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Health for All

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Health for All

[This article was published in the June 2010 issue of the eHEALTH Magazine (http://www.ehealthonline.org)]

With the Tamil Nadu Health Systems Project now in place, the state government is upbeat about making its public sector health services more accessible to the poor

With the Tamil Nadu Health Systems Project now in place, the state government is upbeat about making its public sector health services more accessible to the poor Tamil Nadu has done exceedingly well in improving its health status and ensuring good healthcare services for its citizens. Having achieved the status of a role model state for health, the excellent health of Tamil Nadu is reflected through its improved health indicators including infant mortality rate and maternal mortality rate. The maternal mortality rate in Tamil Nadu witnessed a considerable drop from 145 in 2001-02 to 79 in 2008-09, while the infant mortality rate fell from 49 in 2001 to 31 in 2008. One of the major drivers for this success has been the implementation of the Tamil Nadu Health Systems Project (TNHSP) in 2005, which aimed at overcoming the numerous barriers to good health.

Project Profile

Funded by the World Bank at a total cost of INR 597.15 crore, the TNHSP was implemented in January 2005 for a period of around five years finishing March 2010. Owing to the success of the project in the past five years, the World Bank has provided an extended budget of INR 627 crore for the next three years. Targetting to improve the health of the people of Tamil Nadu, especially the poor and the disadvantaged, the TNHSP covers various other aspects that are aimed at improving the overall status of health in the state. Improvement of infrastructure in district and sub-district hospitals, maintenance of medical equipment, building up a comprehensive health management information system, promotion of public-private partnerships and preventing risk factors for non-communicable diseases are some of the major aspects that the project looks into.

Initiatives under TNHSP

Improving Quality of Care

Enhancing quality of care at various healthcare centres and secondary care government hospitals was the primary issue that the TNHSP aimed at addressing. The project initiated ‘Quality Circle for Excellence’ across hospitals which encouraged a bottom-up ownership to allow the lowest rung of the staff to interact with their superiors and device solutions for enhancing care provided at the hospitals. The project came out with a handbook and standard treatment guidelines and established poison treatment centres as the state had high incidences of snake bites in tribal areas.

Objectives of TNHSP
Increasing access to health services, particularly for poor, disadvantaged, and tribal groups
Developing effective interventions to address key health challenges such as non communicable diseases and trauma cases
Improving health outcomes, access and quality of service delivery through strengthened management of the public sector health systems and greater engagement of the non governmental sector
Increasing the effectiveness and efficiency of the public sector hospital services, primarily at district and sub-district level

 

“The World Bank’s involvement in the TNHSP has helped introduce new approaches in the way the health sector functions in TN”
Dr. S Vijayakumar
Project Director
Tamil Nadu Health Systems Project

Please provide an overview of the TNHSP and the major initiatives taken by the Government of Tamil Nadu under this project.

The main goal of the TNHSP is to improve the health outcomes of the people of Tamil Nadu, especially the poor and the disadvantaged. As a major initiative, we have improved the infrastructure of all district and sub district hospitals. We have refurbished the district hospitals in Tamil Nadu.

The project also focusses on procuring medical equipment for these hospitals. We have appointed biomedical engineers across the state to provide timely and efficient maintenance of equipment.

The project supports health partnerships in the implementation of all it components and we have partnered with several non governmental organisations to enhance the services offered.

CemONC centres have been created in existing government hospitals to provide comprehensive obstetric and neonatal care, especially to the poor and tribal populations.

We have a double burden of diseases in the country, but so far our primary focus has been on public health and communicable diseases. We are not giving much importance to the non-communicable diseases. The two pilots on cancer cervix and hypertension, implemented under TNHSP, would now be upscaled to all districts. Our primary focus would be preventing hypertension and diabetes by supporting them clinically, which is a very massive effort. We also want to link up the identification of these with our insurance scheme the Chief Minister Kalaignar Insurance Scheme for Life Saving Treatments.

