The Noolpuzha PHC, the first Family Health Center (FHC) in the Wayanad district of Kerala, was ranked as the number one PHC of the country by the expert panel of the Union Health Ministry, an acknowledgement of its proactive, inclusive and equitable approach towards delivering high-quality services. It’s accolades and recognition are found with a quick search on google, with many cheering on its inclusive and preventative approach to healthcare. The quick rise to stardom is intriguing and upon further reading, I found the vision and journey of this PHC can be credited to the exceptional leadership of Dr. Dahar Muhammed. Dr. Dahar Muhammed, a Medical Officer at the Noolpuzha facility, has spent perhaps a little less than 4 years in his tenure there but has managed to achieve feats that may have taken a decade to finance and complete. This was due to his ability to take alternative routes when faced with financial blockades, create innovative ways to engage the community through participation and ownership and form integral relationships that brought together stakeholders to materialize his vision of a comprehensive PHC. To understand the vision, mission, and leadership, its secret to success, we sat down with Dr. Dahar Muhammed and mapped out the paths this PHC took over the past 4 years.
The Model
The Kerala government has long focused on health as one of their top priorities. In September 1995, the Primary Health Centres and Government Dispensaries were transferred to the Village Panchayats. Therefore, decisions with respect to funding are determined at the level of the state and local self government institutions (LSGIs) and public funding in healthcare is substantially decentralised and high in Kerala compared to other Indian states. The decentralization of decision-making has made it possible for the state to shift approximately 40 percent of state healthcare funding to local governments, thus, creating community-based services that are accessible and affordable. Along with various patient-centered policies, in February 2017, they launched the Aardram Mission under the umbrella of ‘Nava Kerala’ to achieve the following objectives -
- People-friendly Outpatient Services
- Re-engineering PHCs into FHCs
- Access to comprehensive health services for the marginalised/vulnerable population
- Standardization of services from primary care settings to tertiary settings.
The focus was to bring PHC to the forefront, in line with the Alma Ata Declaration of 1978, and encourage PHCs within Kerala to focus on incorporating the community voice and address community needs while hoping to move away from the increasingly popular curative approach to health towards a more preventative one. One of the key shifts is that of PHCs to FHCs or Family Health Centers. Family Health Centers are geographically bound to a local level, specifically to a singular panchayat, indicating that they have the responsibility towards only this community and that the gram panchayat serves as their governing body.
The panchayat being a powerful stakeholder in the PHC/FHC system in this region, the Swasti team and I reached out to talk to Hema, the former Secretary of the Noolpuzha Gram Panchayat. Over her tenure as the secretary, she saw the Noolpuzha PHC be the first to be converted to an FHC, and worked with the Panchayat to support the FHC through both funding and access to the community. Dr. Dahar Muhammed, the Medical Officer of the Noolpuzha FHC, had close relations with the gram panchayat that gave him an in into the community, spurring multiple innovations and building trust. Hema credited Dr. Muhammed for not only taking the FHC to the next level but creating an environment where Noolpuzha staff became the first responders to the community. Any issue was first brought to the FHC and if needed be taken to the nearest hospital, Talique hospital, approximately 10 kilometers away.
FHCs are meant to be the first point of contact operating at the most fundamental level of our community existence, and convincing people of this is surprisingly hard. Many choose to go to specialty care, rather than taking a referral, because why waste money on an additional visit? So what did this model do right? This was possible in this case through trust. The community truly believed in Dr. Muhammed and their outreach workers and the fact that they responded to the needs of the community. After all primary healthcare only works when primary healthcare providers take responsibility for the community around them and the community accepts them as first responders. And this could only happen if the community feels heard and finds the services useful.
Based on formal and informal population surveys, Dr. Muhammed recognised that eating and drinking behaviours constituted the main cause of health ailments in the village. Apparently, the routine community outreach programs in place were attended by community members, but they were not putting any of the information into practice. One of the programs was on the importance of clean water and chlorinating wells, but even if members allowed chlorination, Dr. Muhammed pointed out that due to the smell, they would travel to ones that were not yet cleaned. Similarly, many accepted they needed to have varied diets, but did little to change their day to day nutritional intake. Supplementation and treatment for water borne diseases was not the simple answer, it never is the silver bullet people make it out to be, but rather a sense of community investment and ownership for behavioral change. And so, a Nutrition Rehabilitation Centre (NRC) was constructed, along with a public park. To build more sense of community, the FHC hired tribal women to create brown covers to hold tablets and medicine. This allowed for the socio-economic upliftment of women in the community, positively impacting greater ownership by the community, ensuring a higher participation and proactiveness on its part.
Through all of this, Dr. Muhammed wanted to imbue the human centeredness around all parts of care, and scrutinized who is included and who is not within his staff. Afterall in a rural tribal setting, a lot is a function of social and community relationships, and representation of each type of community member brings inclusivity. They recruited some members of the tribal community and made them the Gothramas under the Gothrasparsham initiative. They were hierarchically above the AMAs and ASHAs, acting as liaisons between the tribal community and the FHC. An immediate impact of this innovation was the visible reduction in the workload of the medical staff.
