How Tata Trusts plans to take health care services to rural India's fringes

In a Q&A, H S D Srinivas, Head-Health, Tata Trusts, dwells on his set-up's role in Ayushman Bharat, and its association with various states' healthcare initiatives

Tata Trusts has identified a series of verticals to focus its energies on. Healthcare is one such. Apart from cancer hospitals, several other initiatives are underway. Earlier the group would give grants to NGOs or hospitals that approached them. A few years ago, that thinking changed, and while grants are still being given to 87 NGOs currently, the group also began creating innovative solutions in the space, and is actively involved with as many as fourteen projects. 

In a conversation with H S D Srinivas, Head-Health, Tata Trusts, Gina Krishnan finds out how the organisation is partnering with state governments to improve health care within the fringe communities. Excerpts:

What is Tata Trusts' mandate in the healthcare space?

Tata Trusts is committed to identifying, perpetuating and scaling up any innovative solution for intractable healthcare problems in this country. Initially, we used to encourage NGOs and hospitals by giving them grants. Around four years ago, we decided to get hands-on into implementation ourselves.

Our work spans the primary and preventative segments, with some focus on secondary and tertiary care as well. We want to enhance institutional best practices in primary care. There are huge supply-side constraints, with distribution of resources both, human and infrastructure, being skewed towards cities and tertiary care. Only 10-15 per cent of care is needed in tertiary, but almost 70 per cent of the resources are deployed there. Ayushman Bharat will change all this, and we are very excited about the initiative.

What we need is to manage a whole host of diseases in primary care in the community set up. We aim to take care to the doorsteps of patients. Then there is the preventative segment, where the idea is to screen and identify at-risk patients and arrest disease progression and manage it at the lowest level of care. 

Our agenda is to create access to high-quality healthcare in the preventative and primary spaces through capacity building of existing or new resourcesresources and integrate with higher levels of care. This is where where most of our investment grants go -- whether it is mother-and-child, malaria, NCDs, cancer care or TB. The idea is to create better access, make it high quality. In order to leave something for perpetuity, we are training many more people to handle things better.

In addition to cancer care, what are some of the other initiatives in healthcare that Tata Trusts is supporting?

One is ASMAN. It is a five-member project involving Tata Trusts, Reliance Foundation, USAID, Bill and Melinda Gates Foundation and Merck for Mothers. The cost is underwritten by the consortium and we are supporting 60 government facilities.

The initiative we are excited about is the one we have with the hospital run by Ramakrishnan Mission in Vrindavan. It is a secondary-care facility moving towards tertiary, and sees patients from a 100 km radius. A daily footfall of over 1,400-1,500 patients taxing the hospital’s resources.  Almost 30 per cent of the patients come for minor ailments that can be taken care at the primary level. 

To de-clog the OPD, we worked with them to prepare an outreach programme managed by the hospital. We set up mobile medical vans that offer doorstep care to inhabitants of several villages. They do a population-level screening and patients requiring longer-term care for hypertension, diabetes, asthma or other chronic conditions are linked to the nearest telemedicine units we have set up. This enables both preventative and primary care. We aim to see almost 20,000 patients in the villages, and save them the trouble of travelling 100 km to the main hospital. A similar program with Ramkrishna Mission Hospital in Varanasi benefitting another 100 villages is also launched.

Similarly, there is a 60-year-old hospital in Bisamkhatak in southern Odisha. We gave them a grant to upgrade their OPD facilities and set up diagnostics, but now we are working with them in partnership.

In southern Odisha, we have worked in grant mode for over ten years to deal with malaria. This crystallized into a programme about a year ago under which we have adopted about 500 villages, and have placed frontline health workers in the community.  We've trained them to identify early symptoms of malaria and fever, treat almost every fever and carry out screening for malaria. Women who are 8th or 10th class pass are given basic training in doing small tests. They are authorised by the state government, which has been prompted to take up this programme in the entire state in the next five years. 

