Steering away from hierarchical and rigid doctor-led health delivery structures, Dr Pavitra Mohan is building a network of affordable and decentralised primary healthcare clinics that ride on the capable shoulders of professional tribal nurses. The nurse-led clinics drill deep into remote and inaccessible communities to improve their health-seeking behaviours. They also galvanize once- voiceless communities to own, lead and have a stake in their own well-being and improved health outcomes.
The New Idea
In India’s remote last mile regions, the Primary Health Care system lies fragmented and dysfunctional. Its very location (generally 15-20 km away from many villages) deters large swathes of population from accessing them. The absenteeism of medical staff combined with irregular and erratic services, force the poor to consult quacks and private hospitals, pushing them deeper into debt and destitution.
Breaking through these barriers, Dr Pavitra Mohan and his team at Basic Health Services (BHS), are building a responsive, empathetic primary health ‘circle of care’, that is rooted in the community. Working in remote districts of south Rajasthan, Pavitra designs and sets up a network of ‘AMRIT Clinics’, that is within an access radius of 4-5 kilometres for patients. They offer the full continuum of preventive, promotive and curative care, with services starting at a village-level unit and going right up to the entire state health infrastructure.
Pavitra recognizes that in any primary health care system, more than 60% of care is provided by nurses, followed by doctors who provide 25% and specialists who deliver 15% of the care and treatment needed. With this insight he has re-engineered the roles of health service providers in remote clinics where doctors cannot reach. The roles have been broken up into manageable components and distributed to a three-tier system of nurses, para-health workers and community volunteers, supported by a doctor. The community has also been ushered in to take charge of reasonable health management tasks. Together, they are creating a health eco-system that previously did not exist.
At the heart of the AMRIT ecosystem, and leading from the front, are trained professional nurses, drawn deliberately from historically excluded tribal communities. Their affinity with the rural context accelerates nuanced and personalized care in AMRIT Clinics. The nurses are provided accommodation so that they can live and work in remote catchment areas. They are backed by a team of doctors, trained community health workers (CHWs) and a cadre of volunteers (Swasthya Kirans who are sourced from the community).
For a decentralized health care system to succeed, the community is a key stakeholder for Pavitra. At every site, communities recommend and provide design solutions to BHS at the time of launching a clinic. It provides infrastructure to the AMRIT Model and offers intimate insights into local health burden patterns. They also enable the AMRIT team to effectively address the social and cultural norms that obstruct health-seeking behaviours. By setting up and facilitating active community advisory group, Pavitra and his team are turning asset-less communities into resourceful partners and problem solvers for the local health system.
Evidence shows that countries with a strong primary healthcare system, record improved health outcomes at affordable costs of care. But, India spends only 1.2% of the GDP on its health requirements, 60% of which is allocated for tertiary care. The skewed focus on specialised care has created deep chasms around health-care accessibility, leading to inequalities along income, gender, caste, and geographical fault lines.
Tribal communities across India are burdened by poverty and geographical isolation. Historically dependent on forest produce, unfriendly forest laws coupled with rampant deforestation, have resulted in a near loss of traditional livelihoods. Pushed deeper into poverty, the menfolk migrate to cities, ending up in lowly paid and exploitative unskilled jobs. In the absence of the primary male member and constrained by low mobility, women face significant challenges in seeking timely healthcare for themselves and their families. Erratic and volatile cash flows ensure that nutrition and health are hardest hit, with most delaying medical attention until later in the disease cycle.
A report released by the Expert Committee on Tribal Health noted that tribal communities lag far behind the general population on all health indicators. 42% of all tribal children are underweight – 1.5 times more than non-tribal children. Constituting 8.6% of the population, they account for 30% of cases for malaria, reporting 50% of all malaria related deaths. In an alarming revelation that rapid urbanisation and changing lifestyles had caught up with this populace, one out of every four tribal was found to be suffering from hypertension (Tribal Health in India – Bridging the Gap and a Roadmap for the Future – brought out by Expert Committee on Tribal Health, headed by noted social entrepreneur Dr Abhay Bhang).
For rural communities, the Primary Health Centre or PHC and its sub-centres serve as the first point of contact with formal health-care systems. But, located almost 10-12 km away from their villages, most PHCs are unmanned and understaffed. A third of the PHCs in Rajasthan do not have a physician on call. Most of these unmanned PHCs fall in tribal populated regions, as working in remote areas is considered a punishment for doctors. Ill-equipped to negotiate with state systems and demand quality services in their vicinity, communities turn to unqualified but available private practitioners, getting trapped in expensive and dubious treatments.
