A Global Model of Accessibility and Inclusivity

The Alma-Ata International Conference held in Kazakhstan in 1978 defined primary health care as “essential healthcare made universally accessible to individuals and acceptable to them, through their full participation and at a cost the community could afford.” “Good health and wellbeing” is one of the goals of Sustainable Development 2030. The second global conference on primary health care was in October 2018 in Astana, Kazakhstan. This conference again endorsed the critical role of primary health care in promoting good health, social and economic development, and global security. Health is considered a fundamental human right. Everyone, everywhere, should be able to enjoy the highest possible attainable standard of health. Our state is committed to meeting all people’s health needs across the life course through comprehensive primary care, which includes preventive, promotive, curative, rehabilitative, and palliative care. The health indicators of Kerala have always been the best compared to the rest of India and also at par with the developed countries of the world. With the introduction of the Aardram Mission, which aims at the people-friendly transformation of all healthcare institutions, the transformation of Primary Health Centres to Family Health Centres, and the improvement in the quality of care, the state has achieved a unique position in the health sector and is a role model for the entire country

Primary Health Care in Kerala

The state has a long history of efficient primary care. Ayurveda was the popular system here before the introduction of modern medicine by Europeans. By 1900, the concept of primary care started in rural areas. With the formation of Kerala in 1956 and the establishment of the Department of Health Services, public health gained momentum, and primary health care services were strengthened through a robust primary care system. Parallel initiatives of the state, like the provision of safe drinking water, free primary education including education for women, the public distribution system, and land reforms, supported the health system. The primary health care system in the state consists of 226 Community Health Centres (CHCs), of which 152 are Block Community Health Centres (Block CHCs), 849 Primary Health Centres (PHCs), and 5415 sub-centres. Each CHC serves roughly 1 lakh population under which there are PHCs serving a population of 25,000-30,000. Under each PHC, we have sub-centres that serve 5,000 people. Since the launch of the Aardram Mission, 688 PHCs have been transformed into Family Health Centres (FHCs) and 67 Block CHCs into Block Family Health Centres (Block FHCs), and all subcentres into Janakeeya Arograya Kendrams. Apart from this, there are urban PHCs under the National Health Mission to deliver primary care services to the urban poor.

Health System Challenges in Primary Care

The major threat in the health sector as well as primary care is the huge burden of non-communicable diseases (NCDs) or lifestyle diseases. There is an increasing trend in newly detected cases of hypertension, diabetes, cardiovascular diseases, cancer, and lung diseases. The study conducted in the state by Achutha Menon Centre for Health Sciences, Thiruvananthapuram in 2016-17 reveals that one out of three has hypertension and one out of five has diabetes in our state. Even though the state has witnessed a steep decrease in the use of tobacco, there is an increasing affinity to alcohol, and the age of first use of alcohol has come down. The unhealthy dietary practices, lack of physical exercise in all sections of the population irrespective of age and economic status, and the aging population have contributed to the rise in lifestyle diseases. It is estimated that 52% of total deaths in the productive age group between 30 and 70 years of age is due to non-communicable diseases. Kerala also reports higher levels of mental illness compared to the all-India average. Increasing numbers of suicides and alcoholism are concerns in the state. As per the National Family Health Survey-5 (NFHS-5) done between 2019-2021, there has been an increase in the prevalence of anemia among women and children when compared to NFHS4 (2015-16). Although the state has been successful in controlling a number of communicable diseases, emerging and re-emerging communicable diseases in recent years have led to considerable morbidity and mortality. Vector-borne, water-borne, air-borne, and zoonotic diseases are reported from all districts. Dengue fever, leptospirosis, H1N1, hepatitis, malaria, and Japanese encephalitis are the leading causes of mortality among communicable diseases. In the health sector, special attention has to be given to the vulnerable population like tribal, coastal, migrants, urban slum dwellers, older citizens, women and children, transgenders, and people with disabilities in terms of services and accessibility. Exploitation of natural resources, environmental degradation, water quality issues, climate changes, road traffic accidents, etc. are also considered public health threats.

Re-engineering Primary Care

To address the challenges in the health sector through primary health care services, as part of the Nava Kerala Karma Padhathi, the state has introduced a mission named the Aardram Mission. Under the leadership of local self-governments, ensuring people’s participation and technical support from the health department, the mission develops the appropriate plan to tackle each and every health issue faced by the people. Other missions of Nava Kerala Karma Padhathi, namely Haritha Kerala Mission, Life Mission, and Vidya Kiranam, are closely related to the Aardram Mission since their activities indirectly improve the overall health of the people. The primary care system has undergone a silent revolution in the state through its people-friendly transformation of PHCs and CHCs to FHCs/Block FHCs. There are significant changes in the services in terms of quality and quantity. All FHCs are provided with three medical officers, four staff nurses, a laboratory technician, pharmacists, along with the ministerial and field staff. The working time has been extended to 6 pm. Standards are laid down for infrastructure, human resources, and functioning, especially outpatient services, nursing care, pharmacy, and laboratory. Duties and responsibilities of all staff are redefined. Management guidelines, including referral protocols, are developed for the disease conditions that can be approached at the primary care level. The supply chain of medicines, vaccines, and consumables is maintained. Infrastructure is designed to suit the needs of women, children, the elderly, and people with disabilities. To address the challenges of non-communicable diseases at the primary level, innovative programs are introduced. To mention a few of them are the “SWAS” program to manage chronic respiratory diseases, the ‘ASWAS’ program to tackle depression in the early stages, “Amma Manas” to manage depression among pregnant and lactating mothers, Sampoorna Manasika Arogyam to manage all types of mental illnesses, Nayanamrutham to detect diabetic retinopathy, and Amrutham Arogyam to detect hypertension, diabetes, and cardiovascular diseases. Palliative care services are mandatory in all FHCs. Proper follow-up, counseling services, and maintenance of medical records through the e-health system are also available in FHCs. All other national programs are implemented through FHCs as routine programs.

Janakeeya Arogya Kendrams

Health sub-centres are renamed as Janakeeya Arogya Kendrams by the state government with additional facilities. Standards are laid down for infrastructure and services. Service delivery packages have been developed for all age groups according to their health status. Out of 5415 sub-centres, 4558 centres are provided with one qualified nurse (Middle Level Health Provider-MLHP) through NHM. All sub-centres are provided with Junior Public Health Nurses, and on average three centres have one Junior Health Inspector. These health field staff work in coordination with ASHA (one for each ward) Anganwadi workers, health volunteers, NGOs, and other agencies in the health sector. Janakeeya Arogya Kendrams function six days a week conducting various clinics for antenatal mothers, vaccination, adolescents, elderly, NCD, smoking cessation, etc. Field staff, along with ASHAs, conduct house visits fixing priority on diseases and vulnerability.

Role of Local Self Government in Primary Care

Since all institutions delivering primary care are transferred to Grama Panchayat and Block Panchayat, the LSG plays a crucial leadership role in managing and coordinating the primary care services under its jurisdiction. LSGs not only address direct health issues but also other social determinants of health like environmental sanitation, drinking water, provision of nutrients, housing, etc. LSGs coordinate all related departments, agencies, missions, and NGOs. The Health Status Report (HSR) of the population is prepared by LSGs with the technical support of the FHC team. Analysis of HSR and prioritising the health issues are done before preparing health and related projects. Kerala’s model of primary health care is hundred percent people-friendly, addressing all sections of society, accessible and affordable to all irrespective of their status, with special attention to the marginalised population, thereby reducing out-of-pocket expenditure on health and achieving the Sustainable Development Goal.