A Journey Through Health Services in Kerala (2019) by Shaiju Sense

A JOURNEY

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A JOURNEY

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A JOURNEY THROUGH HEALTH SERVICES IN KERALA

CONCEPT & GUIDANCE

EDITORIAL BOARD

Dr Rajan Khobragade

Dr V R Raju

Sri Keshvendra Kumar, IAS

Dr Nitha Vijayan

Dr Sarita R L

Dr. Bindu Mohan

IDSP

Director of Health Services

Addl. Director Medical

Dr Divya V S

Dr P K Jameela

Dr Meenakshi V

State Nodal Officer (Training), NHM

State Consultant Aardram

Addl. Director, Public Health

Dr Arun PV

Dr Nita Vijayan

Dr C K Jagadeeshan

DPM, Thiruvananthapuram

Deputy Director & SNO Aardram

Sri. Suresh

Dr Bipin Gopal

HR Manager, NHM

Principal Secretary Health State Mission Director, NHM

State Program Manager (RCH), NHM

Additional Director Planning SPM RCH

State Nodal Officer, NCD programme

Dr. Anil V

Asst. Director Public Health

Dr Veena Saroji H Assistant Director Planning

Dr Sreehari M

State Nodal Officer (Child Health), NHM

Dr Manu M S

State Co-ordinator, SWAAS Programme

Dr Amjith E Kutty SQAO

COMPILED & EDITED BY Dr Ajan M J

Jamo Planning DHS Thiruvananthapuram

Dr Sukumaran

Dr Bipin Gopal State Nodal Officer, NCD programme

Dr Ajan M J

Jamo Planning, DHS Thiruvananthapuram

GOVERNMENT OF KERALA

PINARAYI VIJAYAN Chief Minister No.498/Press/CMO/19

MESSAGE

t gives me great pleasure to note that the Department of Health Services along with the National Health Mission is organizing a Technical Workshop on the theme â&#x20AC;&#x153;Kerala Health-Way Forwardâ&#x20AC;?. I hope that the deliberations at the programme will help the professionals who participate in it. I extend my warm greetings and felicitations to the programme and to the souvenir which is being brought out to mark this occasion.

PINARAYI VIJAYAN

Secretariat Thiruvananthapuram-695 001 25th May 2019

Tel:(0471-)2333812 & 2333682 | Fax: (0471) 2333489 e-mail : chiefminister@kerala.gov.in | website : www.keralacm.gov.in

GOVERNMENT OF KERALA

KK SHAILAJA TEACHER Minister for Health, Social Justice, Women & Child Developement

MESSAGE No: 049/Press/H&SJ/2019 Dated 27-05-2019

s I look back, I can see the toughest of times. Days unprecedented like those during the flood last year, combating which the entire health system of Kerala stood together to avert the crisis. Scary times like that when we supported each other to overcome the fear of a neverbefore-heard ‘Nipah Virus’. And there had been moments that tested our skill and patience in setting the road map right towards achieving the development goals in the health sector. It’s always delightful to commemorate these moments that history by now has marked in Golden letters. Now as the Health Department of the state along with National Health Mission

is organizing a Technical Workshop on the theme “Kerala Health- Way Forward”, I feel immense pleasure to extend my best wishes. The event will document the resourceful activities that the department has co-ordinated, the achievements brought about by futuristic programmes like ‘Ardram’, Upgrading of PHC’s to FHC’s, e-Health Kerala, etc. . The organizers have also brought out a Souvenir as part of this programme, which I presume will be a chronicle of developmental initiatives that has changed the face of Kerala’s health Sector. To the organizers of the programme

and to its participants also, I here convey my best wishes. Wish the programme great success.

KK Shailaja Teacher

MESSAGE

The health sector of Kerala is going through a progrsessive phase of its development, Inviting global attention. We have been implementing newer initiatives aiming to reduce the increasing incidence of life style diseases, to minimize the risks of epidemic outbreaks and to control the surge in treatment cost. Government has given form to “Ardram Mission” for providing comprehensive and affordable healthcare in the public health system. Primary Health Centres of the state are being upgraded to Family Health Centers. And revolutionary programmes like E-health Kerala, Oorumitram, Arogya Jagratha etc., are being implemented with a vision to effectively address all the needs and issues of our changing health scenario. To discuss about these newer initiatives, to share the lessons that they taught us and also to set the goals for the coming years right; we are organizing a Workshop – “Kerala Health- The Way Forward” in Trivandrum on 30th May 2019. On this occasion, we are also bringing out a Souvenir that is a documentation of the fruitful ventures we had in the course of development. We are sure that this programme will be a milestone in ensuring that the health sector in the days coming will achieve success more glorious.

Dr. Sarita R L

Director of Health Services

Keshvendra Kumar IAS

State Mission Director NHM

A JOURNEY

Govt of Kerala

From the Editor’s Desk

n the last two decades ‘Kerala health’ embarked on a journey, which is unprecedented in terms of its vision, unleashing number of interventions to ensure quality health care services to all. The interventions have touched the entire spectrum of one’s life cycle starting with detection of foetal anomalies to post death organ donation by willing donors and their families. For the last one and half decades, Shri Rajeev Sadanandan Addl Chief Secretary in his various capacities has led the team of health professionals, helping put in place a solid foundation of Health systems. The Health sector is progressing forward with the various relevant policy initiatives under the able guidance from Smt K K Shailaja Teacher, Hon’ble Minister of Health and Family Welfare, Government of Kerala. The interventions mentioned in this book and many more are being implemented because of the well studied approach of the Addl Chief Secretary, which can be seen in the form of various structures, processes and key performance indicators. I express my sincere gratitude to Sir for guiding us. We will strive to take the unfinished agenda forward. I appreciate the huge efforts taken by ‘the Team’ who have done the compilation of write ups, photographs, editorial works and follow up with all to publish this book.

Dr. Rajan N Khobragade IAS Principal Secretary, Health & Family Welfare

Secretariat, Annexe II, Thiruvananthapuram, Kerala

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കേ ആര�ോഗ്യ മേഖലയ്ക്ക് അഭിമാനിക്കാം ശ്രീ. രാജീവ് സദാനന്ദൻ കെ.കെ. ശൈലജ ടീച്ചർ ആര�ോഗ്യ, സാമൂഹ്യനീതി വനിതാ ശിശുവികസന വകുപ്പ് മന്ത്രി

