Governments That Work - I : Primary Health Care Finally Takes Off in the States

A combination of fortuitous circumstances – high rates of economic growth coupled with spiraling government revenues; the information revolution; Panchayati Raj; public-private partnership; and the emergence of political leaders who are determined to turn things around in quick time – is changing the face of rural India and effecting a significant improvement in the quality of life in the villages.

Whatever the cynical and negative media may be dinning into your ears about the failure of the political class and the incompetence of the bureaucracy, the truth is that our governments have begun to work at the grassroots – at least in some states – and the results are there right before those who have their eyes open and who are not wearing political blinkers.

Following their own political agendas, media houses have put a lid on the good work being done in many states, specially Gujarat, Andhra Pradesh, Madhya Pradesh and Karnataka. As a result, while the people in these states are aware of the positive changes that have come about in some areas, the rest of India has been kept in the dark. For example, both Gujarat and Andhra Pradesh have forged ahead of other states in the area of emergency medical care via the 108 ambulance programme; these two states have also ensured efficient delivery of pensions to senior citizens, widows and the handicapped; Gujarat has produced a miracle by ensuring 24X7 electricity to every home in every one of its 18080 villages through its Jyotigram Scheme; and Karnataka and Andhra Pradesh have stolen a march over other states by introducing innovative health insurance schemes for the poor. However, this is not the end of the list. Add to it the `bicycle trick’ devised by Karnataka and followed by Gujarat and Madhya Pradesh to cut the drop-out rate among school girls (they offer a bicycle to every girl who enrolls herself in high school); the Ladli Lakshmi Yojana devised by Madhya Pradesh to discourage female feoticide and to correct the imbalance in the male – female ratio; and the commitment shown by these states to implement the `Janani Suraksha Yojana’ to bring down infant and maternal mortality rates and you have a sample of good governance in the rural areas in these states.

This two-part series on `Governments That Work’ will touch on these issues. The first part deals with health –related schemes which have been efficiently implemented. The second part will deal with primary education and other social sector and infrastructure related schemes. I will first begin with the ambulance scheme – 108 – launched first in Anbdhra Pradesh and Gujarat and later to Uttarakhand and Goa. This service – planned and executed by Emergency Management and Research Institute (EMRI) – a not-for-profit organization, is hailed the world over for its extraordinary efficiency, social purpose and commitment and is being showered with International awards and accolades, but in India, this is a closely guarded secret. The media does not want you to hear the good news, lest you begin to feel good and bring down Television Rating Points which are normally fuelled by cynicism and negativism!

Emergency Management and Research Institute, EMRI for short, was launched as an NGO by Mr.Ramalinga Raju, the founder of the Satyam Group, in Andhra Pradesh in 2005. Raju was impressed by 911 – the emergency ambulance services in the U.S and felt that India too should have a comparable service. EMRI is an integrated emergency service that covers medical emergencies, police and fire. Impressed by the success of the programme in Andhra Pradesh, Mr.Narendra Modi, the Chief Minister of Gujarat decided in August, 2007 to operationalise the service by March, 2009. But, as we are all aware, where there is political will, there is speed. Therefore, with Mr. Modi pushing it, the 400 ambulances needed to cover the entire state were operationalised six months ahead of the deadline in September, 2008 itself.

Apart from Andhra Pradesh and Gujarat, the other states which have fully operationalised the emergency ambulance service are Uttarakhand and Goa. In all these states, villagers say the ambulance reaches their doorstep in 15-20 minutes after a call to 108, a toll-free number, and takes the critically ill to the nearest civil or private hospital. This is a facility which even residents of Delhi and Mumbai cannot claim to have. Some other states which have taken the first steps to introduce 108 are Rajasthan, Karnataka, Assam, Tamil Nadu. All these states have introduced these ambulances in some areas and are still a long way off in implementing this emergency service all across their states. The Karnataka government has made budgetary provision to operationalise 100 ambulances this year.