We have also started EMRI 108 ambulance services in which we want to add another 200 ambulances to strengthen the emergency transport services of the state. We are planning to create a state data resource centre. We want to strengthen our activities for standardising equipment designs and maintenance. We want to establish state-of-art laboratories in all districts that can network with all other centres.

How has the health management information systems programme, initiated under TNHSP benefitted the healthcare facilities in Tamil Nadu. What have been its advantages in terms of cost containment and improving the overall efficiency?

We proposed to link up all the secondary care government hospitals and health institutions in the state with a comprehensive health management information system. Already, 41 facilities have been fully computerised and the remaining hospitals are currently in the process of acquiring a comprehensive health IT infrastructure. We are looking at introducing HMIS in all government hospitals as well as medical colleges/institutions.

We haven’t done any analysis on the advantages of this system, yet. However, there has been a definite decrease in costs as the manual systems are being done away with, because of the government orders. One year from now, we should have enough data available to quantify these benefits.

How has the World Bank’s involvement aided in the success of the project?

The World Bank’s involvement in the Tamil Nadu Health Systems Project has helped introduce new approaches in the way the health sector functions in the state, such as promoting collaboration with the nongovernmental sector, adopting quality assurance mechanisms and addressing the growing burden of non-communicable diseases. Having successfully completed the initial five years of the project at an estimated investment of INR  597.15 crore from the World Bank, the extension of the project for the next three years has received an additional financial support of INR 627 crore from the organisation.

State Health Systems Strengthening Projects Funded by World Bank in India
Andhra Pradesh  |  Karnataka (KHSDP Completed, KHSRDP Ongoing)  |  Punjab  |  West Bengal
Orissa  |  Maharashtra  |  Uttar Pradesh  |  Uttarakhand  |  Rajasthan (Ongoing)  |  Tamil Nadu (Ongoing)

“One of the big success stories of World Bank’s work in public health domain in India is the TNHSP”Dr. Preeti Kudesia
Senior Public Health Specialist South Asia Human
Development Unit
The World BankPlease provide a brief overview of the achievements of Health Systems Development Programme of World Bank, in view of Tamil Nadu Health Systems Project.

One of the big success stories of World Bank’s work in public health domain in India is the Tamil Nadu Health Systems Project. As part of the project, the state has done a commendable job in documenting and filing non-communicable disease details with appropriate facts and figures. Another significant achievement of the project is the development of an excellent information management system, with 41 government hospitals of the state being fully computerised. The project also gained substantial momentum from the hospital system improvement team, which enhanced the quality parameters of healthcare units.

What is the quantum and scale of World Bank’s investment in the Tamil Nadu project?

In the first phase of the project, we invested USD 110.8 million. Out of this, USD 20 million went for rescue and rehabilitation of Tsunami victims and the balance USD 90 million was invested directly into the project over a duration of five years. Ninety five percent of the fund had been utilised with an excellent performance. We have now approved the second phase funding for next three years till 2013, amounting to USD 117.7 million, which will be primarily used for scaling up the project and continuation of activities.

Private hospitals have slowly become preferable option than government hospitals these days. According to you what can be done to reform the latter?

Yes, I do agree with you that government hospitals have many challenges. As a part of the project, we are into the process of advancing the integration of recent development across verticals. Doctors are advised to engage in skill upgradation, team-performance activities and leadership development. But what-ever be the changes, it has to be a gradual process. Earlier, there were a lot of irregularities in the process for instance the NABH accreditation, which was treated as a voluntary act. However, it has now gained momentum among public healthcare institutions. In the second phase of this project, we are actually into the process of getting government hospitals accredited and that too by improving qualities and performance.

Which other Indian states is World Bank currently focusing on and what are the thrust areas? 