രളത്തിന്റെ ആര�ോഗ്യ മേഖലയിൽ അടിസ്ഥാനപരമായ മാറ്റങ്ങൾക്ക് വേദിയ�ൊരുക്കിയ മൂന്നു വർഷമാണ് കടന്നുപ�ോയത്. 1957 മുതൽ കേരളം സർക്കാർതലത്തിൽ നടത്തിയ ഇടപെടലുകളുടെ ഫലമായി പ�ൊതുജനാര�ോഗ്യ രംഗത്ത് വലിയ നേട്ടങ്ങൾ കൈവരിക്കാൻ നമുക്ക് കഴിഞ്ഞിട്ടുണ്ട്. മാതൃശിശു മരണനിരക്കിലെ കുറവും പ്രതിശീർഷ ആയുസ് വർധനവും അടക്കം പല മേഖലകളിലും ഇന്ത്യൻ ശരാശരിയേക്കാൾ കേരളം മുന്നിലാണ്. എന്നാൽ എല്ലാ നേട്ടങ്ങളേയും നിഷ്പ്രഭമാക്കുന്ന ചില പുത്തൻ വെല്ലുവിളികൾ വർത്തമാനകാല ആര�ോഗ്യ രംഗത്ത് ഉണ്ടായിട്ടുണ്ട്. 2016ൽ അധികാരത്തിൽവന്ന ഈ സർക്കാർ അത്തരം വെല്ലുവിളികൾ ഏറ്റെടുക്കാൻ കഴിയുംവിധം ആര�ോഗ്യമേഖലയെ പരിഷ്‌കരിക്കാനാണ് നിശ്ചയിച്ചത്. വിവിധതരം പകർച്ചവ്യാധികളുടെ വ്യാപനവും ജീവിതശൈലി ര�ോഗങ്ങളുടെ കടന്നുവരവും, ചികിത്സ ചെലവ് താങ്ങാൻ കഴിയാത്ത അപൂർവ ര�ോഗങ്ങളുടെ സാന്നിധ്യവും നാം അഭിമുഖീകരിക്കുന്ന വലിയ പ്രശ്നങ്ങളാണ്. ര�ോഗങ്ങൾ നേരത്തെ കണ്ടുപിടിക്കുന്നതിനും സാധാരണക്കാർക്ക് താങ്ങാനാവുംവിധം ചികിത്സ ലഭ്യമാക്കുന്നതിനും ഇന്ന് നിലവിലുള്ള സർക്കാർ സ്ഥാപനങ്ങൾ വേണ്ടത്ര പര്യാപ്തമായിരുന്നില്ല. ശരിയല്ലാത്ത ആര�ോഗ്യശീലങ്ങളും ചികിത്സാ മാനദണ്ഡങ്ങളും കേരളീയ സമൂഹത്തെ ര�ോഗാതുരമാക്കുകയും കൂടുതൽ സങ്കീർണമായ ശാരീരിക മാനസിക പ്രശ്നങ്ങളിലേക്ക് നയിക്കുകയും ചെയ്യുന്നതാണ് നാം കണ്ടത്. വർഷങ്ങളായി നാം തുടർന്നുവരുന്ന പ്രാഥമിക ആര�ോഗ്യ വിഭാഗത്തോടുള്ള അവഗണനയും സൂപ്പർ സ്പെഷ്യാലിറ്റി സാംസ്‌കാരവും ര�ോഗപ്രതിര�ോധ സംവിധാനങ്ങളെ സാരമായി ബാധിച്ചു. പ�ൊതുജനാര�ോഗ്യ

A JOURNEY

ശൃംഖല ശക്തിപ്പെടുത്തി പകർച്ചവ്യാധികളും ജീവിതശൈലി ര�ോഗങ്ങളും നിയന്ത്രിക്കുക എന്ന ദൗത്യമാണ് പ്രാഥമിക തലത്തിൽ നാം ഏറ്റെടുത്തത്. മുഖ്യമന്ത്രിയുടെ നേതൃത്വത്തിൽ നടപ്പിലാക്കാൻ നിശ്ചയിച്ച നാല് സുപ്രധാന മിഷനുകളിൽ ഒന്ന് ആര�ോഗ്യമേഖലയിലാണ്. ആര�ോഗ്യവകുപ്പിലെ ഇടപെടലുകളെ കൂടുതൽ കരുത്തേകി ആർദ്രം മിഷന്റെ ഭാഗമായി പ്രാഥമികദ്വിതീയ-തൃതീയ മേഖലകളിൽ ര�ോഗി സൗഹൃദമാക്കുന്നതിനും സാങ്കേതികത്തികവ�ോടെ ആധുനികവൽക്കരിക്കുന്നതിനും ചികിത്സാച്ചെലവ് കുറയ്ക്കുന്നതിനുള്ള പരിശ്രമങ്ങൾ തുടങ്ങിക്കഴിഞ്ഞു. 2018ൽ കസാക്കിസ്ഥാനിലെ അസ്താനയിൽ നടന്ന ആഗ�ോള സമ്മേളനത്തിൽ ഊന്നൽ നൽകിയത് പ്രാഥമിക തലം ശക്തിപ്പെടുത്തുക എന്നതായിരുന്നു.

കണ്ടുപിടിക്കുന്നതിനും ഓര�ോ വ്യക്തിക്കും സ്വയം ശാരീരികമാനസിക അവസ്ഥയെക്കുറിച്ച് മനസിലാക്കുന്നതിന് സഹായിക്കുകയും ചെയ്യും. സാമ്പത്തിക ശേഷിയുടേയും മനുഷ്യ വിഭവ ശേഷിയുടേയും കുറവ് കാരണം ഒറ്റയടിക്ക് എല്ലായിടത്തും ഈ മാറ്റം ഉണ്ടാക്കാൻ കഴിയാത്ത സ്ഥിതിയാണ്. എങ്കിലും വിഭവ സമാഹരണത്തിലൂടെയും ബഹുജന പങ്കാളിത്തത്തിലൂടെയും മാറ്റങ്ങൾക്ക് വേഗത കൂട്ടുകയാണ്. സബ് സെന്ററുകളുടെ നവീകരണവും പ്രൈമറി തലത്തിൽ നടക്കുന്നു.

ര�ോഗപ്രതിര�ോധത്തിനും പ്രമ�ോഷനും പ്രാധാന്യം നൽകിക്കൊണ്ട് ഓര�ോ വ്യക്തിക്കും എല്ലായിടത്തും ആധുനിവും ഗുണനിലവാരമുള്ളതുമായ ആര�ോഗ്യ സേവനം ലഭ്യമാക്കുക എന്നതാണ് അസ്താന പ്രഖ്യാപനത്തിന്റെ ലക്ഷ്യം. ആർദ്രം പദ്ധതിയുടെ ഭാഗമായി പ്രാഥമിക തലത്തിൽ കുടുംബാര�ോഗ്യ കേന്ദ്രങ്ങൾ സ്ഥാപിച്ചുക�ൊണ്ട് 2017ൽ തന്നെ കേരളം ഈ ലക്ഷ്യം പ്രഖ്യാപിച്ചിരുന്നു. അവശ്യമായ പശ്ചാത്തല സൗകര്യങ്ങൾ ഒരുക്കിയും ആധുനിക ഉപകരണങ്ങൾ നൽകിയും ലബ�ോറട്ടറിയടക്കമുള്ള സൗകര്യങ്ങൾ ഒരുക്കിയും പ്രാഥമികാര�ോഗ്യ കേന്ദ്രങ്ങളെ കുടുംബാര�ോഗ്യ കേന്ദ്രങ്ങളാക്കി പരിവർത്തിക്കുകയായിരുന്നു. 3 ഡ�ോക്ടർമാരേയും ആവശ്യത്തിന് സ്റ്റാഫ് നഴ്സുമാരുടേയും ലാബ് ടെക്നീഷ്യൻമാരടക്കമുള്ള ജീവനക്കാരുടേയും സേവനങ്ങൾ ഒരുക്കുക മാത്രമല്ല ര�ോഗ നിയന്ത്രണത്തിനുള്ള വിവിധ ക്ലിനിക്കുകൾ പ്രാഥമിക തലത്തിൽ തന്നെ പ്രാവർത്തികമാക്കുക വഴി നേരത്തെതന്നെ ര�ോഗങ്ങൾ T H R O U G H