States can get much of the capital expenditure needed for this emergency ambulance service through the National Rural Health Mission, provided they have a clear plan of action and pitch for it the way Andhra Pradesh and Gujarat have done. The cost per unit ranges from Rs 10 lakhs to Rs 16 lakhs depending on whether the ambulance is equipped with Basic Life Support (BLS) or Advanced Life Support (ALS) equipment. The running cost ( Rs 1.25 lakh per ambulance per month) is provided by the state government. One ambulance is expected to cover two lakh people in the urban areas and half that number in the rural areas. Each ambulance operates within a radius of 20 km. Gujarat, for example, is divided into 400 segments and each ambulance covers a radius of 9 kms in urban areas and 20 kms in rural areas. The running cost of the present fleet in Gujarat is about Rs 60 crores a year.

Andhra Pradesh first secured 500 ambulances and later added 150 more to its fleet. EMRI has now been asked to augment the fleet further with 150 more units. In Andhra Pradesh, each ambulance handles 8 cases a day while in Gujarat it is approximately five cases a day. Mr.Govind Lulla, COO, EMRI for Gujarat, Maharastra and Goa says “the golden hour is critical in medical emergencies because 80 per cent of the deaths occur within that hour”. Hence the value of the ambulance, which reaches every nook and cranny of a big state like Gujarat or Andhra Pradesh within 15 to 20 minutes. The BLS Ambulance has oxygen cylinders, suction pumps, cervical collars for immobilization of the patient , drips and measuring instruments to measure oxygen level in the blood, blood glucose etc. The ALS ambulances have ventilators and defibrillators. They can take an ECG and transmit the same to the call centre where physicians work round the clock and advise the Emergency Medical Technician (EMT) in the ambulance on the pre-hospitalisation medication to be given to the patient. The ECG and the call centre doctor’s opinion is dispatched to the hospital where the patient is being taken, so that doctors in the emergency room in the hospital have sufficient information on the patient’s condition. The ratio of BLS:ALS is 3:1. EMRI handles 2000 emergencies a day in Gujarat.

Such is the efficiency of the system that sometimes it makes you rub your eyes and ask whether all this is happening in India. The system operates as follows: When there is a medical emergency in a village, the villagers call 108, which is a toll free number. The call centre directs the nearest ambulance to reach the village. It has an Automatic Vehicle Location and Tracking System (AVLTS). The physician (there are 13 of them at the Call Centre in Ahmedabad) decides whether to dispatch a BLS or an ALS to the scene. On reaching the village, the 108 crew get down to their task. Whenever necessary, the EMT calls the call centre, gets on line with a doctor and seeks his advice. He also arranges a conference call with a friend or relative of the patient with the doctor, so that everybody is in the loop in regard to the nature of the emergency and the course of treatment suggested by the doctor. There are 3400 hospitals in Gujarat. By end of 2009, the government plans to double this number and ensure that there are 7000 hospitals in place. The emergency medical service is absolutely free and the ambulances take patients only to hospitals which have signed an MOU with EMRI for receiving patients and handling emergencies. In Gujarat, in the first 16 months, EMRI has handled more than 4.25 lakh cases, of which 1.21 lakh cases related to pregnant women being rushed to hospitals.

Every Ambulance has a pilot and an Emergency Medical Technician (EMT). The crew is trained for 45 days. The pilot learns about extraction of vehicles in accidents and in dealing with similar emergencies. The EMT, who is a graduate in life sciences or nursing or pharmacy, is trained to deal with medical emergencies. Since this is a service-oriented activity, EMRI places a lot of emphasis on ethics and attitude. Mr.Lulla says that “if the attitude of an applicant is not okay, we don’t hire him”. Members of the crew are not to even accept tips from people. Such is the training that the crew of an ambulance handed over foreign currency worth Rs 30 lakhs to the victims of an accident after admitting them to a hospital. The car was involved in a crash while the family was heading to the airport to board a flight to Australia. The 108 crew took charge of their bags, cash and travel papers and handed them back to family after admitting them in a hospital.