We are currently working with three states Tamil Nadu, Rajasthan and Karnataka. However, we had initiated the process way back in 1996 with 10 states across India. The states are focusing on healthcare systems improvement, quality improvement, information system, infection control, risk management, along with issues related to human resources, infrastructure strengthening, supply chain management and above all the quality of care. In the whole process, we specifically focus more on the access of healthcare for the under privileged population.

Accreditation

A major step undertaken by the project was placing 12 secondary care government hospitals for NABH accreditation, out of which two hospitals have already completed the final assessment and achieved accreditation thereby matching the global standards of care. The expected changes in all these hospitals include increase in manpower, inclusion of standardised procedures, inclusion of staff safety procedures, patient exit interviews, strengthening of infrastructure, and introduction of HMIS, among others.


“World Bank has now approved the second phase funding for next three years till 2013, amounting to USD 117.7 million, which will be primarily used for scaling up the project and continuation of activities.”


Comprehensive Emergency Obstetric and Neonatal Care (CEmONC) The rising concern for reducing maternal and infant mortality, the TNHSP conceptualised centres for CEmONC in existing government hospitals. Beginning 1990, with a plan to cover the entire state over three expanding phases, the 51 centres of the first phase were designated in 2004 and process of increasing their capacity to deliver emergency care was completed in 2006. Each CEmONC centre was provided with all necessary equipment for delivery and post natal care and physical facilities such as blood bank, laboratory and neonatal care unit. The centres have done extremely well in improving the maternal and infant mortality rates with Tamil Nadu now has much lower rates of infant and maternal mortality as compared to most of the other states.

Hospital Management Information System (HMIS)

Prior to implementation of the HMIS module, the secondary care government hospitals in Tamil Nadu were faced with several challenges pertaining to data maintenance and management such as ineffective record maintenance, manual records maintenance, duplication of records, unnecessary funds towards manual maintenance of records, difficulty in analysing data, and so on.

The system provides centralised web-based software solution that minimises technology support and maintenance dependencies. The facilities are connected via Tamil Nadu State Wide Area Network (TNSWAN), which is a 2Mbps dedicated leased line supported by M/s Electronics Corporation of Tamil Nadu Ltd. (ELCOT). The solution is an open source software and is simple and user-friendly. Implemented by TCS, the software has brought in several innovations by generating unique patient identification numbers, unique institutional codes, unique employee numbers, and so on.

Improving Infrastructure of Secondary Care Government Hospitals

Hospitals that needed upgradation and renovation were first identified based on various criteria. Under this process the hospitals underwent several internal and external modifications including structural repairs, refurbishing toilets, improving electricity and water supply system, repairing campus roads and boundary walls, landscaping, and so on. Storage and disposal facilities for waste management were also installed.

Civil Work at Secondary Care Government Hospitals
Phase Numbers of Hospitals Total Expenditure
Phase I 35 Rs. 49.53Crors
Phase II 190 Rs. 215Crors

Human Resource
Development

In a bid to develop human resources, the TNHSP undertook various tasks including manpower strengthening and recruiting, training, post creation and rationalisation of staff norms. Manpower training focused on improving technical skills, interpersonal communication training, bio-medical waste management training, management training, equipment training, and basic life support training, among others. Rationalisation of manpower was done on the basis of number of deliveries and number of in-patients and out-patients in a particular hospital. The personnel requirement in hospitals was hence standardised based on the results of this analysis.

“Tamil Nadu is one of the few Indian states that have adopted best of the IT systems for healthcare”Dr. Sumanth Raman
Adviser – Life Sciences & Healthcare Practice & Head
Healthcare Innovation
Tata Consultancy Services Ltd.
TCS had been associated with Tamil Nadu Health Systems Project since its inception. What has been your experience in this project?

We are providing the application software in healthcare management and information system and the hospital management system, both of which are integral and critical parts of a smart healthcare system project. The idea is to bring the functions of all departments onto a unified platform from a reporting, data collation and data analysis perspective. If healthcare system is integrated and managed through a proper information and management system, then anybody can get access of it starting from primary healthcare unit to speciality centre, both from patient care and administrative perspective. In the process, it becomes much easier for the government to provide much better healthcare services. The need was already there, but only a few states have actually come up for adopting best of the IT systems for healthcare and Tamil Nadu is one of them.

