Assam is committed to reduce out-of-pocket expenditure and make healthcare affordable. Hence, the Chief Minister’s Free Diagnostics Services, a PPP model with HLL Lifecare Ltd was introduced. Till date over 2 million patients have availed free services, including high end investigations like CT scan, says J V N Subramanyam, IAS, Mission Director, NHM, Department of Health & Family Welfare, Government of Assam, in conversation with Elets News Network (ENN).
Q How would you describe Assam’s healthcare delivery system in terms of quality, accessibility and affordability?
With about 3.4 crore population, Assam is poised in a unique context both demographically and topographically and is the largest State with 68.4% population of the country’s northeastern region. There are about 26 Scheduled Tribes and 22 Scheduled Castes. One must look at Assam’s healthcare delivery system in this context. In context of accessibility, quality of services and affordability, we need to look at various factors:
Accessibility: Difficult geographical terrain with hard to reach riverine/ Char areas, tea garden areas, hilly and forest areas spread across the State are the major accessibility issues for healthcare delivery system in the State.
a) Tea garden areas: About 20% of Assam’s population belongs to the tea growing communities. They are one of the most backward and exploited communities in Assam. Many studies revealed that Assam is facing a very high Maternal Mortality Ratio (MMR) among the districts with the high tea garden population, the MMR is very high. As per survey conducted by Regional Resource Centre for North Eastern States (RRC-NE), Ministry of Health & Family Welfare, Government of India, only 428 (57%) tea gardens have functional hospital out of total 758 tea gardens surveyed. Similarly, only 324 (49.9%) have Medical Officer (Allopathic) out of total 649 tea garden hospitals and another 47(7%) running with Visiting Medical Officer. The study revealed poor status of health infrastructure, availability of doctor, nurses and paramedics and healthcare services in the tea garden areas. Proper implementation of Plantation Labour Act, 1951 in the large number of tea gardens in the state remains a challenge.
b) Riverine areas: Around 10% of population of the State reside in the riverine/char areas where healthcare remains a critical challenge due to inadequate number of Health Infrastructure, doctors, nurses and paramedics. critical topographical condition is another challenge to reach these areas.
c) Hilly Areas: Accessibility is an issue with population density. It is very low in Karbi Anglong and Dima Hasao hilly districts. Availability of manpower is a huge issue in these areas. Due to hilly terrain and poor road connectivity referral transport system is inadequate in these areas.
d) Border areas: The geographical location of the State itself is quite unique, sharing borders with seven States and countries like Bhutan and Bangladesh, and having 2276.3 km of inter-State and 529 km of international borders witnessed low coverage of health care services due to accessibility issues.
e) Flood and erosion: Assam is a multi-hazard State and prone to floods, earthquakes, storms and landslides. Most of the Brahmaputra valley and Barak valley areas are prone to annual flooding with flash floods from Meghalaya/Bhutan/Arunachal causing havoc in the state year after year. Frequent change in the course of river Brahmaputra causes massive erosion which leads damage of health institutions also.
Gap in Health Infrastructure: There is huge gap of health infrastructure as per population norms. Till last year, not a single facility was Indian Public Health Standards (IPHS) compliant.
Quality: Quality of healthcare service providers remains an issue with acute shortage of skilled healthcare service providers.
a) Shortage of skilled healthcare service provider: Availability of specialists in the State remains a challenge. Of the State’s 6 medical colleges, only 3 are offering post graduate courses. Only 50% of the PG seats are available to the State which needs to cater to both the public and the private sectors. Shortage of MBBS Doctors, Staff Nurse and other paramedical staff is the major challenge in the health system. Rational posting of manpower is another challenge.
Affordability: 89.2% rural population of the State relies on public hospitals for all types of treatments, resulting high patient loads.
Q Delivering healthcare services in north-east has always been a challenge due to difficult terrain and other issues. What measures have been taken by NHM, Assam?
