Kerala has achieved impressive health targets despite lower per capita income than several other Indian states and many developed countries, but there is still room for improvement, particularly in primary healthcare. Analysis of how public healthcare institutions are used reveals low use of resources at the primary care level, and high utilization of secondary and tertiary care facilities. Sixty to seventy percent of primary care services in Kerala are provided by private secondary and tertiary care hospitals. Even though patients report to primary care facilities – the first port of entry into the healthcare system – staff members routinely refer patients to secondary and tertiary care facilities without any attempt to treat them at the primary care centers.
Historically, the primary healthcare system in Kerala has addressed infectious diseases, child health, and reproductive health, but the health needs of the population have changed. More and more people are living with noncommunicable diseases and other health problems resulting from changes in lifestyle. Many of the current health challenges in Kerala stem from the mismatch between the health needs of the population and the available health services. This mismatch indicated a need to redesign the health system or to reengineer the process cycle in medical institutions.
In 2012, a team from the University of East London, in the United Kingdom, submitted a proposal to the Indian Ministry of Health and Family Welfare to study how the model of general practitioners from the National Health Service in the United Kingdom could be implemented in Kerala to improve primary care services.
In December 2012, the Department of Health and Family Welfare in Kerala launched the Universal Health Coverage Primary Healthcare Pilot Project. The pilot project would address the mismatch between population needs and primary care services and improve the functioning of the primary healthcare facilities. The pilot project, which took two years, from design to completion, gained national and international attention.
The project pilot tested a model to move closer to universal health coverage in three facilities in Trivandrum district. The model was based on a bottom up approach, which focused on expanding services offered, strengthening primary care centers, and addressing the needs of the catchment population.
The government enlisted a core committee of primary care experts to support the proposed pilot project facilities. The team from the University of East London provided technical support for the design of the project, training of staff, development of protocols, and design of the software. The government of Kerala engaged this team of international experts to implement the pilot project at the selected primary healthcare centers for an initial period of six months.
A group of doctors, paramedics, accredited social health activists (ASHAs), auxiliary nurse midwives (ANMs), and local self government representatives from the health sector in Kerala worked together to expand the concepts introduced by the University of East London team into detailed plans further tailored to the health needs in the state. The State Health Systems Resource Center of Kerala was brought in to oversee the management and implementation of the expanded project.
Public health delivery in Kerala is an example of how local health workers can help achieve universal health coverage. High levels of literacy in the state made it easier to involve various groups in the pilot project, many of which took collective responsibility for ensuring the successful implementation of the project.
The pilot project introduced several changes, including new infrastructure to enable patient friendly environments, to create designated preassessment or prediagnostics areas, to redesign patient flow, and to reduce waiting time. Other changes included the introduction of information technology to register patients electronically for ease of data entry and to track each patient record; the provision of laboratory and diagnostic services; and the procurement of drugs, equipment, and supplies.
The pilot project resulted in the introduction of several good practices at the three facilities. These new practices included task shifting, training of facility staff to register patients, strengthening skills to use evidence based protocols for six priority diseases – diabetes mellitus, hypertension, antenatal care, immunization, fever management, mild to moderate depression, and immunization – and the use of referral pathways. The pilot project also emphasized health education campaigns to engage the community and involved the local self government representatives more actively. Staff members at the pilot facilities were trained to strengthen not only clinical but also nonclinical skills to improve the quality of services.
In our independent evaluation of the pilot project, staff at the health centers reported that the health seeking behavior of patients improved. We found that patient trust in the government primary care facilities increased. Patients who used to go to the city for treatment started to use the local primary care centers. Members of the community became willing to visit the primary care facilities as the first point of contact with the health system. These positive changes were attributed to the patient friendly environment at the facilities and the availability of laboratory services and drugs.
The pilot project helped the facility staff improve relations with their local self government representatives and communities. Health awareness within the community increased, due to active engagement of the facility staff in the health education camps. The quality of the primary care facility at Chemmaruthy improved enough to meet the Kerala Accreditation Standards for Hospitals. The other two facilities are also in the process of receiving the accreditation certification.
Other state governments could learn from the Kerala example. Strengthening the primary healthcare system improved the health of the local population and freed up expensive resources from secondary and tertiary care.