Please elaborate the technical architecture of the solution developed for this project.

The solution is based on open source software with a proprietary database at the backend. The software provides most flexible options in terms of reduced total cost of ownership, maintainability, vendor independency and in addition, it runs on a variety of operating systems. From an architecture perspective, it is extremely scalable and can be easily modified.

Which are the areas where this program has benefited the most through use of IT solutions?

Areas like drug and material distribution, inventorying, purchasing and facility management have largely benefited through use of IT. The application also helps to standardise and define different protocols in the system as and when required. All these synchronise towards a significantly enhanced quality healthcare service.

At present, which other states is TCS working for public health projects?

In addition to Tamil Nadu, we have worked in Gujarat and Andhra Pradesh as well. We provided hospital management system for 31 hospitals in Gujarat, which is running successfully and actually preceded the Tamil Nadu project. We have also worked for Aarogyasri program in Andhra Pradesh for its scalability in the application of IT. The project is focussed more into insurance oriented IT application, which deals with elements of medical records.

Is TCS also involved in the process of training or capacity building of end-users of the project?

TCS provides hands-on training at the user level in hospitals. In Tamil Nadu, we have already provided training to 41 hospitals and started with the 42nd one. I must congratulate the state government of Tamil Nadu for initiating and patronising the project so diligently and fruitfully. On the other hand, we are very well positioned in implementing the information and management system in India as the country has got one very good advantage of not having the legacy of organised healthcare system. Therefore, it does not have the threats from the failure factors that could hold it back from the achievements. From technology perspective, none of the factors seem to have much of the challenges. But changing the mindset is the biggest challenge.

Improving Healthcare Services for Tribal Population

Almost one percent of Tamil Nadu’s population is contributed for by tribal people settled across 12 tribal districts. As one of the major initiatives under TNHSP, improving healthcare services to tribal communities was taken up along with addressing issues such as water, food, sanitation and housing services. Prior to the establishment of TNHSP, studies suggested that only one to two percent of the tribal communities accessed hospital facilities; major reasons being inaccessibility and cultural factors.

The TNHSP put in place a tribal development plan, under which six interventions were undertaken including mobile outreach services to improve accessibility, diagnosis and treatment of sickle cell anaemia; providing peer counselors; promoting institutional deliveries; providing bed grants and undertaking IEC activities. Counselors from tribal communities, trained at HMDI Salem in November 2008 and March 2009, were appointed at 30 healthcare centres with an aim to increase accessibility of tribal communities to hospitals. The project, in partnership with non-governmental organisations, also provided mobile outreach services in various districts. In a period of six months (April ’09 September ’09), almost all districts achieved more than 90 percent of planned visits. Through a pilot programme in two hospitals, all inpatient costs of tribals were reimbursed. In addition, the project undertook several other steps to improve healthcare in tribal areas including providing fellowship to doctors, holding sensitization workshops, and initiating programmes for antenatal mothers, among others.

Emergency Ambulance Services

Developing public private partnerships plays a key role in enhancing the services offered, considering which the TNHSP has partnered with several non-governmental organisations to strengthen its healthcare system. An example of a crucial public private partnership in the state is the establishment of 108 Emergency Services in association with GVK EMRI to ensure efficient emergency management in the state. Since its establishment in September 2008, the 108 ambulance service has saved 4,11,288 lives in various emergency situations including accident and trauma cases, pregnancy cases and cardiac cases, among others.

