Universal Health CoverageUHC Experiences of Tamil Nadu with

Universal Health Coverage(UHC) Experiences of Tamil Nadu with the UHC Pilot Project Dr. Darez Ahamed. I. A. S. , Mission Director, State Health Mission, Tamil Nadu Government of Tamil Nadu 12 -12 -17

The UHC piloting in Tamil Nadu • The UHC pilot implementation (2016 -17) in Tamil Nadu is going successfully in following 3 blocks in the State. • Shoolagiri Block – Krishnagiri HUD • Vepur Block – Perambalur HUD • Viralimalai Block – Pudukottai HUD • In 2017 -18, the State is moving towards up-scaling the programme of UHC in the remaining 39 HUDs at the rate of one block per HUD (178 PHCs/CHCs and 918 Health Sub - Centres). • TN UHC pilot is in line with Health & Wellness Centres (HWC) proposed by Go. I.

UHC Pilot Implementation - Objectives • To provide health care services on a assured and rights based approach rather than on a traditional demand based approach • The Essential Benefit Packages laid down will be delivered 100% to all the beneficiaries • The HSCs will be strengthened with additional buildings, infrastructure, equipments staffs, funds after a detailed gap analysis. • The HSCs will be upgraded to deliver minimal curative services, distribute drugs for chronic ailments and to screen for NCDs • The drug availability will be streamlined by making a buffer stock of one month drug requirement available in the facility at any given point of time. • Additional human resources will be provided to each HSC for the pilot UHC implementation. Its mainly deploying one additional SN/ANM/VHN per HSC (one of them will be engaged in field work). 3

Name of the HSC –Rajalipatti (Kodumbalur PHC) As on 26 May 2016 Renovated HSC Rajalipatti As on 10 Feb 2017 – Under Renovation

Total Number of Patients consulted (OPD+NCD+OG) during May, June, July, August, September, October and November 2017 12000 10196 10000 7766 8000 7346 6476 6000 4000 2000 7850 8497 5013 5817 4074 5560 8166 7792 7791 9278 8105 6699 5165 2862 1551 2964 1535 0 May June July Shoolagiri Block (25 HSCs) August Viralaimali Block (21 HSCs) September October Veppur Block (21 HSCs) November

Disaggregated data : OPD, OG, NCD and Community : November 2017 12000 10000 2263 (13. 89%) 8000 504 (17. 47%) 911 (3. 63%) 1126 (13. 89%) 899 (17. 47%) 369 (3. 63%) 1416 (17. 47%) 6000 294 (3. 63%) 8010 (65. 01%) 4000 6518 (65. 01%) 5269 (65. 01%) 2000 0 Shoolagiri (Total=10196) Veppur (Total=8105) OP OG NCD Community Viralimalai (Total=9278)

Average OPD and NCD/OGs as recorded by VHNs Block wise/ Per HSC: September, October and November 2017 September 1 2 3 4 Excluding NCD and OG patients 5 October 6 7 Including NCD and OG patients 8 9 10 Excluding NCD and OG patients 11 November 12 13 14 Including NCD and OG patients 15 16 Excluding NCD and OG patients 17 18 19 Including NCD and OG patients OPD +NCD+O OPD Block Per Per HSC OPD Block Per Per HSC G day day day +NCD+OG HSCs Counts per day per day in OPD (col. 2/25 (col. 3/col. (25 (col. 5/25 d (col. 6/col. OPD (col. 8/25 (col. 9/col. Counts (col. 11/2 (col. 12/co OPD (col. 14/25 (col. 15/co Counts (col. 17/2 (col. 18/co Block Name block Counts days) days) (25 days) 5 days) Counts 1) 1) 1) l. 1) Shoolagiri 25 5959 229. 19 9. 16 7346 282. 53 11. 30 6408 256. 32 10. 25 8166 326. 64 13 6518 250. 69 10. 02 10196 407. 84 16. 31 Viralimalai 21 7317 281. 42 13. 40 8506 327. 15 15. 57 6633 265. 32 12. 63 7792 311. 68 14. 8 8010 308. 07 14. 67 9278 371. 12 15. 43 Veppur 21 4569 175. 73 8. 36 6699 257. 65 12. 26 5517 220. 68 10. 5 7791 311. 64 14. 8 5269 202. 65 9. 65 8105 17. 67 324. 2 Note: Month of August had 4 sundays and September month had 4 sundays; October month had 5 Sundays and Deepavali Holiday ; November month had 4 Sundays. Including NCD and OG, the OP per day is more than 15 per day for all blocks.

