Dr. Rita Isaac M.D, MPH Professor& Head, RUHSA Department, CMCH

1. Strengthening District Level Health Care through involvement of Medical CollegesThe CMC Model Dr. Rita Isaac M.D, MPH Professor& Head, RUHSA Department, CMCH

2. Reorienting Medical Education to Community Health Needs through models of primary, secondaryand tertiary level Health Care Programmes

3. CMC’s Innovations in Medical Education • The story of CMC’S experiments in response to the emerging needs of our Nation dates back to the founding story of the young Dr. Ida's call in 1900 and her whole hearted, enthusiastic response to the dying young mothers in labour in our country. • I dedicate this presentation to all those stalwarts from our institution who toiled hard to put in place innovative models of medical education, community health outreach programme and family oriented health services and through it train young men and women to carry the torch forward.

4. Founder of CMC, Dr. Ida Scudder did her medical education at Cornell University, US, returned to India in 1900, when the average life expectancy was 24 years, and started a hospital with one bed She being the only doctor, by 1902, Dr. Ida Scudder had only seen 12,000 patients Frustrated at the thought of so many patients remaining outside the ambit of medical services, she began setting up road side clinics (1906) – taking services to villages and hamlets outside Vellore. Dr. Ida Scudder going for one of the community visits

5. District Level Health Care ModelsSecondary and Primary Level Care Programmes of CMC Community Health and Development Programme (CHAD)-1rural block Rural Unit for Health and Social Affairs (RUHSA )-2nd rural block Low Cost Effective Care Unit (LCECU)-Urban ward College of Nursing Community Health (CONCH)-urban ward

6. Strategies for strengthening health care • Established secondary and primary care level, affordable medical services for the rural, poor urban and tribal communities with tertiary care support at 2400-bed CMC Hospital • Develop all levels of health care personnel through relevant training programme • Identify and empower the most vulnerable groups in the communities through social and economic development programme and community education programme • Relevant, cutting edge research to improve services

7. Affordable Medical Services (through a 3-tiered referral system) 2 rural blocks Urban wards Tribal area PRIMARY CARE Outreach clinics Govt. Linkage CHAD -140 beds RUHSA – 70 beds LCECU- 40 beds SECONDARY CARE CMCH, Vellore TERTIARY CARE

8. Medical Services • Outreach Mobile Primary Care Clinics • Secondary Care Community Health Center • Tertiary Care - CMCH Secondary Level care • General medical care • Obstetrics • Paediatrics • Ophthal clinic- once a week • ENT- once a week • Dental Care • Orthopaedics clinic • Infectious disease clinic • Psychiatry clinic • Occupational and physio-therapy Care • Inpatient Services • Manage all common illnesses in adults &children • Obstetrics care with Caesarian sections • General surgeries OPD ID Clinic OT/PT Center

9. Primary care through mobile clinics by CHAD & RUHSA • A peripheral health care team (Doctor, nurse, Rural community officer, health aides, Community health worker) visit each village once in 4 weeks • Nurses make home visits once in a week • Service focus: Antenatal care, NCD treatment, RHD prophylaxis, Seizure medications, Psychiatric medicines delivered at home (free or subsidized) • Referral to CHAD/RUHSA for further investigation/ treatment • Referral to CMC if needed • Feedback and follow up Mobile Clinic

10. Socioeconomic & Community development programme • 5 Elderly day care centres with noon meal programme • Youth clubs • Farmers clubs for marginal farmers • Play center for poor rural children • Self-help groups microfinance/microcredit scheme • Block-wide cervical cancer “Educate, Screen and treat” programme; IVR mobile technology to raise awareness

11. Medical EducationCommunity Medicine Curriculum at CMC Enables students to understand society and communities in India, culture and environment in which people live and acquire knowledge, attitude and skills required to deliver Effective patient care • Four phases • Each with special objectives • Designed to build on experience gained from the previous phase

12. Practical Application of knowledge and Skills Internship Community Based Research 3rd Year CHP II Learn about Health systems Plan a health program 2nd Year CHP I Live In Experience First Impression about rural community life 1st Year COP

13. PHASE I(First Year of Medical School) Community Orientation Programme (COP) Objectives: • Socio-demographic survey • Community diagnosis • Study environmental, nutritional and social determinants of health • End of First Year • 3 weeks block posting • Multidisciplinary • MBBS, BOT, BPT, Dietarystudents