Cardiovascular Diseases Prevention & Treatment Pilot Programme

Cardiovascular diseases account for 24 percent of deaths in India, which is expected to rise to 30-40 percent over the next few years. In Tamil Nadu, more than 30 percent of people suffer from diabetes, more than 20 percent of people suffer from hypertension and more than 10 percent of people suffer from other cardiac related disorders. Tamil Nadu has the highest crude mortality death rate due to cardiovascular diseases in India, which is 360 430 deaths per 100,000 population. Owing to these statistics the TNHSP implemented a pilot programme on cardiovascular diseases prevention and treatment considering that prevention is the best option to control these diseases. Implemented in 2007 in two districtsVirudhunagar and Sivagangai, the project had a four-pronged intervention of behaviour change communication at schools, work places, communities and clinics.

Cervical Cancer Training Pilot Programme

In India, one woman dies of cervical cancer every seven minutes and every year more than 1,32,082 women are affected, while around 74,118 women die of the disease every year. As early detection of the disease provides an opportunity for treating it completely, the pilot project aimed at early detection of cervical cancer among women. The primary intervention focussed on creating awareness among women and secondary intervention focussed on screening for early detection, referral and management. The confirmed cases were tied up with the Kalaignar insurance scheme for free treatment in the various empanelled hospitals.

Chief Minister Kalaignar Insurance Scheme for Life Saving Treatments

Recognising the importance of health insurance for enhancing the access and affordability of healthcare services, the Government of Tamil Nadu introduced the ‘Chief Minister Kalaignar Insurance Scheme for Life Saving Treatments’ for the poor, low income and unorganised groups. Implemented in partnership with Star Health Insurance, the scheme is eligible for families with annual income of/less than INR 72,000 and members of unorganised groups in urban and rural areas. Each family is insured of INR 100,000 for a period of four years. Till April 2010, 83,991 patients had been treated through the scheme at an estimated cost of INR 238.03 crore.

Procurement and Maintenance of Equipment

Equipment procurement and maintenance is crucial for providing quality healthcare. Under this programme, based on analysis of requirements at various centres, procurement was done through TNMSC at competitive prices following the World Bank procurement procedures. During the first phase INR 47.9 crore was invested in equipment procurement, while INR 41.14 crore and INR 29.38 crore were invested during the second and the third phase of the project respectively. Further, biomedical engineers were appointed at across three districts to ensure proper functioning and minimise the downtime of equipment. The biomedical engineers also ensured that the equipment procured across centres met the required technical specifications. Systematising the maintenance process was taken care of by introducing registers and reports which undergo a periodic analysis to ensure efficiency of the process.


“Recognising the importance of health insurance for enhancing the access and affordability of healthcare services, the Government of Tamil Nadu introduced the ‘Chief Minister Kalaignar Insurance Scheme for Life Saving Treatments’ for the poor, low income and unorganised groups. Implemented in partnership with Star Health Insurance, the scheme is eligible for families with annual income of/less than INR 72,000 and members of unorganised groups in urban and rural areas. Each family is insured of INR 100,000 for a period of four years. Till April 2010, 83,991 patients had been treated through the scheme at an estimated cost of INR 238.03 crore.”


Infection Control and Bio-Medical Waste Management The TNHSP aims at implementing a state-wide biomedical waste management scheme and the first two districts that where the programme was implemented were Dharmapuri and Krishnagiri. At government hospitals (excluding PHCs) at these districts, proper systems for waste segregation, storage, transport and end disposal were put in place, as per the standard biomedical waste handling rules. The government also plans to establish a common treatment facility in five regions of Tamil Nadu that can cover all private and government hospitals.

In addition to the above initiatives the TNHSP has formed a strategic planning cell, which is the think tank of the Tamil Nadu Health Systems Project that conducts various surveys from time-to-time to strategise and implement efficient schemes and programmes. The TNHSP also conducts management training programmes to train heads of various healthcare facilities in managerial and administrative skills. Further, the TNHSP has undertaken an intensive ‘Information, Education and Communication (IEC) programme to generate awareness among the masses about various ailments and diseases and the different programmes and schemes offered by the government. With the extension of the project, the next three years would witness improved healthcare services, delivery and reforms in Tamil Nadu.

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