Integration of Tertiary care institutions with Primary &Secondary Health care for discharging Social Responsibility

B S GARGMD, Ph D, FAMS

Secretary, Kasturba Health Society

Director, Dr Sushila Nayar School of Public Health Mahatma Gandhi Institute of Medical Sciences

Sewagram, Wardha, India

Bapu’s home - Sewagram Ashram

All other pleasures and possessions pale into nothingness before

service, which is rendered in a spirit of joy.

Mahatma Gandhi

“

”

MGIMS Sewagram-India’s First Rural Medical College

Milestones• 1944: Gandhiji arrives in

Sevagram after imprisonment at Aga Khan. Dr Sushila Nayar, a young doctor, was also with him.

• Frequent epidemics of cholera and other diseases in Sevagram and around.

Milestones• Villagers started coming to

Dr Sushila Nayar for treatment at the Ashram. Soon the Ashram was flooded with patients.

• Birla guest house near ashram was converted in to an OPD for the patients.

Milestones• Dr BC Roy and Dr Jeevraj

Mehta drew the plan for starting OPD. Dr Sushila Nayar was appointed incharge.

• Later it was developed into a 15 bedded Kasturba Hospital and ANM training centre.

Establishment of MGIMS• 1965: PM Shastriji

suggested starting medical colleges in rural areas

• 1969: MGIMS established as Gandhi Centenary Year Project

Mission Statement

MGIMS today is committed to the pursuit of professional excellence by evolving an integrated pattern of medical education and it seeks to provide accessible and affordable health care primarily to underprivileged rural communities.

“”

MGIMS: ObjectivesMEDICAL EDUCATION• To evolve an integrated pattern of medical

education• To provide value based and cost-effective medical

education with a community oriented approach• To teach and train doctors with a focus on rural

orientation

MGIMS: ObjectivesHEALTH SERVICE• To provide state-of-the-art health care facilities at

affordable cost• To evolve a comprehensive health care delivery

system consonant to the needs of the community• To empower the community by involving them in

their own healthcare• To provide accessible and affordable health care,

primarily to underprivileged rural communities

MGIMS: ObjectivesRESEARCH• To conduct appropriate and community-based

research on priority health issues• To promote research in Indian systems of medicine

along with allopathic medicine.

Code of Conduct• Wearing Khadi• All Religion Prayer• Shramdaan • Vegetarianism• Eschew alcohol and tobacco (in

any form)

Imparts Community-Oriented Medical

Education aims to provide

community-oriented doctors who

deal effectively with health

problems at primary, secondary

and tertiary levels

Medical Education Now

• Based in a tertiary care hospital fragmented between specialties

• Focus on individual diseases

• Dominated by biology and technology

Lacks• Comprehensive

understanding of health and healing

• Understanding of role of social, political, economic and psychological factors

Orientation Camp• 15 days camp in Gandhiji’s

Ashram immediately after admission to MGIMS

• Acquaintance with Gandhian principles, ideology & programmes

Social Service Camp: 15 days• Each batch of medical

students adopts a village and learns in the community throughout their course

• Students oriented with social problems in rural communities

Health Exhibition

Community Kitchen

Adopting a Rural Family

Regular Visits to Adopted Families

Reorientation of Medical Education (ROME)

• 15 days camp in rural training center during final MBBS

• Students trained to provide primary healthcare

• Trained to work with minimum resources in rural areas

Internship• Posted in rural training

centres • Learn to apply skills in

community with minimum resources

General Out Patient Department (GOPD)

• Replica of PHC in tertiary hospital

• Reduces burden on consultants by treating minor ailments

• Link between peripheral health services and Kasturba Hospital

• Immunization cell, MCH, Psychosocial cell, Leprosy and DOTS centre

GOPD Continued• Guidelines for prevention, care and

rehabilitation, norms for referral

• Epidemiological surveillance of disease.

• Guidance/Counseling cell

How to Provide Doctors to Rural Areas?

▪ To provide health care to rural masses

▪ Rural placement scheme started in 1992

▪ Mandatory for all graduates to serve for two years in villages as an eligibility criterion for application to PG course

▪ Posted in recognized NGOs working in rural areas identified by Institute

Clinical Forensic Medicine Unit (CFMU)

➢ Country's first CFMU has been started by dept of

Forensic Medicine of MGIMS. Also developed

Forensic Medical Software for generation of all

Medico-legal Reports (MLR)

➢ This unit works hand in hand with the Accident &

Emergency Dept/ casualty of hospital 24 X 7.

24

CFMU• Medico-legal work of MLCs is handled by Forensic

Experts

• Organized standard MLR’s containing adequate & comprehensive medico-legal information with reason based opinion

• Computer printed reports are generated through the Forensic Medical Software.