In Madhya Pradesh, a cadre of auxiliary nurses and midwives (ANMs) is being trained to become ANM mentors. The government believes a mentor can build the capabilities of ANMs, so we needed to define the qualities of an ANM mentor, and equip her with skills. So far, we've deployed 25 of our trainers for two years in MP, and have developed a three-step methodology to build the capabilities of ANM mentors. The methodology is based on central govt guidelines to see how ready a facility is to receive expectant mothers. This was a specific request from the state government. The ANMs are taught to handle emergencies, and are also given hand-holding in terms of creating a checklist every day, every week, and every month to see if they are ready for receiving mothers and babies. We have also implemented E Rakthkosh – a central government scheme to share data about blood availability in different blood storage units of secondary and district hospitals.

In Nagpur, we have partnered with the municipal corporation and are equipping urban primary health centres to provide diagnostics and better primary care for patients at the corporation's 20 clinics. There has been a 30 per cent increase in footfalls at these centres. We cleaned up the PHCs, added an air-conditioner to the doctor's room, added diagnostic facilities and trained people to manage and welcome patients. We created a digital network so a patient can go to any of the twenty clinics across the city. These clinics will be further included in the Ayushman Bharat network of HWC. 

We are also doing a clinician-to-leadership development programme which is academic. At Srichitra Institutes, physicians in line for administrative promotions are taken through a 72-hour training regime that equips them for future management responsibilities. We created the entire module, and did a similar programme for the Public health professional, DMs and superintendents for the government of Telangana.

How are the government partnership initiatives funded?

An MOU is signed, after which we demonstrate the success of a model working in a small area. Scale up is done by the government. We do not invest in infrastructure or hiring personnel. That is the government's mandate -- it needs to invest in its own infrastructure. 

The Government has enough funds. We put in marginal amounts to, say, bring in architects to demonstrate plans or engineers to make suggestions on upgrading facilities. Soft skills training of government staff, along with the provision of a few facilities, changes the outlook of the caregivers. Upgradation of PHCs happened two years ago. The government is going for it only now, so we have to stay ahead of the curve by offering innovations. 

Similarly, in Vijaywada, we are supporting 256 villages that we adopted three years ago and have been completely funding them. Multiple interventions have happened there including building toilets, information gathering, and setting up 20 telemed units, each of which caters to 25 villages. We also have a mobile unit that goes to the doorstep to screen people and link them to telemed centres to save patients the trouble of travelling to Vijaywada 100 km away. Clinics give referrals to patients to go to secondary or tertiary care hospitals. Continuum of care is afforded to patients with chronic illness and Tata trusts funds health insurance of up to Rs 100,000 and above the government fund of Rs 150,000 for each person. The entire cost is absorbed by the Tatas under the Swasth Kutumbam programme. Insurance and primary care are available to all and there is no income cut-off.

Similarly, in Nagpur, we signed an MoU with the state government. Institution reform was the first step and involved changing the ambience of the place, upgrading practices, inducting IT for record keeping and putting in place a programme to assimilate people back into society with livelihood training. We presented our finding to the experts and it was well received.

Our aim is to train the primary health physicians and even nurses who can identify the first signs of mental health, going down to district level.

Can you tell us about your partnership with Ayushman Bharat?

Again it is at the primary-care level. We haven't yet been associated with the tertiary care insurance part.

The NCD programme that we are part of in Ayushman Bharat's primary and preventative segment, has started health and wellness centres in partnership with Dell Foundation in Andhra Pradesh and Telangana. The app that stores data on tabs was developed by Dell. In Andhra Pradesh, every woman over 35 was screened for five conditions -- hypertension, diabetes and three common cancers. Telangana did the screening for every adult over 35. We facilitated the programme by placing 5-6 data analysts at certain points to monitor the data uploads on a daily basis, follow up on the data emanating from these screenings and giving analytical inputs to district health authorities for corrective action at their end. The analysis sent to the Telangana government revealed that in a population of 100,000, about 15 per cent was Hypertensive and eight per cent was diabetic. Seventy per cent of the inhabitants didn't even know they were afflicted. It was also found that a large population was at risk of cancer, so that is how the Tata Trusts Cancer hospitals came up in partnership to upgrade the state infrastructure. 

Looking at the outcomes of the NCD screening, the central government has been inspired to adopt the model of screening at the Ayushman Bharat level. Under Shri Manoj Jhalani, a group of seven major institutes got together, including AIIMs, WHO, National Institute of Cancer, US along with Dell and Tata Trusts. The best subject matter experts were brought together to enhance this app so that it strengthens the comprehensive primary care model. It morphed from an NCD-focused to a primary care-focused product that became the second pillar of Ayushman Bharat. 