HSC utilization data (excluding OG, NCDs) during July-November 2017 – based on UHC-app data. Month July August September October November Total Block Population % of individuals utilized Shoolagiri block 2, 677 2, 223 4, 528 4, 596 4, 485 18, 509 Veppur block 2, 083 2, 082 2, 477 2, 239 2, 166 11, 047 Viralimalai block 2, 042 2, 736 3, 472 3, 083 3, 259 14, 592 1, 84, 940 1, 44, 789 1, 409 10. 01% 7. 63% 10. 32% Note: This table, shows the number of individuals that have utilized the HSCs at least once during the past 5 months.

Gender Distribution for the last Five month data (July to November 2017) Gender Shoolagiri block N (%) Viralimalai block N (%) Veppur block N (%) All three Pilot blocks N (%) Female 19, 128 (64. 90) 14, 877 (63. 17) 18, 777 (65. 05) 52, 782 (64. 46) Male 10, 333 (35. 06) 8, 672 (36. 83) 10, 081 (34. 93) 29, 086 (35. 52) 10 (0. 03) 0 (0. 0) 6 (0. 02) 16 (0. 02) 29, 471 (100) 23, 549 (100) 28, 864 (100) 81, 884 (100) Others Total Note : Female patients account for about 65% of all OPDs.

UHC – Lab Services • The UHC pilot EBP includes 40 laboratory services of which 4 will be available in HSCs, 20 will be available in PHCs, 25 will be available in Block PHCs (CHC), 11 in District Public Health lab and 4 as referral outs to CMCHIS empanelled labs. • The results will be transferred online and can be issued to the beneficiaries at the health facility itself through LIS. • It will operate via Hub & spoke model. 12

Hub and Spoke Model • Operational in all 3 Blocks • Sample Flow increased in PHCs and DPHL • Urine Culture for ANC cases from PHCs being referred to DPHL 13

UHC Pilot - Overall Lab Performance (All 3 Blocks/All 17 PHCs) Patients Referred to UHC - PHC Labs – April - Nov 2017 Total No of Patients 11274 9507 13636 12217 12961 12243 13879 7901 April May June July Aug Sep Oct Nov Average No of Patients/Day 394 440 375 263 April May 432 306 June July Aug Sep 462 394 Oct 75% Nov 14

UHC Pilot - Overall Lab Performance (All 3 Blocks/All 17 PHCs) Total Tests Performed in UHC - PHC Labs – April - Nov 2017 Total No of Tests 32611 27636 30870 32041 33529 31206 22204 17582 April May June July Aug Sep Oct Average No of Tests/Day Nov 1052 921 996 1068 1117 90% 1006 716 586 April May June July Aug Sep Oct Nov 15

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LIS – Monitoring Equipment 18

LIS – Cell Counter Utilization 19

Emerging Model from Tamilnadu IT System for UHC: TN-UHC App

TN-UHC App Overview Follow-ups & Referrals TN-UHC App Primary Health Consultation Pharmacy & Diagnostics Points of use Community Clinic MD/DD/BMO User ANM/VHN/Nurse Categories Physicians/MOs MD/DD/BMO Salient Features Family Enrollment • Community focus with geo-tagged family enrollment • End-to-end Electronic Health Record (EHR) maintenance at Primary Care level • Integration of Pharmacy, Diagnostics services • Service delivery support for General OP, NCD & O/G at HSC/PHC levels and Specialty services (such as ENT, Opthal, etc) at Urban Polyclinics • Portability with Digital Accessibility (“Offline” access in “Tablet” devices) • App availability in both “Tablet” and “Web” versions • Deployed in 67 HSCs across 3 Blocks with a coverage of 4. 5 Lakh population