Advocating radical course corrections, health experts are calling for a paradigm shift in the design and delivery of primary health services, to maximize health impact (GOI, 2013; Rao and Mant, 2012). https://accessh.org/wp-content/uploads/2016/05/Primary-Care-Landscape_ACCESS-Health-International.pdf. Keeping in mind changing epidemiology and high migration, the scope of healthcare delivery must be widened to include different cadres of primary care workers, and creation of stronger institutional linkages with social sectors beyond healthcare.
Serving a catchment area of 2000 households, every Amrit clinic addresses the triple challenge of access, availability and affordability through simple solutions. Clinics are located within a 4-5 km radius of its patient catchment. They are housed in structures owned by the Panchayat (local self-government) which are refurbished by Pavitra’s team in partnership with the community.
Each clinic is managed by three female nurses, who are backed up by a proficient three-tier system of upward and downward support. Upwards, doctors visit the clinic once a week and are available for tele-consultation with nurses 24x7. Downwards, the nurses supervise a cadre of trained community health workers who flank out into villages to influence positive health behaviours such as family planning, childcare, nutrition and hygiene practices. They deliver antenatal and postnatal care, and follow up on chronic patients. Further downstream, community health volunteers or Swasthya Kirans (loosely translated means light of health) serve as interface between them and the clinic staff. They are drawn from the local community and run health education and counselling services. Most importantly, they build the fundamental trust necessary for uptake of the clinic’s services. Because each clinic is staffed by three nurses, each takes turns to visit villages and keep their ears to the ground.
This expanded human infrastructure has enabled Amrit Clinics to offer a one-stop, end-to-end spectrum of health care services in villages that till recently had no formal health provision structure. The clinic team starts from health education in hamlets. They go on to cover diagnostics, curative, drug dispensation and basic laboratory test services at the clinics. The clinic galvanizes community-led crèches that provide nutrition to village children. Community advisory groups are also catalysed to evoke innovative solutions such as an escort system led by village youth to enable critical patients to navigate through complex government hospitals.
All services at a clinic are delivered at a cost that tribal populations can afford. Though the user fees cover only 15% of the operational cost of clinics, they go far in deepening the patient’s investment in the care being provided. To further enable families to access health entitlements such as free diagnostics and conditional cash transfers, Pavitra and his team have forged relationships with the public system. They have also partnered with specialised hospitals to provide free or highly subsidized care to referred patients.
Recognizing that young tribal women nurses are most likely to stay and work in rural areas, the optimization of human resources in Amrit Clinics starts with their recruitment and up-skilling. Through an intensive induction and monthly refresher trainings, nurses are trained in critical tasks which their formal training would not have equipped them for. These include the ability to diagnose, analyse and take decisions on cases, patient communication and counselling and the ability to follow standardized protocols. With new technologies placed in their hands (such as those that allow the accurate detection of malaria) and doctors available over whattsapp for consultation, nurses at Amrit Clinics experience autonomy that they would not find in other private hospitals. Accommodation is made available to them, breaking through the mobility barriers that obstruct female nurses to travel and serve in remote areas. Pavitra also opens up growth pathways for the nurses in his team. He moves the more experienced ones to the role of a senior nurse coordinator who then takes on responsibility of managing the entire clinic.
While nurses sit at the heart of the Amrit Clinic model, Pavitra has addressed the challenge of recruiting doctors through a Fellowship program. Created in consort with the Academy of Family Physicians of India, and Equitable Access to Health Care Consortium, the Fellowship enables young medical graduates to engage in a long distance diploma program with field work in Amrit Clinics.
To further optimize resources, Pavitra has chosen to co-locate Amrit Clinics with a livelihoods and financial inclusion organization, led by a leading Ashoka Fellow (Rajiv Khandelwal). The partner organizations, Aajeevika Bureau and Rajasthan Shram Sarthi Association (RSSA) work with tribal communities that depend on migration and labour. They have co-created a health loan product for tuberculosis patients with BHS. To illustrate, while TB treatments generally lasts for 6-8 months, most patients of Amrit Clinics were opting out after 3-4 months and returning to work, aggravating the risk of a relapse. BHS in partnership with RSSA designed a monthly loan of INR 3000-5000 to cover essential costs. They are repaid on completion of the treatment at an annual interest of 8-9%. The flexible payment models syncs with the acute cash flow volatilities faced by migrants. This product has achieved a high treatment completion rate: 52 out of 54 patients completing their treatment.