Those who step outside this ethical framework are fired. EMRI ensures quality and courteous service because of the autonomy it enjoys in its operations.

EMRI pays special attention to the recruitment process. Since the crew has to handle medical emergencies and deal with people in distress, the organization ensures that the recruits have the right attitude. Mr.Lulla says the catchment area is “good souls with right values”. According to him, soft skills and value skills are as important as technical skills for those who work for EMRI. Mr.Amit Desai, Head, EMRI, Gujarat says the challenge is to get the right people and to train them. As Mr.Lulla points out, “this is not a government job and those who join us must realize this”. We tell them that if money is your objective, don’t come here. EMRI currently has over 12,000 employees all over India. Mr.Desai says the employees like it because “they have the best of both worlds – corporate culture plus public service”. The emergency service runs like clock work because of the hands-on approach of the management. Mr.Lulla, Mr.Desai and other top executives often accompany ambulances when on call and watch the crews at work. The training programme is designed to make the employees mentally strong and sensitive. “It is a combination of leadership, technology, innovation and research, which are the four pillars of the organization” Mr.Lulla says. We want persons with passion, energy, modesty and reliability.

The dedicated crew have made 108 a roaring success. This writer caught up with the crew of one ambulance on the outskirts of Ahmedabad. Ms.Preeti Patel and Mr.Vyas Pratik, the Medical Assistant and Pilot of the Ambulance, which is effect is a medical emergency unit or a mini hospital on wheels, were checking the equipment and gearing themselves up for the next call when . Both of them do 12-hour shifts but women are exempt from the graveyard shift. The Ambulance is well equipped with several emergency facilities. Disposable Syringes, Anti-Snake Venom. Equipment to deal with emergencies like cases of drowning and poisoning. The communication link between the call centre and the Ambulance is through a mobile phone. The crew are also given a digital camera to get photographic evidence in medico-legal cases. This evidence is passed on to the police. All calls to the crew and from them are recorded and made available in medico-legal cases to investigators and courts.

Mr. Prathik, who pilots the ambulance did an Industrial Training Institute Course in Automobile Engineering after passing his 12 th board examinations. Thereafter he joined a one-year computer course but abandoned it half way when he landed this job. He was given a ten-day crash course to handle medical emergencies. He has a licence to drive heavy vehicles, which is a must to get this job. Ms.Patel has a BSc in Chemistry and an M L T ( Medical Lab Technician) Diploma to her credit. In addition, she has also done a one-year certificate course in Dialysis from the Ahmedabad Civil Hospital. She worked as a lab technician for one year before joining the Emergency Ambulance Service. According to her, several of her colleagues in this service have Lab Technician Diplomas. She was given a three-month training programme before being sent into the field. Both Preeti and Vyas are happy with their jobs. They say there is a lot of job satisfaction because they are able to help people in times of distress. The people are very appreciative of their work. They are also sent out into the villages to hold impromptu classes for rural folk on how to deal with medical emergencies.

Anyone traveling through Gujarat or Andhra Pradesh today can sense the positive vibes that 108 has generated in even the remote villages of these states. Villagers in Narmada, Mehsana, Gandhinagar districts of Gujarat and Srikakulam, Vizianagaram and Vishakapatnam districts of Andhra Pradesh, to which this writer traveled to assess governance at the village level, swear by this service. Amazingly, although a “government service”, there was not a single complaint of corruption, bribery, inefficiency or bad behaviour of the crew in any of the villages of these six districts in these two states. This is indeed something extraordinary for a “government service” in India, but it is true. It is the most efficient service running in this country and the chief ministers of all states which have fully operationalised 108 are certain to milk it politically. There is such an outpouring of public gratitude for this free and efficiently delivered critical health care service that it is certain to bring in political and electoral dividends for all the chief ministers who have introduced 108. In that sense, this could be called a `108 Election’ in Gujarat, Andhra Pradesh, Uttarakhand and Goa.

