The intense heat of Vellore had just been vanquished temporarily by a freak storm. The speeding wheels of the ambulance leave no trail of dust behind. Inside the vehicle, Ellama, pregnant and full-term, is clutching her stomach with one hand and with the other, her husband’s arm. The ambulance is trying to balance urgency with a smooth drive. As it races from Banavaram Panchayat in Vellore to the Institute of Obstetrics and Gynaecology in Egmore, Chennai, Ellamma and her family send up a small prayer.
Ellama had been referred to the ISO-certified Banavaram Primary Health Centre (PHC) for a Caesarean. The district’s flagship PHC does elective and emergency C-sections five days a week. She was scheduled for surgery, when suddenly she developed complications.
“Ordinarily, we could have delivered here, but the fainting episode made it a complex case. We stabilised her, and made the decision to shift her to a higher institution in her best interests,” explains S. Manonmani, Block Medical Officer.
With its blood storage units, availability of a trained obstetrician, anaesthetist, ultrasound scan facility and doctors and nurses on call 24 hours, the block-level PHC at Banavaram is itself a referral centre for surrounding areas. Ellamma had been referred to it from the PHC at nearby Panapakkam, but prudence is the better part of valour, especially when it is the question of saving two lives.
“Part of the task of providing quality medical care to patients is also about knowing when to refer them to a higher centre,” says A. Somasundaram, Deputy Director of Public Health, Vellore district, who was on a regular inspection of the PHC
The Banavaram PHC is significant to the evolution of Tamil Nadu’s public health history. It is here that Uma Natarajan, a gynaecologist performed the first ever C-section surgery at a PHC (in the State) on a young Saranya, back in 2007.
“Up until then, most deliveries were happening at home, or they were happening in private centres. That is also when things changed in Tamil Nadu, leading it on to its much-feted achievements in maternal and child health care,” explains A. Padmanabhan, Advisor, Public Health Administration, National Health Systems Resource Centre, under the National Rural Health Mission (NRHM).
The tipping point came, said Dr. Padmanabhan, who has also served as Director of Public Health in the State, when people began asking for more.
“People started protesting and complaining. They started demanding facilities at the PHC level, because going to the private clinics for delivery was a luxury only few could afford. The administration sprung into action and created an ‘enabling’ environment for doctors at the PHCs.”
That included operation theatre facilities, semi auto analysers (laboratory testing facilities), ECG machines, blood storage units, training in anaesthesia for doctors (MBBS), and appointing three trained staff nurses round the clock to take care of deliveries. Faced with the same human resources shortage that health care in the rest of the country has to contend with, the State government turned to innovation to tide over that looming crisis: it hired doctors working in the private sector on contract, and paid them for services rendered.
Fewer complications
“Merely that was not enough. Once the nuts and bolts were taken care of, the focus shifted to the small, non-infrastructural issues, like attitude of health-care staff towards patients,” Dr. Padmanabhan explains. Ostensibly, it was the tougher task. In this, small things began to make a difference. One of the ideas that took off was getting PHCs to conduct the ( valakappu ) bangle ceremony for pregnant women, a ritual usually conducted by her family.
“The idea was to make the PHC seem like an extension of the family. It is only the closest members of the family who are involved in such a ceremony. It will increase the confidence of the women and the community in the local PHC,” he adds.
Subsequently, the novelty of the valakappu wore out, but the idea of throwing a feast for the woman has stayed. On two days of the week, ante natal mothers can eat a sumptuous meal in the PHC they report to. Besides helping patients bond with PHC staff, this move has delivered a significant twin result: improvements in the nutritional status of the women.
“Improved nutrition means fewer complications, better birth weight and better healing for the mother,” says Dr. Manonmani. Iron-Folic Acid tablets, and iron sucrose injections are provided to beat anaemia among young mothers.
It is not surprising then that Tamil Nadu has notched up substantial achievement in human development indicators in the last decade or so. “Today, we have an impressive number of deliveries taking place in the public health-care sector, right from the PHC level to the tertiary hospital. About three lakh deliveries are now taking place in government health-care centres in Tamil Nadu,” says J. Radhakrishnan, Health Secretary of the State. Before the changes, that number was a low 70,000. Home deliveries have come down to less than one per cent.
“Once out-of-pocket expenses come down, which is what the system has managed to do in Tamil Nadu, people will see the benefit of going to a public health-care set-up, especially if outcomes can measure up,” Dr. Padmanabhan adds.
In addition, the government provides monetary assistance to all pregnant women registered with a government health-care institution, with the last allotment to be credited only when the baby has finished the course of inoculations. Any case of death (mother and child) in an institutional delivery was scrutinised and set on record via a maternal death audit.
Newborn intensive care units are being set up across the State, to revive, stabilise and provide life support for infants. For emergencies, the babies are rushed to higher institutions in special ambulances. More lately, in association with Mediscan, detection of birth defects using ultrasound machines has also been initiated in some PHCs.
This period of hectic public health activity in Tamil Nadu coincides with the State clocking the country’s fastest average decline in under-five mortality rate between 2008 and 2010.
In her presentation at the recent Call to Action Summit (for child survival and development) held at Mamallapuram, Anuradha Gupta, Mission Director, NRHM, had abundant praise for Tamil Nadu’s average Under-Five Mortality Rate decline (at 12.5 per cent), when the national average decline was just over seven per cent. The Common Review Mission of the NRHM has not only commended Tamil Nadu, but has also indicated some experiences that can be replicated in other States.
However, she tempered her praise with a note of caution: “No State can rest on its laurels. We have to continue to make efforts to reduce our under-Five mortality and maternal mortality rates. For this, business as usual is not enough.”
As she pointed out, four or five districts in the State were lagging behind the rest. So, while Tamil Nadu marks milestones in public health care, it should also look towards achieving equity in health services across the State.
ramya.kannan@thehindu.co.in