14. Familiarizes the 1st year students with the life of India’s rural folk • Expose the students not only to the socio-demographic structure of the village but also to the socio-cultural context in which they live and work

15. Determinants of health • Existing health practices and beliefs about disease; its causes and prevention

16. Divided in to small batches - Each batch (3-4 students) is assigned 10-12 households to study

17. Students Interaction with the community

18. Working with the community

19. Government officials interacting Role of Government and voluntary organizations and their programmes in improving the welfare of the rural community

20. Involvement of other departments • Preclinical departments – community studies • Clinical departments – take sessions at the camp site, make house visits

21. PHASE II (Community Health Programme - I)First Clinical Year of Medical School 2 weeks in the 1st clinical year OBJECTIVES • Study health systems(Public Health Sector) • Understand the morbidity profile • Plan and evaluate health programme

22. Phase II – Community Health Program I • Cross-sectional survey to understand the morbidity profile in the community • Utilization of health services • Functioning of various types of health services • Health programme planning exercise in groups of 8-10 students

23. Phase IIICommunity Health program II Objective - Conduct a population based research in common areas like MCH, ENVIRONMENT, NUTRITION etc. • During the second clinical year, lasts 2-3 weeks • Design and carry out a epidemiological study • The pace and schedule of the work entirely dictated by the students • Staff serving as resource persons

24. PHASE IV (Internship)2 months posting in Community Medicine • Gains practical knowledge and experiences in primary health care and prepares them to be effective community physicians • Reinforce skills, knowledge and attitudes • community health practice • Plan community health education programmes • Learn to work as members of health care team including experts from other disciplines

25. Interns’ Training Program Emergency Management OPD & IP Mobile Clinics Major project-Population based Research Health Education

26. Internship • Trained in Quality Assurance through audits • Monthly meeting/review all services data • mortality Audit (perinatal, maternal and general) • OP & IP charts review • Referrals review • Caesarean sections review • Major project: research • Ethics in health care through Case Discussion (with involvement of other departments)

27. Each Phase ends with • Student assessment of the programme • Evaluation of students’ changes in attitude towards medical care in the community • Evaluation of knowledge acquired

28. Training of Allied Heath Personnel • PG Diploma in Health Management – 1 year course • BSc in Medical Sociology affiliated to TN Dr M.G.R Medical University • 1-12 weeks workshops/courses on “Integrated Health and Development Rural Health Care Programme” for graduate and masters degree students in nursing, social work, Sociology and Health Management courses • MPH • PhD in Social Science under Tiruvalluvar University • PG Diploma in Health Administration affiliated to TISS for health managers in private and public sector organisations [to start this year]

29. Family Medicine TrainingLow cost effective care unit

30. Objectives • To orient the students to the principles and practice of Family Medicine • Management of common illnesses • Emphasize on Patient centeredness • Socioeconomic impact of illness • Sensitised to the Cost of treatment and affordability

31. Family Medicine training Orientation 3 days FM posting 2 weeks FM elective 3 weeks Internship training Community health 2 months 31

32. Secondary Hospital Programme

33. Network of Secondary Hospitals 200 secondary hospitals 20-200 bed hospitals Rural and semi-urban areas of India Broad based Services 2 years ofservice obligation after graduation INDIA Vellore 33

34. Secondary Hospital Program SHP I 1 week SHP II 2 weeks SHP III 2 weeks To orient the students to the practice of medicine in rural Secondary Level Care Hospitals 34

35. “Assam itself was a memory to savor, the ubiquitous bamboo, the all-to-real possibility of being shot despite having a military escort, travelling on top a vehicle rather than inside one, bathing in open air, forgetting the intrusions of cell phones and the internet, and the gracious hospitality of villagers who opened their home to us strangers..” Student Quote 35

36. Diversity of cases Bear Mauling Huge Ovarian Cyst “Everyday we are faced with a host of new experiences we had never dealt with and will unlikely see again..” 36

37. ROLE MODEL TEACHERS “What shocked me was the hard work, perseverance and commitment of the people who work hand-in-hand as one team. I realized that the life and work in rural areas with the less privileged and no great facilities is ‘no less’ to the work done in a tertiary hospital” Student Quote 37

38. Revolutionize Health Care in India Thank You for your patient attention