With a network of 6 clinics, three doctors, 32 nurses,13 Community Health Workers and 60 Swasthya Kirans, the Amrit Clinics serve a rural under-served population of 1,25,000 and have recorded 1,80,000 patient visits (including repeats). More than 90% users are tribal, 60% of these are women. Most are accessing formal healthcare in their neighbourhood for the very first time. Areas served by Amrit Clinics show a greater adoption of healthy practices – family planning and birth control, measures to ensure safe pregnancy or abortions, early care-seeking for suspected tuberculosis and acceptance of referrals to a higher facility. Cure rates for Tuberculosis patients have increased from 45% to 70% over past three years. One clinic has the proud distinction of increased Institutional childbirth rates from 5% to about 50% after five years.
These early impressive outcomes have resulted in BHS being invited by the state Government of Rajasthan to manage one Primary Health Centre (PHC) and by a large NGO – Sewa Mandir, to run their community hospital under the aegis of Amrit Clinic.
Moving forward, Pavitra would like to scale the model in partnership with value aligned organisations and bodies, and open 4 more clinics in the Udaipur district by 2020 to serve 2,50,000 people. Parallely, Pavitra is strongly advocating for design shifts in the primary healthcare model and for an enhanced role for nurses. In partnership with the Indian Institute of Management, Udaipur, he is setting up the Primary Heath Care Initiative for further research and dissemination of his model within the medical and health management community of India.
As a child, Pavitra was deeply influenced by his grandfathers – one a scholar of Sanskrit and the other a freedom fighter who fought alongside Gandhi. Surrounded by deep spiritual conversations and Gandhian philosophy, Pavitra’s growing years were infused by Gandhian thought.
Keen on serving the nation, Pavitra was inclined to join the army, but a chance viewing of a Hindi film, based on the life of a compassionate doctor, kindled his interest in the medical profession. While preparing for admission to Wardha Medical College – set up by Mahatma Gandhi –he studied Gandhian philosophy in some depth and was influenced for life. His exposure to Gandhian philosophy sparked a passion for community medicine and the India “that lives in its villages”.
Throughout his internship and medical career as a paediatrician, Pavitra was witness to failing systems, lack of accountability and the unending hopelessness and misery of families. The heavy focus on medicines without adequate patient education resulted in them landing back in hospitals, overloading the understaffed and overworked facilities. This vicious cycle troubled him greatly. After completing his MD, he was given charge of the nursery of a well-known government hospital in Delhi. With high mortality rates - 4 out of 10 children dying, Pavitra insisted on simple practices – using sanitizers, washing hands, ensuring maintenance of appropriate temperature. After initial resistance, the staff complied, and the mortality rate went down to an impressive 10%. For Pavitra, the experience demonstrated how through collective action and implementation of simple solutions, significant impact is achieved.
And so though doing well in his profession, in 1999, Pavitra opted out of paediatrics, joined a course run by University of North Carolina and studied for a master’s degree in public health. In 2001, he was part of a research team set up to study the ‘role of counselling in ensuring families bring their children to PHCs when they fall ill’. The study took him to almost every PHC in the district, providing deep learning and insights into rural mind-sets where healthcare is concerned. The study also brought home the glaring gaps in the system as well as the inability and lack of will to address them.
An opportunity to join UNICEF presented itself and Pavitra worked both at the Rajasthan state office and the national office in Delhi. His stint at UNICEF opened new avenues and exposed him to the world of bureaucracy and government systems – the value of convenings and networking, of building institutional partnerships.
The years at UNICEF deepened his interest in community health. Pavitra had travelled enough to appreciate that even in developed states like Tamil Nadu, the system was broken at the last mile. As he says, “I knew it was not easy – from a systems point of view – so many factors – water, sanitation, distance, behaviour, status, hierarchies, and cost – all coalescing to ensure collapse of systems at the last mile. The Big Question is – how do we set up a friendly healthcare system – delivering quality, affordable services with dignity and respect, through community involvement and ownership”?
Pavitra set out to explore the models that existed. While the reach of auxiliary nurses and ASHA workers was huge, he saw their limited capacity to respond beyond data collection and inputs in maternal and child healthcare. Hospitals set up in rural areas by dedicated doctors, offered another option. But they were capital intensive and centralized. Tele-medicine could not penetrate remote outposts of the country with no connectivity. Neither did they offer the personal connect. Finally in 2012-13, he quit UNICEF and founded Basic Health Services to cater to health needs of tribal communities in South-western Rajasthan.