetables
- Adolescent Health
- Awareness creation, Counselling and follow up on:
- Improving nutrition
- Sexual and reproductive health
- Prevention of substance misuse (Vimukthi program)
- Healthy life style promotion
- prevention of Anaemia
- Provision of IFA under National Program
- Identification of eligible couples for temporary and permanent methods
- Follow up of contraceptive users
- Counselling and facilitation of safe abortion services
- Follow up for any complication after abortion and appropriate referral if needed
- Awareness creation and referral services for infertility
- Identification and referral of visual impairment or defects in general population.
- Identification and referral of cases for cataract surgery
- Promoting annual retinopathy screening for all diabetic and hypertensive patients.
- Screening for common oral diseases/conditions and referral with special emphasis on geriatrics and palliative care patients.
- Screening for oral cancer and premalignant conditions in high risk individuals and referral
- Tobacco cessation activities and COTPA and IEC/BCC activities at community and schools level for primary and secondary prevention
- Identification of high-risk groups like persons living alone, widows, persons with co morbid conditions, addictions, bed ridden patients etc