KASTURBA HOSPITALService with Compassion

Kasturba Hospital: 2015-16• 934 bedded hospital

– Teaching beds690– Private beds 32– Service beds 100– ICU beds 54– Melghat 50

• All major specialties • Separate ICUs: Medicine,

Surgery, Pediatrics, ObGyn, Stroke unit

• Inpatients 47,204• Outpatients 8,26,808

Kasturba Hospital: 2015-16• Major operations: 25,403• Lab Investigations: 9,17,536• X-Ray, CT, MRI & USG: 1,45,118• Blood donation camps: 37• Children delivered: 5,542

Diagnostic services • Fully automated chemistry analysers,

blood gas & electrolyte analysers, automated blood cell counters, Cytospin, Rapid TB culture (BACTEC)

• Microbiology, Clinical Biochemistry labs participate in EQA program

• Accredited cytopathology lab• Microbiology Lab selected as referral

laboratory for 4 districts under IDSP• Recognized by ICMR-WHO Centre for

Population Based Cancer Registry of Wardha district

Hospital Information System▪ Funded by Ministry of IT▪ Designed and executed by

C-DAC, Noida

Hospital Modules College ModulesRegistrationInsuranceOutpatientInpatient departmentAdmission & DischargeOperation TheaterLabsBlood BankMedical Record Dept.Drugs storeDietSupport Services

Accounts SectionPersonnel SectionStudents SectionCentral StoreTransport

Low Cost Medicine Initiative at MGIMS

• Drug and Therapeutic Committee formed• Essential drugs and surgical items listed• Drugs from reputed companies procured in bulk at

unbelievably cheap rate• Drugs made available at the two in-house medical

stores• Generic Drugs introduced in the hospital

Low Cost Medicine Initiative at MGIMS

• Electronic system to order, store, sell and keep track of drugs and surgical items

• Drugs sold at 20% profit margin and not at MRP• Major reduction in costs of anti-cancer drugs,

antibiotics and life saving drugs (up to 300%)• Cost of treatment of chronic diseases reduced by

one-third to half• Doctors sensitized by discussions• Consumers made aware of the low cost drugs

Health Insurance Schemes• Aims at integrating

development of rural communities

• People in community contribute towards their own health

• Avoids charity, Creates health consciousness

• Provides health care at doorstep, arranges hospitalization of those who need it.

Scheme Cards

General 18,807

Jawar 3,561

Village 23,363

Village Institutional 29,305

Institutional 794

Total insured in 2015 - 16 : 78830 with 3,02,315 members

Annual Family Health Insurance Schemes

GENERAL:• Rs.400• Upto 5 family

members covered,

• For dependent Rs. 140/year

• 50% concession OPD/IPD services

• No concession for private room

• CT scan, MRI 10%

• Meals not free

INSTITUTIONAL:• Employees of any

institution/industry and family members

• Can be insured by Institution head,

• Premium Rs. 75 per head

• Benefits same as general

• 100% employees or their families should insure.

JAWAR:• Beneficiaries pay in

kind – Jawar (Sorghum), according to capacity.

• 100% waiver for all emergencies, delivery of primigravida, Unforeseen Illness

• 50% waiver for rest of illnesses, outpatient facilities

• Free hospital meals

Annual Family Health Insurance Schemes

VILLAGE

• Rs. 40 per member

• Prerequisite >75% families of village need to be insured

• Benefits same as general insurance.

SMALL SAVINGS GROUPS• Same as village

scheme but for registered small savings groups (Bachat Gat).

• 100% members or their families should insure

INPATIENT SLIP

• Only for one time use.• For Inpatient Care.• Rs. 150 per slip.• Benefits same as

General• Offered to institutions

only or to the village communities.

Other Developments• Dr. Sushila Nayar School of Public Health designated in

2009 as WHO Collaborating Center for Research, training in Community based Maternal, Newborn Child Health

• ICDS Monitoring Centre for State• First Model MCH wing has been constructed with financial

support from NHM• Dept of Medicine & Paediatrics involve in imparting 6

months training to MO

WORKING TOGETHER FOR HEALTH

Community

District Health System

MGIMS

Collaboration with the Public Health System Human Resource Development

• Training program for ASHA in Wardha district

Collaboration with the Public Health System Human Resource Development

MGIMS also involved in recruitment of ASHA, >60% of ASHA had worked as “CLICS doot”

+ Training for MPWs and ANM in NVBDCP

Collaboration with the Public Health System Support Service Delivery for

Primary & Secondary Health Care

✓ Continuing professional

education for health care

providers posted at these health

facilities

✓ Out-Patient services

✓ In-Patient services

✓ Specialist visits

✓ Village Health Nutrition Days

1 Rural Hospital (RH) and 3 Primary Health Centers (PHCs) undertaken by the MGIMS through MOU with the District Health System• Extends Technical support• Regular posting of Interns, Medical Officers and Post-graduate

students

Support Service Delivery for Primary & Secondary Health Care

• Field practice area – Three PHCs– One Rural Hospital

• Technical support• Regular posting of Interns, Medical

Officers and Post-graduate students• Community mobilization and health

promotion activities at village level• Continuing professional education

for health care providers posted at these health facilities

National Blindness Control Programme

• Regular eye screening camps in all the villages of Wardha district covering a population of 8.3 lakhs

• So far 28,604 poor rural patients have undergone cataract surgery at Kasturba Hospital; 96.8% of these successfully implanted with IOL

Community Ophthalmology in 2015Cataract surgeries 4,247

IOL implants 4,237

Visual acuity tested 31,706

Referred to Kasturba Hospital 4,701

Free transport provided 4,312

RNTCP• RNTCP Microscopy

center at General OPD, KHS and Urban Health Center, Wardha.

