Taking healthcare to the people | The complete Makkalai Thedi Maruthuvam experience in Tamil Nadu

There is, no doubt, that the Tamil Nadu government’s Makkalai Thedi Maruthuvam is well-intended. But no policy can be only about successes; there are failures as well as grey areas in between that need to be acknowledged and addressed, writes Serena Josephine M.

Makkalai Thedi Maruthuvam has helped improve accessibility to healthcare services for many and in early detection of diabetes and hypertension. | Photo Credit: B. Jothi Ramalingam

A path-breaking massive surveillance and intervention project, the Tamil Nadu government’s Makkalai Thedi Maruthuvam (MTM) is definitely an example of how a welfare state would take care of the health requirements of its people. No doubt, the scheme has made an impact, especially among patients of the rapidly growing non-communicable diseases (NCDs).

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Improving accessibility to healthcare services for many, early detection of diabetes and hypertension, and reduction in out-of-pocket expenditure are among its successes. But, as all massive, population-based projects go, there are some gaps and shortfalls, starting with human resources, accuracy of data and equipment, drug delivery, and a larger need to evaluate the outcomes so far, especially the hypertension and diabetes-control rates.

A tough task

Taking home-based screening and drug delivery to the doorstep of beneficiaries is no small exercise.MTM, which will complete two years in August, is a massive programme involving lakhs of beneficiaries and a nearly 20,000-strong workforce. The scheme was recently profiled by the World Health Organization (WHO) for its outreach. As of July 20, official data show around 5.50 crore individuals were screened — 1,00,55,514 first-time beneficiaries and 3,20,53,880 repeat-service beneficiaries — though it is reliably learnt that the actual line-list would be lesser.

So what brought up the need for such a large-scale initiative? A survey in 2020 — the WHO’s STEP-wise approach to NCD risk factor surveillance — put the prevalence of hypertension and diabetes mellitus among the adult population of Tamil Nadu at 33.9% and 17.6% respectively. The findings of the survey, coupled with the disruption in health services, challenges in patients reaching health facilities for follow-up and receiving drugs for hypertension and diabetes because of the COVID-19 pandemic, prompted the government to launch MTM, aimed at doorstep delivery of health services.

Health Secretary Gagandeep Singh Bedi lists the achievements so far: skilled health workers delivering quality and people-centered care, reduction in out-of-pocket expenditure and financial risk protection, improved health service coverage and outcomes through availability and accessibility, greater equity, social inclusion and cohesion, community participation, and social accountability. The State Planning Commission, in a survey of 6,856 persons across the State, documented that MTM increased healthcare access for the poor. Before the scheme was launched, only one-third of the people of low-income groups were screened for diabetes and hypertension. The number rose to nearly 50% after its implementation. The survey found that the scheme helped to cut out-of-pocket medical expenses, especially for those in low-income groups; expenses have halved for these groups after the scheme started operating.

Soumya Swaminathan, chairperson, MSSRF, Chennai, said MTM is a good scheme in terms of finding people who have NCDs in the community and treating them. “I have heard from people, particularly the elderly, that it was convenient to receive the medications at their doorstep. But the programme does not address prevention. In order to make a dent in NCDs at the population level in the long term, we need to address the root causes; risk factors, like unhealthy diet, lack of physical activity and air pollution,” she said.

Lifelong compliance with treatment has to be ensured and this is where digital tools can really help. “Adding the prevention component will help the State reduce the burden of chronic diseases, thereby reducing healthcare costs and help people lead healthy and good quality lives. While MTM screens for hypertension and diabetes, we also have a huge burden of mental health issues that need to be addressed as well,” she added.

A public health expert, who is familiar with the scheme, agrees that MTM has solved the problem of access for people living in remote areas and elderly patients. “On the positive side, doorstep screening enhances accessibility to healthcare services, making it easier for individuals, especially those in rural and underserved areas, to undergo regular screenings. Early detection of NCDs such as diabetes, hypertension, and cardiovascular diseases allows for timely intervention, lifestyle modifications and treatments, potentially reducing the severity and progression of these conditions. By reaching out to individuals who may otherwise not seek medical attention, doorstep screening helps in identifying risk factors and promoting preventive measures, reducing the overall burden of NCDs in the State,” he explains.

Switch from private hospitals

MTM has brought on other advantages. As a health official in the Tiruchi Corporation points out, a significant number of people previously being treated at private hospitals in the city were enrolling for the scheme. “We are monitoring 27,562 persons for hypertension, 21,745 for diabetes, and 24,008 persons for both through 91 volunteers. Given the convenience and free medicines, many patients are shifting from private doctors to MTM,” he says.

Patients from low-income groups have benefited from the door-delivery system. Take R. Malar, 55, for instance. She has arthritis and was diagnosed with diabetes last year. For her medicines, she had to travel more than 20 km every month from Malaipatti village in Pudukottai district to the Government Hospital, Viralimalai. But she now gets the medicines at her doorstep. “It was tough to get to the hospital, and I always had to go with my husband. We had to take a bus from our village to the hospital, and since he was a construction worker, his work got affected,” explains Malar.

Like her, S. Selvi, a tribal woman of the Kattupatti tribal settlement in the core area of the Anamalai Tiger Reserve (ATR), said on the phone that medical teams visited her settlement a few times and conducted checks. “Some residents were found to have high blood pressure and given tablets. A few other medicines were also given to our people at the doorstep,” she said.