The Gothrasparsham initiative implemented by the FHC in collaboration with the Gram Panchayat mobilized tribal antenatal mothers to attend ante-natal clinics. State of the art electric auto rickshaws were arranged in collaboration with the Canara bank to transport antenatal and pregnant women as well as the elderly to the PHC and sub centres for check-ups. The Gram Panchayat built cottages in the villages for pregnant women to stay, with adequate nutrition provisions supplied through NGOs for safer pregnancies. It was through these partnerships that Dr. Muhammed built that the community needs could be met if existing infrastructure was not adequate.
Listening to all these innovations, we wondered where all the funding was coming from. The most pressing issue when it comes to government administered units including FHCs is — Where does all the money come from? Supporting lofty visions and ambitions is no small feat in tribal communities’ PHCs and the Noolpuzha seemed to be addressing every need seamlessly. Dr. Muhammed replied with a short laugh, saying ingenuity and involving your stakeholders is all it takes, a common theme we start to see through his stories. The key remained a judicious utilisation of funds of approximately Rs 1.83 crore routed through the Gram Panchayat, as claimed by MO —
“ out of 8 different categories of funds, which includes general purpose grant, financial commission grant, development fund - general, developmental fund- ST, developmental fund - SC, I utilised all 8.!” - Dr. Muhammed Dhar
The FHC also mobilised support through CSR— for its physiotherapy unit—MP and MLA fund, Block Panchayat, IEC and National Health Mission funds, thus, accepting and proactively seeking all help available to ensure the PHC was supporting the community. This funding did not only go towards quirky community ownership innovations, but also helped build up and maintain infrastructure and management within the FHC.
Firstly, the availability of drugs, which happens to be a prime concern across PHCs and and even at higher levels of health infrastructure, had to be addressed, and Dr. Muhammed delivered. A workable system was designed for the projection of required drugs, to preempt shortage and facilitate further procurement. This ensured that there was no shortage at crucial junctures, leading to equitable treatment of ailments.
He additionally went ahead to digitise medical records and while this seems to be an arduous task in a tribal setting, it was contextualised by simplifying the process wherein each individual connected to the FHC was given a token number connected to his/her name, which connected them directly to their medical history. This practice helped in establishing a more one-on-one connection with the doctor, leading to a more effective treatment. In one instance, an elderly lady had walked into the FHC with knee pain. Her token automatically connected the doctor to her medical records, informed him of her current complaint, and so when she entered the doctor’s office, he greeted her with her name and asked her how long her knee had been paining. She could not believe that the doctor knew her name!
A patient with a chronic knee injury is grateful when the doctor says “Good afternoon aunty! How has the arthritis and knee pain been recently?”. The patient feels like they don’t need to repeat their entire story, their issues, and they feel welcome. It becomes a huge pull factor to feel like you are heard. This form of digitization also allows for more accurate documentation and treatment of conditions.
These incremental gestures make up a large portion of the successes of this PHC, and the marriage of good governance, people centered-ness and a community focus.
Key Insights
The health outcomes of the Noolpuzha FHC are thus a result of favourable system level determinants— the Aardram mission of the state government, and the proactive role played by FHC authorities to ensure internal components are in place to achieve desired outcomes. The Noolpuzha FHC brings out some lessons for the rest
- A CPHC is built from a multitude of stakeholders. Be it funding, human capital, or digital innovations (ie, funding from state, national, and grant based funds, gynecologist volunteers, NGOs providing food, private hospital providing scans)
- An individual with a big picture view is required to fit these puzzle pieces of the PHC system together
- Focusing on needs (ie eating behaviors NOT supplementation, maternal and child health)
- Primary health care works when there is accountability and trust. The Noolpuzha FHC worked through trust and community needs to become the first response of care within the community
- Focus on inclusivity, be open to inclusion of the private sector, and go beyond the bare minimum—best exemplified by the Gothrasparsham initiative, to win the trust and confidence of the larger community.
Successful models have a strong consistent proactive population outreach, respond to population needs and especially in CPHCs, focus on health determinants according to population need.
Ways to move forward
Noolpuzha FHC is a textbook example of how those in the positions of authority should think out of the box to come up with context specific interventions and actionables to serve the population needs. It highlights the need for a proactive leadership. However, excessive reliance on individual leadership comes at its own cost, since a well functioning system is much more than the goodwill of an individual. A system which fosters this leadership is required and the gram panchayat’s governance can offer that. Since FHCs are bound to one panchayat, they can remain constant in the training and building of leadership within the FHC and keep accountability through surveillance of community indicators and needs. This can ensure the health and performance of the FHC for years to come.
Contributors
Dr. Mohammed Dahar V P (Protagonist)
Dr. Muhammed Dahar is the Medical Officer at the Noolpuzha Family Health Center and has been incharge of the facility for a little less than 4 years. In this short span, with the help of a team of 4 doctors, nurses, a lab technician and a pharmacist he has developed the Noolpuzha PHC into an FHC that scored 98 per cent in the national quality certification of PHCs by the Union Health Ministry.
Nilakshi Biswas (Author)
Nilakshi Biswas is a Technical Health Specialist at the Catalyst group and focuses on research and knowledge synthesis projects. Her experience is within synthesis research and research design and evaluation, her background in global health policy and policy advocacy from George Washington University, MPH and her heart in global 7 and policy prioritisation. But nothing comes without evidence and data!