• Department of Microbiology, MGIMS is a designated to carryout the culture and sensitivity for the region.

Other Services• Surveillance and reporting of

infectious diseases.• ICDS Monitoring for

Maharashtra• Reporting of infectious diseases

through IDSP• Technical support for

investigation of epidemics• Drug De-addiction centre: Only

one in Vidarbha• Reconstructive surgery for

leprosy patients

“Coming together is a Beginning;Staying together is Progress;Working together is Success”

- Henry Ford

• Developed an interface between– MGIMS, Sewagram– Community-based Organization– Health Care Providers (Public & private)– District Health System

• Utilizing this interface for improving quality of life & Health Care through health system

Partnership Initiative

Health System Research• A model of decentralized health care delivery

(CLICS Program)• Multi-centric task force study on Home-based

management of young infants• Utilizing near-miss approach to improve maternal

health• Survey on Prevalence of TB in Wardha district:

Central TB Division, New Delhi• National Quality Monitoring Unit for EmOC & LSAS

training

Community-based Research in Maternal, Newborn and Child Health

• WHO Collaborating Center For Research and Training in Community Based Maternal, Newborn and Child Health

• ICMR Advanced Center for Community-based Maternal, Newborn and Child Health– An Alternative Model of Community

Monitoring for Health – Central India Rural Pregnancy Cohort– Improving health care seeking for

newborn danger signs in rural Wardha, India

– Workshop on Capacity Building

Department of Community Medicine

“ All other pleasures and possessions pale into nothingness before service, which is rendered in a

spirit of joy. " -Mahatma Gandhi

VHNSC : 65Women’s SHG : 275Kishori Panchayat : 89Kisan Vikas Manch : 10

Kisan Vikas ManchKishori Panchayat

Self Help group

Behavior Change Communication

• Family Life Education for adolescents through both schools and community-based

• Parenting workshop• Suraksha Aaichi aani Balachi Mohim• Mulgi Wachwa Mohim

Village Health Nutrition Day (VHND)

✓ Immunization services✓ ANC and PNC check-up✓ Health education and Counseling

• Developed a module for

training of VHNSC members

(based on experience of

community mobilization)

• Training of master trainers in

two batches

Kisan Vikas Manch

Women's’ Self Help Group

Kishori Panchayat

Venn diagram on MCH services with SHG

women

Iron rich food cooked by using locally available food products

by Kishori Panchayat girls during cooking competition

Social Mapping with VHNSC members

Transect walk with KVM members

FGD with SHG women

Sanitation drive organized in an adopted village by students through VHNSC

members

Intern facilitating a KP meeting

Kishori Panchayat

Kishori Panchayat girls performing against Open field defecation

Kisan Vikas Manch (KVM)

36081 patients benefitted across 22 villages

Kiran Clinics

Center Villages Total

Anji 9 14392

Talegaon 7 6339

Bhidi 5 5827

Kharangana 1 1056

Urban Health Centre 9715

TotalTotal 22

• Quality of services at Kiran Clinic

• Quality of services at VHND

• Services provided through the AWC

• Institutional Maturity Index for VHNSC

Behaviour Change Communication

Multiple channels for changing community norms– Empowerment of CBOs

through regular monthly meeting– Family life education – Parenting workshop– Campaigns

Challenges• Resource intensive• Pressure of sticking to University

& MCI guidelines• Developing a system of

assessment for CBME • Student’s safety in the field

Challenges• Garnering commitment and

adequate provisions• Availability of field practice area

and long-term relationship with the community

• Engaging community members, health professionals and other sectors

Awards and Recognition

12th Mahaveer award for Excellence in the sphere of Education & Medicine 2008

The Department of

Community Medicine was

conferred the

“GLOBAL SAFE MOTHERHOOD

AWARD" 2001

by The White Ribbon Alliance for

Safe Motherhood, USA for

“SURAKSHA AAICHI”

Awards and Recognition Designated as WHO Collaborative

Centre for Research & Training in

Community Based Maternal, Newborn

& Child Health

WHO Award for Excellence in

training of Primary Health Care at

a tertiary health facility , 2011

(ICICI Lombard and CNBC-TV 18

India Healthcare Awards)

Awards and Recognition

MGIMS is free India’s first attempt to change the destiny of

rural health

Thank You