Here is what some citizens living in the rural parts of these two states had to say:

Diheshchandra Kalidas Shah of Garudeshwar Village, Narmada District: “ The ambulance is just a call away. It reaches our village in 5-10 minutes. There is no payment to be made and there is no corruption”. Virender of Bilodiya Village in Rajpipla Taluk says 108 is a real boon for the people because the ambulance is at their doorstep in around 15 -20 minutes. “Yesterday, a little boy was injured in an accident in our village. We called 108 and it reached the village in 20 minutes. The boy was taken to the civil hospital. He is now recovering”. Mohammed Bhai of Chanwada Village in Rajpipla :”Just the other day there were several medical emergencies in their village. We called 108 three times and on all occasions, the ambulance reached the village in 15 -20 minutes”.

The praise for the service provided by EMRI is uniform across the villages of North Andhra Pradesh. Sayamma of Gandhinagar in Kurupam Panchayat in Vizianagaram District says that recently, even at 2 a.m. when they called 108, the ambulance reached the village in 15 minutes and rushed the patient to the Parvathipuram General Hospital.

Mr.Poovalapatti of Biyyalavalsa village in Vizianagaram District said that the fact that 108 is a toll free number added to the value of the service. “Even a person who is broke can call the ambulance” he says. Jyotamma, Secretary , Mahila Mandal, Durubili Village says “earlier we used to carry patients to the Civil Hospital, which is 7 kms away. Now we have the ambulance in our village in 20 minutes”

This is also probably the first “government” service that is free of corruption and inefficiency. Shikalu Ushansa Diwan, of Bunjatha Village in Narmada District says this of the crew of 108: “They are very courteous and efficient. There is no corruption and bribery involved. All are treated equally and with respect”. Ashwin Patel of Amjagaon in Gandhinagar District agrees. “We have no complaints. We have not heard of any kind of corruption or bribery. There is no problem with this service” he says. This is indeed high praise for a government funded programme. This is echoed by Majiba of Manasa Village in Mehsana District. He says “108 is of great help when we have to rush a woman in labour to a maternity hospital. We frequently call the ambulance for this purpose. It is also there for other medical emergencies”. Prashant of Nadari Village in Gandhinagar District says “The government deserves to be congratulated for the Ambulance Scheme. I am told that such a service is not available in other states. People in my village are happy with 108. Now, when there is a medical emergency, we don’t have to search for transport to take patients to the civil hospital”. S.K.Goush, a social worker in the area says the quality of the service is attributable to discipline among the crew. “strict action is taken against erring 108 employees. Also, much attention is paid to the maintenance of ambulances. The vehicle is serviced regularly and the tyres are changed after the mandatory mileage”. This is rather unusual for a `sarkari service” because even residents of big cities in India often see ambulances with flat tyres and in various stages of disuse lying in the courtyards or sheds of government hospitals.

The most obvious spin off of 108 is the contribution of this quality emergency medical care facility in bringing down the Infant Mortality Rate (IMR) and the Maternal Mortality Rate (MMR) in the states which have ensured state-wide coverage. This has further been dovetailed to the Janani Suraksha Yojana (JSY), which seeks to entice pregnant women to deliver their babies in civil hospitals or primary health centres, in these states. For example, in Gujarat, 3800 babies are “108 babies” in that they were born in these ambulances. The state government has urged rural folk to discourage “home deliveries” and to reach pregnant women to primary health centres and civil hospitals in time for delivery. Anganwadi workers, rickshaw pullers and many others have been roped into this scheme. They get an incentive if they call 108. This is helping the state bring down both Infant Mortality Rate (IMR) and Maternal Mortality Rate (MMR). The non-profit that runs the ambulance service has a manager in every district and this manager meets up with health officers every month. At these meetings, health officers and EMRI get valuable taluk-wise data on number of expectant mothers and babies due in each of the 18080 villages in the state. Apart from dealing with emergencies, EMRI also organizes demonstrations of available services in the villages in order to encourage people to call 108. Anganwadi workers, Sarpanchs and even rickshaw pullers are sensitized to the idea of reaching out to quality medical help rather than quacks or mid-wives. The 108 crew explains the advantages of the Chiranjeevi Scheme which offers a cash incentive of Rs 500 plus a saree to every woman who delivers the baby in an established medical facility. The villagers are told that by calling 108, they ensure proper medical care for the expectant mother and the baby. People in the villages of Gujarat say that while the cash incentive and the saree offered by the state is a major draw, rural folk have also realized that by going to the Civil Hospital they get proper medical attention both for the mother and the baby. The facilitators at the local level also get a cash incentive.