We will place 150-200 people across the participating states. Dell, the app partner, has done its job. We are the partners to train the workers on screening. It is exciting because technology adoption is fast. We tasted success in Telangana where we helped in 800 sub-centres in four districts. About 1,000 nurses were taught how to use tabs and data entry. The electronic health records we created aren't comprehensive, but include as many as 1.5 million people. 

Can any of your OPD models become profitable?

OPD as a standalone facility isn't profitable anywhere in the world. It needs a host -- a mother institution -- as an investor. Even with telemedicine, they don’t make money. Even in a private primary care practice, it is hard to make money. So OPD must stay within the government purview, as it makes sense for the government to invest in the health of its citizens through preventative and primary care programmes. 

When we look at the demand side, we are nowhere prepared to cater to the needs of the population. The private sector is there for the profits, but public service is the government's responsibility. Ultimately, we will have a mixed-care model.

How do you choose projects?

We are aligned with national goals and committed to the sustainable development goals of the Government of India. 

When we look at a problem, and then we look for innovative solutions that should be replicable and scalable. 

Recently, we partnered with the Global Fund and signed the India Health Fund. We are focusing on communicable diseases. One such is hepatitis. While Hepatitis B is not curable, Hepatitis C is, so we are working on finding an affordable diagnostic tool. 

We are excited about creating the next best practices and innovation for the country. The power of IT is not fully leveraged. So we want to demonstrate the power of digital healthcare and bring in efficiencies.

How critical is technology in the healthcare models that you are demonstrating?

Technology is critical and we want to demonstrate how to leverage it effectively. Telemedicine is one such, NCD screenings is another. Data was collected earlier as well but it was one of thirty registers and nobody was using it.

Andhra Pradesh has been using technology in healthcare since 2005 -- be it the Arogyashree scheme, the 108 ambulance helpline or the 102 helpline. 

A good Information system is the backbone of healthcare, and makes patient records accessible anywhere at any point of care. Through ASMAN we are trying to demonstrate facilities that are digitally equipped, and can capture all information of an expectant mother, irrespective of where she gives birth -- at her home or her parents’ home. 

What is Tata Trusts' investment in IT and its partnership with the government?

There is TCS, working on organizing the OPD at AIIMS to decongest or regulate patient flow. In Kolar, we are working with a medical college, a hub and smaller hospitals. In Trivandrum, we are working with the regional cancer centre -- a large digital hubs that functions as a call centre. The docs and nurses there are following up with patients for next level, continuum of care.

Much of it is about appointment scheduling, but doctors have to adopt it as well. It is in the making and there is some time to go before we demonstrate value there.

How significant is data capture?

It is a significant part of the programme. TCS is working on the insurance part of the software for Ayushman Bharat. For HWCs, there are disparate programmes that need to be integrated. There is a no single electronic health record software. Right now it is programme-based, for NCDs and mother-and-child. What we need is a horizontal software that cuts across all verticals and maintains records from cradle to grave, and in which data, once codified, cannot be changed. Programs such as EPIC in the US meet this objective but are too expensive. So we have a hospital information system (HIS), but electronic health record keeping still isn't a success. 

There is no clear referral system of moving patients from primary to secondary to tertiary. We are trying to push it, but the effort has to be systemic. In our cancer care initiative, irrespective of the point at which a patient enters, he will be directed to the appropriate point of care. But then, the system is under the tight control.

Are you doing data analysis as well?

The first mandate is to have complete and true data capture. For the NCD component, our job is to provide data analysis. It will help understand the disease profile of the population, and enhance deployment of resources and management of diseases. 

The central government isn't very comfortable with deep analysis as of now, because of privacy issues. But at a later stage, the actual benefit and impact will be found once data is captured. 

How receptive is the government to partnership with the Tata Trusts?

A point of contact happens where the chances of success are high. We don't want our initiatives to fail. Sometimes it is the government which approaches us, and sometimes we approach it. The scale up happens once we demonstrate the model. In Gorakhpur, when several children died, a team visited and approached the government. We found that the Gorakhpur hospital was the only one in that area worth its name and practically no secondary and primary care centre in the area. We now have a mandate to develop the hospital's primary care system.