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സെക്കന്ററി തലത്തിൽ താലൂക്ക് ആശുപത്രികളുടെ ശാക്തീകരണം, ജില്ലാ ആശുപത്രികളിൽ നിർദേശിക്കപ്പെട്ടിട്ടുള്ള സ്പെഷ്യാലിറ്റി സൗകര്യങ്ങൾ ഒരുക്കൽ, മെഡിക്കൽ ക�ോളേജുകളെ മികവിന്റെ കേന്ദ്രമാക്കി മാറ്റൽ എന്നിവ ധൃതഗതിയിൽ നടന്നു വരുന്നു. 3,000 ക�ോടിയിലേറെ രൂപയുടെ നിർമ്മാണ പ്രവർത്തനങ്ങൾക്കാണ് വിവിധ സ്ഥാപനങ്ങൾക്ക് ഭരണാനുമതി നൽകിയത്. 4,260 പുതിയ തസ്തികകളാണ് ഈ സർക്കാർ സൃഷ്ടിച്ചത്. ഇത് കേരളത്തിന്റെ ചരിത്രത്തിൽ സർവകാല റെക്കോർഡ് ആയിരിക്കും. സമ്പൂർണ ട്രോമകെയർ പദ്ധതി, ക്യാൻസർ സ്ട്രാറ്റജിക് ആക്ഷൻ പ്ലാൻ, എ.എം.ആർ, റിഫ്രക്ഷൻ പദ്ധതി, വിവിധ മേഖലകളുടെ ലക്ഷ്യങ്ങൾ പ്രഖ്യാപിച്ച് സുസ്ഥിര വികസന ലക്ഷ്യങ്ങൾ, ഹൃദ്യം പദ്ധതി, ജീവിതശൈലീ ര�ോഗങ്ങൾ നിയന്ത്രിക്കാനുള്ള പദ്ധതി തുടങ്ങി നിരവധി പുതിയ പദ്ധതികൾക്കാണ് തുടക്കം കുറിച്ചത്. ഇത�ോട�ൊപ്പം കാരുണ്യ സമ്പൂർണ ആര�ോഗ്യ ഇൻഷുറൻസ് പദ്ധതി പ്രഖ്യാപിക്കുകയും സാർവത്രികാര�ോഗ്യ ഇൻഷുറൻസിലേക്കായുള്ള നീക്കത്തിന് പദ്ധതിയിടുകയും ചെയ്തിരിക്കുന്നു. ‘ആര�ോഗ്യ ജാഗ്രത’ പദ്ധതിയിലൂടെ പ്രതിദിനം പ്രതിര�ോധം എന്ന ആശയം കേരളത്തിലാകെ

K E R A L A

വ്യാപിപ്പിക്കുന്നതിന് കഴിഞ്ഞു. കൂട്ടായ പരിശ്രമത്തിലൂടെ മൂന്ന് പ്രധാന ദുരന്തങ്ങളെ അതിജീവിക്കാനും ആര�ോഗ്യ വകുപ്പിന് കഴിഞ്ഞു. ഓഖി, പ്രളയം, നിപ വൈറസ് ബാധ എന്നിവയെ നേരിടാൻ ആര�ോഗ്യ വകുപ്പിന് കഴിഞ്ഞത് കൂട്ടായ്മയിലൂടെ മികവുറ്റ പ്രവർത്തനം കാഴിചവയ്ക്കാൻ കഴിഞ്ഞതു ക�ൊണ്ടാണ്. കഴിഞ്ഞ 3 വർഷങ്ങളായി ആര�ോഗ്യ മേഖലയിൽ തുടങ്ങിവെച്ചതും ബഹുദൂരം മുന്നേറിയതുമായ പ്രവർത്തനങ്ങൾ ഒരുമിച്ച് പരിഹരിക്കാൻ കഴിയാത്തവിധം വലുതാണ്. മെഡിക്കൽ ക�ോളേജുകളിൽ മാത്രം നടന്ന വികസന പ്രവർത്തനങ്ങൾ തന്നെ വലിയ വിശദീകരണ സാധ്യതയാണുള്ളത്. ഈ ഭാരിച്ച പ്രവർത്തനങ്ങളാകെ ഏറ്റെടുക്കാൻ കഴിയുന്നത് ആര�ോഗ്യ മേഖലയിലെ ഉയർന്ന ഉദ്യോഗസ്ഥരുടേയും മറ്റ് ജീവനക്കാരുടേയും ക്രിയാത്മക പ്രവർത്തനത്തിന്റെ ഫലമായാണ്. ഗവ. പ്രഖ്യാപിച്ച ജനകീയ ആര�ോഗ്യ നയം നടപ്പിലാക്കുന്നതിലും ഈ കൂട്ടായ്മ പ്രകാരമാണ്.

നിസ്വാർത്ഥമായ സേവനം നൽകുകയും ചെയ്ത ശ്രീ. രാജീവ് സദാനന്ദൻ മെയ് 31 ന് സർവീസിൽ നിന്ന് വിരമിക്കുകയാണ്. ആര�ോഗ്യ വകുപ്പിനെ സംബന്ധിച്ച് അത�ൊരു വലിയ നഷ്ടം തന്നെയാണ്. കൂട്ടായ പ്രവർത്തനത്തിലൂടെ ഏത് സന്നിഗ്ധ ഘട്ടത്തേയും നേരിടാൻ കഴിയുന്ന ഉദ്യോഗസ്ഥരുടേയും ആര�ോഗ്യ പ്രവർത്തകരുടേയും വലിയ നിരതന്നെ ആര�ോഗ്യ വകുപ്പിലുണ്ട്. ശ്രീ. രാജീവ് സദാനന്ദനെപ്പോലുള്ളവരുടെ ഉപദേശ നിർദേശങ്ങൾ തുടർന്നും ആര�ോഗ്യ മേഖലയിൽ ലഭ്യമാകുമെന്ന് പ്രതീക്ഷിക്കാം. ബഹു. മുഖ്യമന്ത്രിയും സർക്കാരും നിർദേശിച്ചതു പ�ോലെ പ�ൊതുജനാര�ോഗ്യ ശൃംഖലയേയും ആര�ോഗ്യ വിദ്യാഭ്യാസ ഗവേഷണ രംഗത്തെയും ല�ോക�ോത്തരമാക്കി മാറ്റാനുള്ള പ്രവർത്തനങ്ങൾ പൂർവാധികം ശക്തമായി നമുക്ക് മുന്നോട്ടു ക�ൊണ്ടുപ�ോകാം. എല്ലാവരുടേയും സഹകരണം പ്രതീക്ഷിക്കുന്നു.