In Karnataka, the women get an incentive of Rs 750 and a kit for the child which includes warm clothes, sheets and a mosquito net. Lalitha Lokesha of Hosanagara says women are happy with the cash incentive and the kit for the baby. More importantly, they are happy to be under proper medical care in the civil hospital at the time of the delivery. She says no woman has delivered a baby at home in her village in the last five years. Residents of H. Kodihalli said the last time a baby was born in a village home was seven years ago.

The Madhya Pradesh government too has stepped up the campaign to popularize this scheme. This is part of a clutch of women and girl-child related programmes initiated by Chief Minister Shivraj Singh Chauhan. According to Mr.Anurag Jain, Secretary to the Chief Minister, the programme was launched in September, 2005 and in the last four years, the percentage of institutional deliveries of babies has jumped from 26 per cent to 70 per cent. The Union Government picked up the programme in the year 2006-07 and called it JSY. The state government offers every woman who delivers her baby in an established medical facility Rs 1400. Ramkali of Kharwai Village in Vidisha District says while her first two daughters-in-law delievered their babies at home, she took her third daughter-in-law to the civil hospital for delivery. Usha Tewari, the Anganwadi worker in Chandla Village in Hoshangabad District said women preferred to go to hospitals because they were assured of better medical care while also getting a cash incentive.

The other big spin off of 108 is the remarkable boost it has given to the health care sector in Andhra Pradesh and Gujarat. The number of hospitals in Gujarat will double within a year’s time. The Primary Health Centres and the Civil Hospitals have got upgraded. The efforts to bring down the IMR and the MMR have received a big boost, as also the efforts to correct the gender imbalance because of the discrimination against the girl child. In Andhra Pradesh, 108 provides a crucial link between medical emergencies and Arogyasri, the health insurance scheme that guarantees reimbursement of costs of major surgeries in government or private hospitals to card holders. These cards are issued to all members of families below the poverty line. It covers them for treatment of serious ailments which includes, coronary bypass surgery, kidney transplant, treatment of cancer etc. These patients are referred to private or government hospitals by the civil hospitals in the districts. Arrangements are in place to transport these patients from the taluks to the hospitals in the big cities. The hospitals admit the patients and once the surgeries are over, claim reimbursement from the state government. Kammidi Kalavati, the mother of 8-year old Raju, who has a congenital heart problem, took him to the Apollo Hospital, Vishakapatnam. The doctors have advised her to bring her son for surgery after August, 2009. She says she incurred no expenditure for the consultation and the hospital has said that the health insurance scheme will cover the surgery charges.

Ms.Uyaka simhachalam of Gujjupada village in Vizianagaram District met with a

fire accident at home when a can of kerosene spilled onto the kitchen stove. Thanks to the Arogyasri insurance cover, she was taken to the Abhaya Hospital in Vishakapatnam for skin grafting. The hospital treated her for post-burns contracture over neck and the right hand. She says the doctors took good care of her and advised her to return regularly for follow-ups but she does not have the funds to visit the hospital in Vishakapatnam.

The beneficiaries say that an official designated as `Arogya Mitra’ in the district hospital, who is a pharmacist or para-medic takes the call of referrals to big hospitals.

