Primary Health-Care Innovations with Superior Allusion to Family Health Centers.

The present case study discusses about the Primary Health Care system of Kerala and the Government's innovative step to promote the Primary Health Centres to Family Health Centres. The case study also deliberates about the FHC working model and its superiority over the current PHCs in the areas of manpower, OP time, lab services, nursing services, social security projects etc. and the transformation of PHCs to a well-functioning PHC, thereby it can become a model for other states. Copyright:

INTRODUCTION

Primary health-care system envisages access to health services, environment, and lifestyle to people in the most affordable manner. Kerala state represents a model to other states of India in the health-care sector and has been able to accomplish attainments akin to the developed countries. Health indicators such as the child mortality rate, maternal mortality rate, and life expectancy highlight this (based on the Government of India's Ministry of Health and Family Welfare, Bulletin of Rural Health Statistics, 2016–2017),[1] and all these activities are executed through the primary health centers (PHCs) at the grass-root level. The present case discusses the family health center (FHC) working model, an innovative model for meeting the health-care requirements and to address the preventive, promotive, and rehabilitative health-care interventions of local community.

PRIMARY HEALTH CARE

This is a method to health, and it comprises all areas that show a role in health, that is, access to health services, environment, and lifestyle, to people in the most affordable manner. Thus, primary health care taken together, may be considered the keystone of universal health systems. The World Health Organization elaborates on the goals of PHC as defined by three foremost categories, “empowering people and communities, multisectoral policy and action, and primary care and essential public health functions as the core of integrated health services.”

According to Figure 1, the primary health-care system in Kerala is in the direct control of the Directorate of Health Services (DHS)[2] headed by the Ministry of Health Services Kerala and the Director of Health Service with seven additional DHS, eight deputy DHS, three assistant directors, program officers, and other officers in the headquarters. Under the DHS, district medical officers (DMOs) of each district are coordinating the respective district health-care system along with three deputy DMO, Reproductive and Child Health (RCH) officer, junior administrative Medical Office (MO) and administrative assistant, and other officers in the district headquarters. Under the DMO, there are district hospitals, general hospitals, district TB centers, women and children hospitals, mental health centers, TB hospitals, leprosy hospitals, taluk headquarters hospitals, taluk hospitals, community health centers, 24 × 7 PHCs, FHCs, PHCs, and various subcenters. The respective district DMO is in complete control of the health-related activities of the district through these health-care centers.

Figure 1

Kerala's primary health-care organizational structure Source: Created model after going through different literatures

PRIMARY HEALTH CENTERS

PHC is the rudimentary structural and practical unit of the public health services of a country. Based on Figure 2,[3] as part of decentralization of powers, the Kerala government has transferred the control of health-care institutions to the three levels of panchayats. Hospital management committees are constituted in each PHC to keep constant vigil on the working of institution, to ensure steady development of the institution, and to take up certain responsibilities for the improved functioning and enhancement of the PHC. Each PHC is working under the control of a charge medical officer and is responsible for implementing all activities grouped under health and family welfare in the institution area. There are health inspector (HI) and lady HI (LHI), and their functions are mainly associated to the supervision and general administration of the field staff under them, coordination of the primary health-care activities in their service area, and coordination of activities with the local self-government institutions, actively involving in public health-related activities and supporting their supervisors in the day-to-day activities of the institution.

Figure 2

Hierarchical functioning of a primary health center in Kerala Source: KILA, Administration Manual for Transferred Functions: Primary Health Centre, June 2017

One junior HI (JHI) and one junior public health nurse (JPHN) constitute the members of a subcenter. They have both institutional and field responsibilities and have to maintain various registers; implement national programs and activities related to maternal and child health; educate the community on environmental sanitation and hygiene practices, control of communicable and noncommunicable diseases, and activities related to school health; attend various meetings in subcenter and PHC, etc.

Accredited social health activist (ASHA) workers are the grass-root level workers in this system; one ASHA is selected from each ward of the panchayat to constitute basic health-care services to each and every family of their area. They were given basic training regarding the various aspects of primary health care, awareness on national programs, immunization services, family planning services, palliative care, and antenatal and postnatal care.