ആര�ോഗ്യവകുപ്പ് അഡീഷണൽ ചീഫ് സെക്രട്ടറി ശ്രീ. രാജീവ് സദാനന്ദന്റെ നേതൃത്വവും ഇടപെടലും പ്രത്യേക പരാമർശം അർഹിക്കുന്നതാണ്. ആര�ോഗ്യ മേഖലയെക്കുറിച്ചുള്ള അദ്ദേഹത്തിന്റെ അഗാധമായ അറിവും വിശ്രമമില്ലാതെ പ്രയത്നിക്കാനുള്ള മന�ോഭാവവും ആഗ�ോള തലത്തിലുള്ള ആര�ോഗ്യ രംഗത്തെ പ്രതിഭകളുമായുള്ള ബന്ധവും കേരളത്തിലെ പുതിയ പരിഷ്‌കാരങ്ങൾക്ക് ഏറെ സഹായകമായിട്ടുണ്ട്. ഇ-ഹെൽത്ത്, ട്രോമാകെയർ, ജീവിതശൈലി ര�ോഗനിയന്ത്രണം എ.എം.ആർ, ക്യാൻസർ പ�ോളിസി തുടങ്ങിയവ എല്ലാ പദ്ധതികളിലും ശ്രീ. രാജീവ് സദാനന്ദന്റെ ഭാവനയും ചടുലമായ ഇടപെടലുകളുമുണ്ട്. അച്ചടക്കമുള്ള ഒരു സർക്കാർ ഉദ്യോഗസ്ഥനായി സർക്കാരിനെ സേവിക്കുകയും

Aardram Mission Keshvendra Kumar IAS

ublic Health in Kerala has attracted international attention for its outstanding achievements despite a relatively modest progress in the economic front. However the public health system in Kerala had failed to keep pace with the epidemiological and demographic transformation that the state has gone through in the last three decades. Despite past improvements, there are serious emerging concerns. Some of them are listed below. • Change of focus from prevention and promotion to specialty curative care • Rising burden of NonCommunicable Diseases (NCDs) • Emerging and re-emerging Communicable Diseases • High out of pocket health expenditure • Health problems of the marginalized population • Paucity in addressing the Social Determinants of Health (SDH). • Insufficient resources and determination to commit “Universal Health Care” with “Health as a Right” framework

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• Reduction in the proportion of budget allocation for health over the years Multipronged interventions were designed to tackle the shift of service access for health from Public to private sector. Strengthening the primary health care system is one of the main strategies for addressing these concerns. Government of Kerala has decided to revamp the health care system in the state with a thrust to Primary Health. Aardram is one among the four missions under the “Navakerala Karmapadhadhi” launched by the Government of Kerala. Mission Aardram with the main objective to completely transform the public health sector was launched in the backdrop of the WHO’s Sustainable Development Goals (SDG) 2030. In 2015 UN had declared a set of all-encompassing and inclusive sustainable development goals for 2030. The third SDG goal is“Good Health and Well Being”. The health status of Kerala being different from the rest of the country, there was a need to redefine the SDGs in the context of our state as part

Dr C K Jagadeeshan

of which Mission Aardram was launched in February 2017. SDGs set for Kerala has short term goals to be achieved by 2020 and long term goals to be achieved by 2030. This was formulated by various expert committees who worked on health issues prevailing in Kerala. This has been incorporated into the 13th five year plan of the state. Four heads of Aardram Mission • People friendly outpatient services • Transforming Primary Health centres to Family Health Centres • Access to Basic health services for backward tribal communities and Urban Slums • Super specialty services in District Hospitals and Specialty services in one hospital in each District & Taluk. Vision-To provide comprehensive and complete health care for each and every individual Mission-To achieve SDG targets thereby providing quality comprehensive health care affordable, accessible and acceptable to all

Strategies

Way Forward

• Strengthening primary care

With extension in timings of outpatient services, transformation of old buildings into clean and people -friendly institutions, provision of additional human resources, capacity building of all category staff and augmenting services in both quality and quantity has improved the community acceptance of the public health system which is evident from the increase in OP load. Gramapanchayats of many institutions not included in the list have taken their own initiatives to transform their institutions to

• Improving the quality of services • Addressing the social determinants of health • Community participation, community mobilization

provide quality primary health services to the public. Some of the institutions have gone way beyond the concept of Aardram in implementing the reforms which indicates the acceptance of the mission by the common people.

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New Cath Lab at GH Pathanamthitta

A JOURNEY

COMPREHENSIVE PRIMARY HEALTH CARE

The New Kerala Model Evolving Dr P K Jameela

Dr Shinu KS

Dr Rekha Raveendran

Former Director of Health Services State Consultant Aardram Mission

Executive Director SHSRC

SRO SHSRC

s part of Navakerala initiative Aardram Mission was started in Kerala in 2016. The major objective of the mission is to convert all the primary health centres in the state to family health centres focussing on comprehensive primary care. Other measures being standardization of Taluk and District level hospitals along with patient friendly transformation of all institutions. In the first phase of implementation 170 primary health centres were selected for transformation to family health centres. The strategies adopted were infrastructure restructuring , additional human resources and capacity building. The mission intended to achieve SDG targets for 2020 and 2030 as well as reducing out of pocket expenditure in health. It also aims at providing basic health care services to marginalized group in the state mainly focussing on tribal communities and fisher folks. Though the existing primary health centres were constituted to provide comprehensive primary care, majority ended up in focus

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on curative aspect of health.The idea of bringing in a new health culture with a comprehensive approach which provides a vision of considering family as unit for health services delivery plan resulted in the formation of Family health centres. The first FHC â&#x20AC;&#x201C; FHC Chemmaruthy in Thiruvananthapuram district was inaugurated on 17th august 2017 by the honourable chief minister of Kerala. By now around 163 out of 170 FHC are functional. Looking at the performance of FHCs from three dimensions viz infrastructure, human resources and functional, it is very encouraging to see that a huge transformation has happened in the primary care sector of the state. All the selected FHCs has undergone basic infrastructural transformation in people friendly manner with provisions of adequate waiting area , seating facility, drinking water, token system, doctors consultation room with adequate privacy nursing station with facilities for precheck, observation, pre check, post check counselling, well equipped lab facility, standardized pharmacies with adequate drugs and

consumables. All the FHC s are provided with standard facilities for immunization, child, women and disabled friendly facilities. Majority of FHCs have completed landscaping with beautiful garden, childrens play area, areas for improving physical activity, farming and agriculture etc. Infrastructure modification was done mainly utilizing state plan fund for health additional support was given by LSG, MLA s and MPs local area development funds, sponsorships by various NGO s and individuals. Selected FHCs had only one medical officer one nurse one pharmacist, very few had lab facilities provided by concerned Local self government. But as part of the FHC transformation state government created additional post for 170 doctors, 340 staff nurses, 170 lab technicians and 150 pharmacists. It was decided by the government that an FHc should have minimum 3 doctors and 4 nurses 1 lab technician and 1 pharmacist in place before inauguration. The human resources gap was to be filled by the local self government or national health mission. The FHC OP services was extended upto 6PM