In fact, the idea of an effective health insurance cover was first launched in Karnataka when Mr.S.M.Krishna was the Chief Minister. Following consultations with public spirited doctors and health care managers, Mr.Krishna launched the Yashaswini health insurance scheme. This scheme is open to all members of farmers’ co-operative societies in the states. Every member has to pay Rs 120 a year towards this insurance cover. Yashaswini underwrites the cost of major surgeries in any medical facility in the state.

In a large number of villages, the office-bearers of the agricultural or milk co-operative societies deduct the annual premium amount from the money that is due to each member and remit it to the government. The co-operatives often ensure that the premiums are paid and the insurance policies are live. Farmers in several villages in the Mysore region of the state were all praise for this scheme. They said no scheme had ever given them such a sense of security vis-à-vis health.

Residents of H.Kodihalli village in Mandya District in the state see the Yashaswini scheme as a major advance in the area of health care. Ms. G.C.Sudha, President, Gopalapura Gram Panchayat says that all the 200 families in the village are covered by the insurance scheme. The policy holders get a Yashaswini Card and their policies are renewed by the farmers’ or the milk co-operatives in the village. Kenche Gowda and Sanne Gowda of Hosanagara in Hassan District, Karnataka are two policy holders in the village who have undergone surgeries in private hospitals. Both of them say they are fortunate to have such an affordable policy. D.H.Venkatesh of this village said Yashaswini was a boon for all poor people. Earlier, most of them just accepted their fate and succumbed to illness because of lack of funds.

The third important advantage of 108 is the valuable data that it provides to health authorities, the state police and traffic planners on road accidents and accident-prone spots. It also offers valuable research data in a variety of other areas which help public policy formulation.

The health insurance schemes however have some draw backs. The first is the misuse of the insurance cover available to patients by private nursing homes and hospitals, which needlessly perform surgeries in order to bill the government. While there are a few complaints of this nature in Andhra Pradesh, the cases of fraud is certainly high in Karnataka, say doctors and leading NGOs who are worried about this phenomenon.

According to Dr.Balasubramaniam, President of the Swami Vivekananda Youth Movement, which is doing exemplary work in the area of primary health care and education in Heggadadevanakote in Mysore District of Karnataka, says though Yashaswini is a good scheme, private nursing homes “have made this a tool for business”. This health policy works only in the case of surgeries but only 7 percent of illnesses have a surgical load, he says. The most worrying fact he says is that in some parts of the old Mysore region, unscrupulous private hospitals and nursing homes have been conducting hysterectomy ( removal of uterus) on a lot of women who visit these hospitals for minor illnesses. As a result, the number of women whose uteruses have been removed is very high in some areas, he said. The private hospitals recklessly conduct these surgeries because only then they can bill the government under the health insurance scheme. They bill the government Rs 8000 per operation.

The second problem is that these health insurance schemes do not cover the cost of post-surgery medication. Since drugs are expensive, citizens who are in indigent circumstances and who cannot afford post-operative costs, face the danger of a relapse or the possible failure of the surgical intervention merely because they do not have money

to buy the drugs prescribed by the hospital. In other words, while the government’s health insurance cover enabled a person below the poverty line to undergo a coronary bypass surgery costing Rs 2 lakhs at a private hospital of repute which is patronized by the rich and famous, lack of a few hundred rupees for post-operative care can prove to be fatal for the patient. This is indeed an irony. Hopefully, policy-makers who have come up with innovative health insurance schemes like Yashaswini will surely find a way to deal with this problem as well. Meanwhile, it would be of immense help to poor patients if NGOs could step in and bridge this gap. Arogyasri also does not fund transport costs of patients to big hospitals. So, while the government pays for high cost surgeries, poor patients

may not have enough funds to go the hospital regular follow-ups. Rama rao of Gujjupadu village says that the government has sought to bridge this gap by providing a weekly ambulance service from Parvathipuram, a Taluk Headquarter, to Vishakapatnam,

to take Arogyasri beneficiaries to major hospitals for follow-up. But, the problem persists because of the costs involved in traveling from the villages to the taluk headquarter. This is another area which calls for NGO intervention.

To be Concluded .

First published in Eternal India, April, 2009