Thursday, April 9, 2009

The goal is not an increase in patient numbers but patient care

Since 1970, CRHP has been a leader in primary health care (PHC) and village level empowerment, especially of women. It has trained over 20,000 people from across the world on its model of equity, integration and empowerment in the hopes of spreading the message of locally-based PHC. By starting at the level of the neediest villager, CRHP has been able to collectively raise the status of the whole village while simultaneously breaking down caste barriers, long-held destructive traditions and the low status of women.


The key player in this primary health program at Jamkhed is the village health worker. She is a woman selected by her villagers to raise not only the health of the village but also its capacity to handle its own problems. At the outset, many of these women were dalits (untouchable caste) and illiterate. She was not accepted, trusted or supported in her village and the knowledge she was had was often overlooked by higher caste villagers. It was not until problems arose that the VHW was given her chance to break through the barriers.


Many of these problems were referred to the hospital, including complicated deliveries, snakebites, and pneumonia. The hospital served not only to care for the referred patients but also to support the village health worker in her decision. Questions asked by the patient’s family would be referred to the VHW, who would give the correct answer and then be supported by the doctor. When a patient was referred, the VHW would be recognized for her work. When complications arose, villagers saw that the doctor taught the VHW and trusted her. The hospital provided an invaluable service in supporting and encouraging the VHW, assisting her to be accepted and recognized in the village. Soon enough, the VHW was allowed into houses, was performing deliveries in high caste homes, and was listened to when speaking on leprosy, snakebites and other health issues.


The secondary care component of CRHP is essential to the success of its primary health program. When a flow chart is constructed of the CRHP model, two adjacent circles are connected by a horizontal line. In one circle is the village & VHW, in the other is the hospital, and in between is the mobile health team. CRHP is known for its PHC program and village work, but its ability to provide low-cost, honest hospital care is invaluable. How effective would the VHW be if she referred cesareans to a government hospital where it cost 10-15,000 rupees ($200-$300) and placed the family in lifetime debt, rather than to CRHP’s hospital for 5000 rupees ($100)? Or to a private clinician who charged extra for leprosy medications rather than to CRHP where the meds were covered by a leprosy fund? Or to a hospital where the staff treated you like an animal, versus CRHP where you were not only respected but you and the village health worker were taught?


The secondary care component, in addition to supporting the VHW and her efforts, provides low-cost hospital care, supports a non-intimidating environment, and allows the villager to learn about medicine, thus breaking down unfounded beliefs. Each year about 26,000 outpatients receive treatment, 350 deliveries take place (usually for high-risk patients), and 500 surgical procedures are performed. Family members are allowed into the operating theater during the procedure and family is expected to care for the patient as a nurse would.


On Sunday, a new 50-bed hospital was opened with a bang at CRHP. Plans have been three years in the making and construction has taken the past year. The hospital is not only bigger but better built. While the old hospital was built thirty years past with tin roofing and one floor, the new hospital is reinforced with plaster and bricks and has two floors with plenty of space, also permitting a much cooler atmosphere in the hot summer months. The larger wards and consulting rooms will allow for better care of patients and the updated surgery rooms (including one for laparoscopy) will make it easier for doctors to operate. Private rooms will provide safety and comfort to patients with burns and smelly wounds. And the building will provide a long-term hospital solution, as the last hospital (while full of character) was not built to last as long as it did.


While CRHP has in many ways set the mould for an effective primary health program, a major focus now is to become a leader in creating low-cost secondary care. Protocols for patient care, drug therapy and operations will accompany the change in space to streamline and improve access and cost. Villagers with little hospital experience but tons of real life experience will be trained to provide patient care. Doctors will hopefully be attracted to the rural setting to provide services to the neediest of Indians – in eye care, dentistry, surgery and pediatrics. The goal for the new hospital is not an increase in patient numbers but rather an improvement and standardization in patient care, something reiterated throughout Sunday’s opening. The opening of the new hospital represents the hope that CRHP will continue to be at the forefront of change in the health sector throughout India and other developing countries.

1 comment:

Pat said...

This was really interesting and really well written :) - Thanks for the insights!