Taking into account , the huge challenge faced by the state in Non communicable diseases, it was decided that functioning should focus on comprehensive primary care in controlling diabetes , hypertension, COPD+ asthma and mental illnesses especially depression. Hence in addition to the existing NCD programme for diabetes and hypertension, two new initiatives were started: SWAAS programme for COPD+ asthma, and ASWAASAM programme for depression. Initially 100 FHCs were selected for this new initiative and now it is functional in all 170 FHCs.

preparation of ward level health status report and discussions in the ward health nutrition and sanitation committee. A new group of health volunteers â&#x20AC;&#x201C; Arogyasena were selected and sensitized for strengthening field level service delivery. One volunteer for each 15-25 houses was selected by the panchayaths, to help the the panchayaths and FHC in identifying various areas of health issues, delivery of services, monitoring and evaluating the services delivered. The concept of Arogyasena was theoretical initially but now it has set in place in many of the panchayaths.

There is a revolutionary change in the role of nurses in a family health centre, they are given the responsibility of pre check up, post examination counselling, management of SWAAS and ASWAASAM clinics. In addition they are supposed to visit other institutions in the panchayaths like government offices, schools, orphanages, workplaces etc for screening for NCD, health assessment and awareness creation programs.

Capacity building of all the different stake holders- staff and panchayaths was a huge challenge to the state. The entire responsibility of imparting training for this transformation was taken up by the state health system resource centre- Kerala. A group of dedicated trainers were selected from among the health services staff, including doctors, nurses, pharmacists, lab technicians, field staff, supervisors and ministerial staff. The curriculum and modules for capacity building were developed by the same groups with the help of experts in the concerned area. Three types of trainings were developed

Strengthening of Subcenters and field activity are integral part of family health centres. Subcentres used to conduct only 2 afternoon clinics that are antenatal and NCD. Under FHC subcentre are supposed to conduct six days afternoon clinics like nutrition clinic, well women clinic elderly clinic and Adolescent clinic adding to the existing clinics. People friendly Infrastructure transformation has been started in many of the FHCs with the help of local self governments. The service delivery framework has been developed for each individual according to their age and physical conditions. Health care delivery plan is based on each ward level action plan after

1. Team building training 2. Concept training for various categories 3. Skill development training 4. Team building training was a novel concept in the history of health service department. A team of stakeholders from the LSG and FHC assembled in the same hall to analyse, discuss and find out a solution for the health issues and facilitating a smooth transition. This training was a great breakthrough for the transformation from

PHC to FHC. The concept of comprehensive primary care and its implementation was imparted to each category of staff from medical officer to part time sweeper. Skill based training is developed for technical staff. In the first phase 163 institutions have been transformed to FHC in the second phase 504 institutions are selected by 2021 all PHC / CHCs in the state will be transformed to Family health centres. The role of local selfgovernment in revolutionizing the primary health care is commendable .It is hoped that the national health mission will also pool resources into the system as part of the health and wellness concept. Thus with a strong political will, good planning and co-ordinated and integrated effort Aardram mission will create history in Comprehensive primary health care all PHC / CHCs in the state will be transformed to Family health centres. The role of local self-government in revolutionizing the primary health care is commendable .It is hoped that the national health mission will also pool resources into the system as part of the health and wellness concept. Thus with a strong political will, good planning and co-ordinated and integrated effort Aardram mission will create history in Comprehensive primary health care all PHC / CHCs in the state will be transformed to Family health centres. The role of local self-government in revolutionizing the primary health care is commendable .It is hoped that the national health mission will also pool resources into the system as part of the health and wellness concept. Thus with a strong political will, good planning and co-ordinated and integrated effort Aardram mission will create history in Comprehensive primary

health care all PHC / CHCs in the state will be transformed to Family health centres. The role of local self-government in revolutionizing the primary health care is commendable .It is hoped that the national health mission will also pool resources into the system as part of the health and wellness concept. Thus with a strong political will, good planning and co-ordinated and integrated effort Aardram mission will create history in Comprehensive primary health care.

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eHealth Kerala

HISTORY IN THE MAKING Dr V R Raju

Dr N Sreedhar

Mr. Dileep Nair

Mr. Bahuleyan

Additional Project Director eHealth State Consultant e-Health

n 31st March 2011 the World Bank approved $150 million loan (Around Rs 700 Crores) to India to accelerate the implementation of its National e-Governance Plan (NeGP), aimed at transforming the service delivery system across the country. Department of Electronics and Information Technology (DeitY) communicated to all States about the funding which will be provided as a grant and requested to forward DPRs.

its Administrative Approval for the Project in the last week of February 2012, for a total estimated outlay of Rs 9612.04 Lakhs with a DietY share of Rs 8669.45 Lakhs and State share of Rs 942.59 Lakhs. This was the largest project funding to any state under that scheme.

Grabbing this opportunity, then Principal Secretary, Dept of Health & Family Welfare H&WD, GoK Sri Rajeev Sadanandan IAS, directed the IT Wing of NRHM to prepare the DPR. The instruction conveyed in just two words was clear and crisp. â&#x20AC;&#x2DC;Dream Bigâ&#x20AC;&#x2122;.

Even while the approval process was underway, Dept of H&WD had been gearing up for the implementation. Two teams were constituted for creating the Functional Requirements Specifications for the Public Health Module and the Hospital Management Module and by the time funding was available the state was ready with the documents required for the implementation. The project was known as eHealth Kerala.

NRHM prepared the DPR with the Technical support of CDAC Trivandrum. The DPR for Rs 269 Crores was forwarded to DeitY in mid-December. At the end of a relentless follow up by the Principal Secretary,DietY conveyed

The project which started with meticulous planning later met several roadblocks inherent for a project of this magnitude and complexity. The State Administration however intervened at various stages

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Administrative Manager

and guided the project and as a result, eHealth Kerala is the most important Digital Healthcare Project happening in the country at the moment. It is extensive, considering the coverage of population; complex, in terms of the interlinkages of modules and complete, in terms of the healthcare interventions involving a citizen. The uniqueness of the project is that it covers the entire population of a state and the focus is entirely on the healthcare management of the individual citizen. At the micro-level, it is citizencentric and at every stage aims to make available optimum healthcare services to the citizen without hassles and irritants. Facilities such as Online Advance Booking, Smart Queue Management System, Integrated Laboratory and Pharmacy, and Electronic Medical Records (EMR) accessible from any hospital, are making life easier for common citizens. EMR is also accessible to the

citizens online hassle-free, using Aadhaar.Dedicated hardware, redundant connectivity, and UPSs are provided at all institutions for the seamless and un-interrupted functioning of eHealth at all institutions.Theperfect synchronization of the Aardram Project with eHealth is creating a new record of high-level standards in Public Healthcare. These two projects which are already blended together, is creating history in making available healthcare facilities to common man which are comparable to international standards. At the macro level eHealth leverages the Government efforts to provide maximum resources for the Public Sector Healthcare Services so that quality healthcare is within the reach of the common man. Accurate and detailed data is now available for healthcare planners to proactively intervene and make available focused medical care exactly where it is needed and when it is needed.

