Universal Health Coverage(UHC) Experiences of Tamil Nadu with the UHC Pilot Project

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

2. 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 GoI.

3. 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).

4. Name of the HSC –Rajalipatti (Kodumbalur PHC)

5. Total Number of Patients consulted (OPD+NCD+OG) during May, June, July, August, September, October and November 2017

6. Disaggregated data : OPD, OG, NCD and Community : November 2017

7. Average OPD and NCD/OGs as recorded by VHNs Block wise/ Per HSC: September, October and November 2017 Note:Month of August had 4 sundays and September month had 4sundays; 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.

8. HSC utilization data (excluding OG, NCDs) during July-November2017 – based on UHC-app data. Note: This table, shows the number of individuals that have utilized the HSCs at least once during the past 5 months.

9. Gender Distribution for the last Five month data (July to November 2017) Note : Female patients account for about 65% of all OPDs.

12. 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.

13. 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

14. UHC Pilot - Overall Lab Performance(All 3 Blocks/All 17 PHCs) Patients Referred to UHC - PHC Labs – April - Nov 2017 Total No of Patients Average No of Patients/Day 75%

15. 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 Average No of Tests/Day 90%

18. LIS – Monitoring Equipment

19. LIS – Cell Counter Utilization

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

21. Community focus with geo-tagged family enrollment • End-to-end Electronic Health Record (EHR) maintenance at Primary Care level • Integration of Pharmacy, Diagnosticsservices • 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 TN-UHC App Overview TN-UHC App Salient Features Points of use User Categories ANM/VHN/Nurse Community Physicians/MOs Clinic MD/DD/BMO MD/DD/BMO

22. 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

23. 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.

24. 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)

25. 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

26. UHC- The Urban counterpart: Polyclinic • Specialty clinic for outpatient services for Urban slum population • Comprehensive specialty care under one roof • 74/96 Polyclinics functioning on pilot mode in Tamil Nadu ( 1 per 2.5 lakh population)

28. An Urban polyclinic in Pudhupalayam Ophthalmologist Consultation Equipment provided under polyclinic

29. 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’

30. 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.

31. 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 GoI. • Tamil Nadu is ready to upgrade its 985 HSCs as HWCs in the coming year with GoI support.

32. 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