There are more than 20 tribal settlements in the Pollachi and Tiruppur divisions of the ATR. Medical teams need to travel through dense forests, often by foot, to reach these places. Similarly, residents will have to travel several kilometres by foot or vehicles to reach the nearest town.

Progress has been made

T.S. Selvavinayagam, Director of Public Health and Preventive Medicine, reckons that reduction in cardiac diseases and strokes and in the State’s overall cost towards NCDs are the advantages.

According to him, progress has been made, compared with the start of the scheme. “Initially, we did not have a portal. Now, with the support of the National Health Mission, we have established a portal on which our Women Health Volunteers (WHVs), field staff and institutional staff nurses make entries. When the patients come to the Primary Health Centre, the blood sugar and blood pressure values are entered. On monitoring these values..., I can say that the results have been satisfying. That said, we need to do one more STEPS survey,” he said.

The scheme has its own share of troubles. Since its launch, MTM has been facing numerous hurdles in many southern districts. To name a few, shortage of WHVs, poor allocation of funds for drugs and serious gaps in drug delivery. More importantly, there is a lack of accountability and sustainability; not every targeted village is 100% covered. Above all, the data submitted by a majority of the WHVs required to be cross-checked as there were allegations of false information or wrong entry.

A health official in one of the southern districts said the government should not have set targets for WHVs; instead, it should have familiarised them with the project first. In many instances, that The Hindu checked independently, the WHVs had quit after two months of having joined duty. There were no replacements for them, and the villages remained uncovered, the official said.

Some doctors at government hospitals in Madurai, Ramanathapuram, Theni and Tirunelveli districts said the objective of the population-based screening was ideal, but there were serious gaps in its implementation. One charge was that the BP apparatus and the glucometer given to WHVs were either inaccurate or the volunteers could not read the measurement correctly.

Similarly, there were gaps in the drug delivery. In many cases, there was a lack of systematic follow-up by the WHVs.

High workload has also hit the WHVs hard. R. Lalitha, a WHV in Perambalur, said the WHVs were initially asked to screen around 10 persons daily, update their data and deliver the medicines according to their needs. But now the authorities have asked them to screen around 50 persons.

With health workers quitting, people are going back to primary health centres to get medicines, sources said. “We are paid ₹4,500 per month, and there are no other concessions, including fuel allowance. Because of this, many have left the job,” Ms. Lalitha added.

Another WHV said they had to spend for battery replacement in the BP apparatus. “We have periodic area visits for screening and drug distribution as well as meetings. We have to visit households when family members are available, and in our region, it is usually at 6.30 a.m. and after 4 p.m. The salary is not sufficient for the work we do,” she said. The sources noted that the out-of-pocket expenditure for these volunteers persisted as they paid for fuel and battery.

Getting timely supplies remains a problem, a staff nurse said, adding: “For instance, there is a delay in getting Continuous Ambulatory Peritoneal Dialysis bags. This week’s supply is given next week. At times, I go around and pool in as many bags as possible to give them to patients.”

One of the main concerns is that the programme’s key aspect — control rates — is yet to be evaluated, official sources said. Questions are being raised about how the outcomes are being measured. A public health researcher said, “We have the number of people screened and receiving drugs. Is that the way the scheme is evaluated and outcomes are measured? Instead, we should have data on those who were newly diagnosed with diabetes or hypertension or both, took consistent treatment, and level of control achieved. With each visit, we should see whether control has been achieved. We need to see if there are complications and document blood sugar levels (at least HbA1c) and BP,” he pointed out.

‘No accountability for lacunae’

He went on to discuss another broader area of concern: human resources. “The programme depends on volunteers, not government staff. There is no accountability for lacunae. We need a trained person with expertise, with clinical acumen, to identify complications in persons diagnosed with hypertension or diabetes. This needs to be corrected immediately. Village Health Nurses (VHNs) are already involved in the reproductive and child health scheme; so, we can at least look at creating more posts of VHN,” he said.

Next comes the wear and tear of equipment. “The accuracy of results may also be a concern, as portable screening equipment may not always match the precision of specialised medical facilities. Adequate training of healthcare professionals conducting the screenings is essential to ensure reliable outcomes,” an expert said. He added, “Let’s put it this way. What has MTM done? It has brought in screening and drug delivery, saving time for people by involving an extra person (WHV). But has the health status of the person improved? The answer is probably no. We are still talking about coverage, when we should have evaluated the rate of control of NCDs.”

“A proactive State like Tamil Nadu should focus on QALY (Quality-Adjusted Life Year) of NCD patients listed under MTM. There should be focus on the control rate of the above population and referral and follow-up for patients with co-morbidities requiring speciality care,” he said.

Officials said certain challenges and shortfalls were observed. Mr. Bedi summed them up — referral linkages and integration between the field-level team and public institutions, handling stakeholders from other departments involved in implementation and functioning of the scheme, and increasing awareness among the patients of the importance of visiting the health facility for confirmation of disease after being screened by the WHVs during doorstep screening are some of them. “As part of data collection, MTM workers are capturing the values of patients on a day-to-day basis. This gives us an overview of the control rate. The Planning Commission took up the study on MTM’s impact recently. Shortly, the National Institute of Epidemiology will take up STEPS survey Round II for a similar impact-based study that will cover the control rate as well,” Mr. Bedi said.

(Inputs from Nahla Nainar and Ancy Donal Madonna in Tiruchi; Wilson Thomas in Coimbatore; and L. Srikrishna in Madurai)