The project has two distinct facets; first, the Public Health module which involves the Public healthcare monitoring activities at the Village level and second, the Hospital Management System. The data collected at all levels of interaction with the citizen is stored centrally to form the State Health Information System Database and provides need based, controlled, secure access for authorized stakeholders. Even though it is being implemented only in the Government Healthcare centres now, eHealth is envisaged to cover the private sector also in the next phase.

2. eHealth is leveraging the Aadhaar to provide Unique Health ID (UHID) to all the citizens with the concept of implementing ‘One Citizen, One EMR’.

eHealth Kerala is unique in the Healthcare IT sector for several reasons.

5. eHealth Kerala is a centralized system and any hospital can become part of it through a very simple on-boarding process.

1. This is the first project conforming to all the Healthcare IT standards prescribed by the Government of India.

3. Integrated Public Health and Hospital management System of eHealth enables the linkage of the entire gamut of the healthcare institutions in the state starting from the Sub Centre to the Medical College 4. eHealthensuresthat the quality and confidentiality of Medical Data meets international standards.

At present,all the 9500 public health units, nearly 50 Hospitals are part of the system which

include Medical Colleges, District Hospitals, General Hospitals, Taluk Hospitals and Primary Care Centres. It was envisaged to cover 11 centers in Thiruvananthapuram on pilot basis and then to scale up the activities in all institutions inthe seven eHealth districts – Thiruvananthapuram, Alappuzha, Ernakulam, Idukki, Malappuram, Kannur and Kasargode in the first phase and to the other seven districts subsequently. The e-Health application is going live in 50 institutions across the state. Out of the 170 PHCs upgraded in to FHCs under the ARDRAM Mission60 institutions shall go live by the end of this month and the remaining institutions by Sept, 2019. The number is fast growing, as more and more institutions are becoming part of the system on a daily basis.

in the making. It is changing the Public Healthcare Service Delivery beyond recognition and in a couple of years the Government Healthcare Institutions will be at par with any international standards in service delivery. This will be another ‘Jewel in the Crown’ for a state which is already far ahead of other Indian States in Healthcare service delivery.

eHealth Kerala is not just an amazing project initiated by a visionary officer. It is history

A JOURNEY

Kerala Clinical Establishments (Registration and Regulation) Act 2018 Dr Krishnakumar Deputy Director,DHS

n Kerala, the Private sector despite being a poorly regulated one provides for seventy percent of the health care services through hospitals, laboratories and imaging centres. There exists no transparency in the services, facilities or rates and packages offered by majority of these establishments and the average out of pocket expenditure is significant though Kerala prides on high health indices. The existing reporting systems provide data in public health only from the public institutions and lacks the crucial data from the private sector required for disease surveillance and effective response to epidemics, disasters and public health emergencies and also for better planning and policy formulation. In order to correct these deficiencies and to strengthen an otherwise robust healthcare delivery system in the State, the Government of Kerala, after

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Dr Kamala Rammohan

Asst Professor Pulmonary Medicine Dept GMC Thiruvananthapuram

considering the demand from the public and other stakeholders brought about the Kerala Clinical Establishments (Registration and Regulation) Act 2018 (KCEA 2018), which was passed by the Kerala Legislative Assembly on 1st of February 2018. The Act has been implemented for establishments under Modern medicine from 1st January 2019 and the implementation for other recognized systems of medicine will done in a phased manner. The Act brings about the registration of clinical establishments under all recognized systems of medicine, both from private and public sector (except those under the control of Defense Services and those establishments offering only consultation services) and ensures uniform standards of care by each category of establishments and transparency of services and facilities offered by them. The

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Act will also help to collect the required data and statistics from clinical establishments for better policy formulations, planning, implementation, response and evaluation.

constitute an independent panel of Assessors/Inspectors to conduct assessment of the establishments before granting registration and inspect the establishments to ensure compliance to standards.

The KCEA 2018, places the entire process of registration and the data of clinical establishments on an online platform wherein the process of submission of application by the establishments and the verification of the application and granting of registration by the Registering Authority occurs. The Act provides for an independent Appellate Authority for the aggrieved clinical establishments to appeal to, and a Grievance redressal mechanism for complaints from the public, which are provisions not available in the other states which have either implemented the Clinical Establishment Act 2010 or have their own state specific Acts. The KCEA 2018, has provision to

The public will be privy to data on services and facilities submitted by the establishments, thereby ensuring transparency of services provided and ultimately empowering them to choose the right facilities and lowering the out of pocket health expenditure. Since the establishments are required to submit data and statistics as notified by the Government and a large chunk of data that has so far eluded the system, will now be available for planning public health interventions and policies and to tackle public health emergencies like communicable diseases outbreaks.

General Hospital, Ernakulam

A JOURNEY

Efforts at Improving Quality at Government Hospitals in Kerala Dr Amjith E Kutty SQAO

erala is the first among the States of India to undergo NABH accreditation of it hospitals. During this time, it was noted that the NABH accreditation process is time consuming and resource intensive. This process requires a substantial investment in infrastructure, equipments and human resources. This made the process rather impractical for assessment of 1254 Govt. hospitals in Kerala within a short period of time. To address this complexity in implementing quality assurance mechanisms in healthcare providers and hospitals, Govt. of Kerala has launched a State level accreditation program, Kerala Accreditation Standards for Hospitals (KASH). Accreditation Board meeting held on 6th July.2011 had approved the Kerala Accreditation Standards for Hospitals for implementation.. The major emphasis of this program is sensitization of healthcare organization towards importance of quality health services, involvement of staffs for improving the quality of patient service, development, review and implementation of policies and procedures in the institution. The aim of this program is to provide better patient care, healthcare quality improvement, patient safety, infection control, medication safety, facility safety, and equity in healthcare.