To cover the hard to reach areas and areas where healthcare facility is inadequate, the Assam Government has deployed 130 Mobile Medical Units (MMUs) of which 80 are deployed in the tea garden areas. At present 414 tea gardens are covered by these MMUs every month. MMUs are basically “hospital on wheel” manned with doctor, nurse, paramedical staff equipped with basic free diagnostic services and free medicines. More than 20.31 lakh patients have been treated in 47,020 camps organised by these MMUs from June 2017 to January 2019.
To provide healthcare services in the riverine and char areas, one-of-its kind Boat Clinics have been deployed with 15 Boat Clinics operating across 13 districts from 2008. These are basically “Floating Hospitals” manned with doctor, nurse, paramedical staff equipped with basic free diagnostic services and free medicines. A total 20,72,880 patients are treated in 27,959 camps organised by Boat Clinics.
Q How PPP model, latest technology and mobile apps are being explored to improve delivery of services?
The 71st National Sample Survey by Ministry of Statistics and Programme Implementation Government of India had very interesting observations where the State has shown a sharp increase in utilisation of government institutions in the rural areas. The percentage of hospitalised treatments received from public sector hospitals varied from 19.2% (Maharashtra) to 89.2% (Assam) in the rural areas. While other States have shown a high degree of reliance on private sector hospitals, Assam is building its own public health systems, nevertheless we have also PPP to fill the critical gaps in health systems.
The Mrityunjoy-108 Emergency Response Services is round-the-clock under PPP mode with GVK-EMRI since 2008 in Assam. This partnership has improved the access to emergency services particularly medical emergencies. With around 380 ambulances and 7 boat ambulances, the 108 services have served more than 35 lakh medical emergencies till date. Similarly, 316 number of 102 ambulances and 235 Adarani drop back vehicles transported more than 7.2 lakh patients and 14.93 lakh mothers.
The State is committed to reduce the out of pocket expenditure and make healthcare affordable. Hence, the Chief Minister’s Free Diagnostics Services, yet another PPP model with HLL Lifecare Ltd was introduced. Till date over 2 million patients have availed free services, which includes high end investigations like CT scan. In partnership with Narayana Hrudayalaya, Bengaluru and Kolkata 6,288 children have been provided free heart surgeries. “Comprehensive” Cleft Care Centre- a state of the art Centre through PPP has been set up in Guwahati to work towards a ‘Cleft Free Assam’ under the name Mission Smile where 17,729 children received free surgeries.
State-run mobile medical units to provide comprehensive primary healthcare services along with diagnostics facilities in the state with 80 MMUs dedicated to tea garden areas which is again a PPP programme with through M/s Hindustan Latex Family Planning Promotion Trust (HLFPPT).
In addition to this, the NHM has entered public private partnership with 150 tea garden management and provides financial support for tea garden hospitals and with various charitable hospitals across the State. The boat clinics providing essential health services in farthest riverine islands of Assam are exemplary PPP initiatives. Assam also has 104 Sarathi, a round-the-clock free of cost helpline and grievance redressal System in PPP mode.
The technology and the mobile applications have been extensively used for effective implementation of flagship programs and intensive monitoring and supportive supervision of the health programmes.
The National Health Mission, Assam has won the Skotch Swasth Bharat Gold Award for implementation of ASHA Payment and Performance Monitoring System (APPMS), an IT tool for regular payment of ASHA Incentive through PFMS and analysis of ASHA programme.
The entire clinical data of sick newborns treated in public health facilities is available in SNCU online software used by policymakers like me to review the quality of newborn care in the State.
There is robust Human Resource- MIS System for comprehensive HR management. The village health and nutrition day (VHND) which is most critical program to deliver most of preventive and promotive services in the community is being monitored by VHND Monitoring System.
The Drugs availability status is being constantly monitored through Drugs Stock Monitoring System and it is also made available in the public domain to increase transparency in the system.
We also have online Inventory Management, Online Maternal and infant Death Reporting System. The entire system is being integrated with GIS based system.
NHM, Assam has also implemented robust HR-MIS system with provision of centralized payment of salaries of close to 21,000 NHM employees on last week of every month.
Assam is one among the few states in the country to use android mobile application for conducting district gap analysis using Indian Public Health standards with the support from UNICEF and the results are utilised for strengthening health infrastructure and service availability.