Illustration - TN-UHC App as an enabler: Ease of Health Administration Governance Report: HSCs’ Performance This report gives the # of health consultations provided in each HSC and assists in performance evaluation

Illustration - TN-UHC App as an enabler: Ease of Health Administration Governance Report: Population Coverage This report gives insights on the # of families that avail UHC services and thereby enables to ascertain the % of coverage, the outreach strategy, etc.

Illustration - TN-UHC App as an enabler: Effective Patient Engagement By showing these values to the patient at the point of service, the VHN/MO can engage him/her in deeper health consultation (e. g. discuss about weight gain/loss & life style modification)

Illustration - TN-UHC App as an enabler: Deeper Understanding of Health Care needs of Communities Kumbalam HSC (Shoolagiri Block) Catchment Villages Most Common Symptoms: Headache, Joint Pain, Muscle Pain, Abdominal Pain Most Common Diagnosis: Hypertension, Allergic Bronchitis… Note: The above map (with data on Symptoms & Diagnosis) has been manually prepared based on the data available in TN-UHC App

UHC- The Urban counterpart: Polyclinic v. Specialty clinic for outpatient services for Urban slum population v. Comprehensive specialty care under one roof v 74/96 Polyclinics functioning on pilot mode in Tamil Nadu ( 1 per 2. 5 lakh population)

Aim: Monitoring mechanism Polyclinic app Referral: CMCHIS linkage. Decongestin g secondary care hospitals. URBAN POLYCLINIC Drugs &Diagnostics Central supply through TNMSC HR: Empanelment of specialists/PG s Target: Urban poor & vulnerable group Timing 4. 30 - 8. 30 pm (convenient for daily wagers) Specialist OP services in UPHC

An Urban polyclinic in Pudhupalayam Ophthalmologist Consultation Equipment provided under polyclinic

Lessons from TN UHC Model: • Tamil Nadu believes that a bottom to top approach is utmost necessary important in India’s pursuit towards achieving UHC. • Primary healthcare should be made the cornerstone in developing any UHC Models. • Continuum of care at all levels should be there- SC level strengthening along with PHC, CHC and DH/MCH level strengthening should converge. • Since equity is seen as the central epithet of UHC, public sector strengthening should be given utmost priority- Needs to dispel the myth that ‘ healthcare for the poor is poor healthcare’

Lessons from TN UHC Model: • UHC is not just health financing, it should cover all components of the health system to be successful • UHC is not only about assuring a minimum package of health services, but also about assuring a progressive expansion of coverage of health services and financial risk protection as more resources become available. • UHC is comprised of much more than just health; taking steps towards UHC means steps towards equity, development priorities, social inclusion and cohesion. • UHC emphasizes not only what services are covered, but also how they are covered through focusing on people-centric health care and integration of care.

Conclusion • The HWCs could be the window of opportunity for strengthening the primary health care system and the locus of providing community based care for NCDs in context of TN. • The ‘role of a mid-level care provider’ in the HSCs in the context of TN is more for a community level engagement rather than institutionalising healthcare. • The State is now open to the idea of deploying a Staff Nurse as MLHP in the HWCs. • The current UHC model followed by Tamil Nadu is in line with the proposed HWC concept of Go. I. • Tamil Nadu is ready to upgrade its 985 HSCs as HWCs in the coming year with Go. I support.

Thank You “I regard universal health coverage as the single most powerful concept that public health has to offer. It is inclusive. It unifies services and delivers them in a comprehensive and integrated way, based on primary health care. ” - Margaret Chan – Ex-WHO Executive Director