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Till March 2019 sixty two institutions in the state were accredited with KASH and 12 more institutions are ready for certification after state level assessments. During the year, 18-19 ,forty one institutions in the state were accredited with KASH certification and 12 more institutions in the state are ready for KASH accreditation after state level assessments and will be accredited in the next SQAC meeting .The state is targeting to accredit 140 institutions by march 2020. In 2019-20 state is planning to accredit all the newly formed FHCs into KASH standards. Now the state is focusing more on NQAS accreditation and the institutions which are taken for NQAS will first accredited with KASH before NQAS

National Quality Assurance Standards (NQAS) Even though NQAS was stated in the year 2013, Kerala was not able to accredit many institutions with NQAS because of certain check points in the NQAS check list which are not suitable for Kerala S socio economic and health conditions. Last year state took initiatives to customize the NQAS check list according to Kerala standards with the help of NHSRC and the checklist were customized according to Kerala conditions in November 2017. The checklist customization was done by removing some items irrelevant to Kerala conditions and by adding PALIATIVE CARE into the check list. After customizing the check list kerala has made tremendous progress in NQAS accreditation. 51 institutions from the state have already completed state level certification and applied for national level certification. Out of this , Assessments are over in 26 institutions and all the 24 institutions whose results are declared got NQAS accredited. TH Chalakudy got 98.08 % in

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TH.Punaloor

Kollam

96%

PHC Chittarikkal

Kasaragod

92%

PHC Narkilakkad

Kasaragod

93%

CHC Panathady

Kasaragod

90%

THQH Chalakkudy

Thrissur

GH Ernakulam

Ernakulam

90%

CHC Pandapilly

Ernakulam

89%

FHC Thirunavaya

Malappuram

89%

W&C Kozhikode

Kozhikode

96%

TSH Kottathara

Palakkad

94%

FHC Kanchiyar

Idukki

91%

FHC Mutholi

Kottayam

90%

UPHC Maithanapally

Kannur

94%

FHC Noolpuzha

Wayanad

98%

PHC Purakkad

Alappuzha

96%

UPHC Anapuzha

Thrissur

92%

FHC Peruvemba

Palakkad

81%

FHC Chemmaruthy

Trivandrum

88%

FHC Karindalam

Kasaragod

96%

FHC Valiyaparamba

Kasaragod

97%

CHC Keechery Ernakulam

Ernakulam

88%

FHC Kayyur

Kasaragod

99%

FHC Valapattanam

Kannur

97%

FHC Therthally

Kannur

95%

98.08%

national level NQAS assessment and become the topper in SDH category in the national level. FHC Kayyur ,Kasaragode district scored 99% in NQAS national assessment and become national topper in PHC Category . FHC Noolpuzha Wyanad scored 98 % in NQAS national level assessment and become second topper among the PHC s of the country. PHC Valiyaparamba , Kasaragode and FHC Valapattanam bagged the third place by scoring 97% marks. PHC Purakkad Alappuzha and FHC Karinthalam kasaragode scored 96 % in national level assessment. With this top six primary health centers in india are located in the state of Kerala. W& C hospital Kozhikode Shares the first prize in district level hospital with 96% marks in NQAS assessments In the financial year 201920 Kerala is planning to take up NQAS accreditation in a large scale. We are targeting NQAS certification of all the newly formed FHC,s. we are also planning for LAQSHYA certification of 40 delivery points in the state as per LAQSHYA standards. At least one Thaluk Hospital /CHC in a district( total 14, one in each district) and one district level hospital in each district will be going NQAS Certification During 2019-2020.

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Kerala Medical Services Corporation Limited, Thiruvananthapuram Activities and Performance Dr Dileep Kumar S R GM KMSCL

Activities and Performance

High Priority Performance Goals

he Kerala Medical Services Corporation Limited KMSCL is a fully owned company of Government of Kerala set up in 2007 and is operational with effect from 1st April 2008 for providing various services to the health care institutions under the Department of Health and Family Welfare, Government of Kerala.

The following are the five high priority performance goals of KMSCL that ensures to attain specific results for the people of Kerala

One of the key objectives of the KMSCL is to act as the central procurement agency for all essential drugs including Medical devices and other stores and equipment for the health care institutions under the department. The Corporation has also been entrusted with the setting up of medical based ancillary facilities such as Dialysis centers, Cath labs, pathological labs, diagnostic centers, x-ray/ scanning facilities, ambulance services etc. The utilization of IT driven practices in a unique manner helped to bring transparency in functioning and also helped to increase the pace of service delivery.

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I. To procure and to sell, supply, distribute or deliver all kinds and varieties of generic and patent medicines and medical supplies of modern system. II. To execute a system for purchase and distribution of drugs III. To establish warehouses, storage rooms, go-downs and cold storage facilities for safe and convenient storage. IV. To provide quality assured atmosphere both in material management and in system operation up to the end user. V. To economize expenditure on drugs through pooled procurement system and to optimize accountability at all levels. The Essential Drugs Division of the Corporation adopts the procurement of drugs/ supplies

by National Competitive bidding process. Two bid systems (Technical Bid and Price Bid) of tendering is followed by the Corporation and e-bids are being invited by through e-procurement portal of Govt. of Kerala and finalized through the online software of the Corporation DDMS (Drug Distribution & Management System. To nullify out of pocket expenditure who seeks treatment in medical college hospitals, supply of specialty drugs was also initiated .Financial caps were also defined for each institution under DHS and DME to gather the more realistic, need based prioritized intent. The warehousing and material transport system planned and adopted by KMSCL is much better and medicines from the manufacturers are received and stored in the District warehouses for delivery to the hospitals. For ensuring the quality and productive standards of the bidders, only WHO GMP certified bidders with average turnover of 50 cr were allowed in bidding process and it was made mandatory to have external NABL, NIB, CDL certificate with each batch supplied. State Govt. has implemented online

Drug Distribution Management Software (DDMS) application through Kerala Medical Services Corporation Ltd for achieving a professional management of medicines procurement and supply

Other Major Contributions of KMSCL

Mission AARDRAM

Trouble free distribution of drugs and supplies is assured by KMSCL to the institutions under AARDRAM .898 FHC’s laboratories were strengthened by providing various lab equipments by utilizing 50 Crores.

KIIFB KMSCL as a special purpose vehicle for the development of Infrastructure works to various Government hospitals worth Rs. 149 Crores under KIIFB. Two of the key projects under KIIFB to be executed in the 14 districts of Kerala, was entrusted with KMSCL and 90% of the works are now completed. Dialysis Centres - The works of 42 dialysis centres were completed under KIIFB with a total estimated cost of 80 Crores. A total estimated cost of 69 Crores were earmarked for installing new Cath labs and the work of 4 Cath labs were successfully completed under KIIFB. Equipment Management Software – Implemented the customized unique software platform for all the operations in Equipment division of KMSCL.

Karunya Community Pharmacies Karunya Community Pharmacies, under Kerala Medical Services Corporation was a novel and a pioneer initiative of Department of Health & family Welfare during the 2012 to act as a messiah in the huge burden of out of pocket expenditure of very large extent of people living in the State of Kerala, in a largely exploited branded medicines market. Started as a one single outlet on a pilot basis at the Medical College Campus of Thiruvananthapuram, the success of it prompted the Government to expand its wings and has now expanded across the State by reaching to 68 outlets and many more to be added in the years to come. This initiative was the brainchild of Sri. Rajeev Sadanandan IAS during his tenure as Principal Secretary (Health & Family Welfare)..