FAMILY HEALTH CENTERS

The AARDRAM mission[4] is one of the components of the Nava Kerala Mission by the State Government of Kerala. The mission aims to deliver patient-friendly superiority health-care services in government hospitals and to enhance specialty and superspecialty facilities in district and taluk hospitals. As a part of the mission, the Kerala government is upgrading the existing PHCs to FHCs, for fulfilling the health-care requirements of all members of the family and to address the preventive, promotive, and rehabilitative health-care interventions of the local community. The upgraded services aim to accomplish services available to all irrespective of whether they approach institutions or not and also include promotive, preventive, curative, rehabilitative, and palliative services. Apart from the regular Outpatient (OPs), FHCs will emphasis on the primary prevention of communicable as well as noncommunicable diseases, maternal and child care services, prevention of infectious diseases, and proper control of lifestyle diseases. Furthermore, FHCs will enable web-based appointment system, patient reception and registration, and improved amenities in the waiting areas. Apart from these, counseling facilities too will be accessible at the FHCs for teenagers, couples, elderly, and the drug-addicted people. The outpatient wing of FHCs will function from Monday to Saturday (9 a.m. to 1.30 p.m. and 1.30 p.m. to 6 p.m.) and on Sundays from 9 a.m. to 1.30 p.m.[5] Laboratory facilities will be available from 8 a.m. to 4 p.m.

According to Figure 3, the FHC working model is explained underneath; the concept of FHC will definitely transform the attitude of many people toward a government hospital, who favor the private sector. Many transformations can be distinguished from the entrance of an FHC itself, and people may even wonder whether this was their old PHC itself. The beautiful garden in the front, play area for kids, ramp facility at the entrance, patient waiting area with various facilities, precheckup rooms, signage boards, distinct OP for each doctor, examination rooms with disguise, observation rooms, improved pharmacy and laboratory infrastructure, distinct sections for immunization with child-friendly atmosphere, breastfeeding room, etc., are few of the topographies of an FHC. The additional staff posted in FHCs will help in delivering quality services to the public. SWAAS and ASWAAS clinics are two other ventures of FHC that deal with the management of patients with obstructive pulmonary disease and also mental health.

Figure 3

Family health centers' working model

The service provisions through FHCs will be institution, field, or outreach based as the case may be. Curative, counseling, health education, immunization, medicolegal, pharmacy, and laboratory are some of the institution-based services. Field-based services include outreach activities carried out for various public health programs and routine services by JPHN, JHI, and ASHA workers. Treatment should be provided to all patients attending the outpatient department of FHC, adhering to the comprehensive primary health-care treatment guidelines. Patients who need an advanced level of care should be identified as per the red flag signs and referred early to the appropriate level as per the treatment guidelines.

Table 1 explains the basic difference between PHC and FHC in terms of services, facilities, workforce, and other activities.

Table 1

Primary health center versus family health center

Services	PHC	FHC
Outpatient time	9 a.m. to 2 p.m.	9 a.m. to 6 p.m.
Workforce	1-2 medical officers	3 medical officers
		4 staff nurses
	1 staff nurse	2 pharmacists
	1 pharmacist	1 lab technician
	0-1 lab technician
Laboratory services	At some centers	At all centers
Service quality	Inadequate	Service quality as per comprehensive primary health-care guidelines
		Continuous training programs for employees
Medical records	Stores as written document	Stores digitally through e-health
Nursing services	Limited	Triage
		Precheck
		Postcheck counseling
		Continuous care
		Telecounseling
		SWAAS-ASWAAS clinics
		Outreach institutional services
Subcenter clinics	Twice a week	Six days in a week
		Nutrition clinic
		Noncommunicable disease clinic
		Child care clinic
	Adolescent health clinic
		Antenatal clinic
		Geriatric care clinic
Health-related sector services	Inadequate	Fully integrates directly affected areas (food, drinking water, fitness, waste disposal, drug addiction, etc.)
		Areas of indirect influence are integrated with other missions (housing, environmental, education, etc.)
Social security projects	Inadequate	Ensures accessibility through a combination of different services
Services for the underprivileged and marginalized	Limited	Gives special consideration

Source: Secondary data analysis. PHC: Primary health center, FHC: Family health center

From Table 1 and Figure 3, it is evident that FHC is having so many advantages over a PHC in terms of services, workforce, working time, facilities which are patient friendly, outreach services, and other health-related activities. Hence, most of the patient related-problems can be solved in the FHC itself, and it will reduce the number of referrals to higher centers. Therefore, FHC can be considered a well-functioning PHC, and it can be a model for other states too.

CONCLUSION

There are numerous health-care innovations that could benefit the PHCs and backing up the continuity of care across the entire health-care system. It is the family health-care system of Kerala to embrace the idea of change through innovation and to make a rigorous effort to become a model for the Indian health-care system. That is, improving the infrastructure as well as the treatment services from PHC level to medical college level. This mission also aims to involve participation from the community by creating awareness on various diseases and changes to be made in lifestyle for preventing these illnesses. Thereby, this mission will transform the entire health-care system in the government sector of Kerala and will develop as a role model for the health-care system in India.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.