Kerala Emergency Management Programe (KEMP) KMSCL has developed software for the operation of control room and successfully developed system for the smooth operations of this project which was earlier run by a private agency. 10 new D-Type ambulances were bought through GeM and equipped as part of strengthening KEMP KMSCL has also been managing Mobile Medical Clinic (MMC) from 2013. Total 14 MMC’s are now operating in Kerala covering almost entire tribal Population.

Involvement of KMSCL during natural calamities and disasters KMSCL has played a major part in procurement, collection and supply of medicines and other materials during flood in Chennai, Cyclonic Storm Ockhi 2017 and Kerala flood 2018. During the Flood disaster, , KMSCL had identified 178 critical items to manage flood related diseases and issued the purchase orders. Government had directed KMSCL to hold 200% of medicines required for this quarter, 400% of bleaching powder and anti snake venom normally consumed and also to ensure that the consumed quantity is replenished at 50%, to estimate the liquid chlorine and chlorine tablets and arrange to stock them.

of how to deal with it. Hence, the support of global agencies was essential for the state government to combat the fatal virus. It was additional chief secretary (health) Rajeev Sadanandan who was instrumental in roping in international bodies and experts to join the battle. Personal protective kit, disinfectants and anti-septic applications were procured and distributed by KMSCL. The importing and storage of antiviral ribavarin, experimental monoclonal antibody against Hendra virus (M102.4) were facilitated by KMSCL.

Meanwhile, donations poured in from all over the state and the country to help out with distribution of aid, provide medical assistance and help in rescue efforts. Drugs and other medical supplies were received from Central govt agencies, other state govts, other medical corporations and other service organizations. With the help of DDMS portal all the stocks were managed properly and evaluated the drugs position of critical items on daily basis.

Nipah Out Break in Kozhikkode When Nipah was confirmed in Kozhikode, no medical agency either at the state or national level had earlier understanding A JOURNEY

Antimicrobial Resistance Need of the Hour Dr Sarada Devi KL

Dr Bindu Mohan

Prof & HoD Dept of Microbiology GMC Trivandrum

Additional Director (Medical)

ndia is among the world’s largest consumers of antibiotics. Even the efficacy of newly discovered antibiotics is threatened by the emergence of resistant microbial pathogens due to irrational prescriptions of antibiotics and over the counter consumption of antibiotics. amplified the crisis of antimicrobial resistance (AMR) in India is amplified by Multiple factors, such as a high burden of disease, poor public health infrastructure, rising incomes, and unregulated sales of cheap antibiotics etc. The Global Action Plan on AMR emphasises the need to increase knowledge through surveillance and research. Health department has actively taken up the issues of

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Antibiotic resistance as a priority and decided to strengthen AMR surveillance, Infection control measures and Rational use of antibiotics. In the first meeting chaired by honorable chief minister a consensus was reached to develop a strategic action plan for tackling antimicrobial resistance. Representatives participated in the first meeting in connection with AMR surveillance by Chief minister. This was followed by a series of workshops and brainstorming sessions with participation from various stakeholders under the “One Health Approach” which lead to development of Kerala Antimicrobial Resistance Strategic Action Plan (KARSAP.

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As a part of implementation, setting up of microbiology labs, automated blood culture system, ban of colistin in vetenary sector and partnering with RGCB for research purpose, the establishment of IPC activities and ASP committees Govt Medical Colleges, primary and secondary care centres and establishment of KARS-NET[Kerala antimicrobial resistance network] were done. KARS-NET acts as a platform to bring together antibiogram from both Government as well as private sector, is another feather to his illustrious cap. The conception of KARS-NET has made it possible for the state to have an antibiogram which truly reflects resistance trends at the community

level. Collaboration with KDISC (Kerala Development and Innovation Strategic Council) to convert the antibiotic policy, standard treatment guidelines and ASP modules into mobile app format were also Initiated . All these efforts became fruitful with Kerala being the first state in SEAsian region to come out with its own action plan-- KARSAP which was released by Hon’ble CM on October 25th 2018.KARSAP and KARSNET are tributes to the vision and perseverance of Rajeev Sadanandan who made sure that KARSAP became a reality and ensured the time bound implementation of this plan .

Unique Initiatives At The State Public Health Lab Dr Sunija S

Director, State Public Health Lab

Newborn metabolic Screening Programme

ne of the landmark programme in the history of Health Dept, the Newborn Screening Programme started in 2013, under the strong leadership of sri.Rajeev Sadanandan IAS, the then health secretary and our present Addl Chief Secretary. Newborn screening aims at the early detection of inborn errors of metabolism and early intervention ,so as to prevent serious consequences like mental retardation. Four PH labs (State & Regional ph labs) were equipped to do the screening tests.In the first phase 44 govt hospitals having hundred or more deliveries were included(including the medical colleges).A sensitization workshop

was conducted for the participating hospitals as the programme was entirely new to the health sector. State specific guidelines for sample collection,storage &transportation were prepared by State PH Lab and was approved by the Govt. Required funds were provided by State Plan & NHM.The following inborn errors were included for screening• Congenital Hypothyroidism • Congenital Adrenal Hyperplasia • Phenyl ketonuria • G6PD deficiency The first phase of the programme lasted for nearly four years & approximately 3.5 lakhs babies were screened.In 2017 september it was expanded to cover all the delivery conducting Govt hospitals. Since there were no positive cases detected, Phenyl ketonuria was replaced by Galactosemia in 2018.

Also the screening tests are performed entirely in the Govt facility,the four PH Labs. Now the programme has completed six years & screened nearly five lakhs babies.About 240 children diagnosed with congenital hypothyroidism is undergoing treatment for the same,who would have otherwise ended up in mental retardation.

Achievements 1. The NBS programme of Kerala achieved first prize for “Innovative & Replicable programme” at the national level summit in2015,at Simla. 1. The State Govt. Appreciated the good work done by PH Labs in the 2019 International Child health summit at Trivandrum.

Kerala is the only state in India conducting Newborn metabolic screening in a programme mode. A JOURNEY

New Public Health Laboratories At Malappuram, Wyanad & Pathanamthitta. Public Health Laboratories were a long felt need for districts like Wynad,malappuram & Pathanamthitta.The proposal for starting these three laboratories were submitted from State PH Lab & was approved by the Govt in 2017,with necessary budget provision.All these three labs started functioning in Nov- Dec 2018. The Public Health Laboratories do provide medical lab investigation facilities to the public for the diagnosis of both communicable &non communicable diseases.For the BPL/Priority category all the tests are provided free of cost.

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WHO - VPD Surveillance Lab In State PH Lab The WHO has selected State PH Lab as the Vaccine Preventable Disease testing Laboratory in kerala in 2015.Hence State PH Lab is performing the confirmatory tests including PCR for diseases like Diphtheria & Pertusis and sending report to the WHO.VPD Surveillance is one of the most important step towards prevention of vaccine preventable diseases. Necessary Transporting media has been supplied to all the fourteen Dist from State PH Lab. All the hospitals including private hospitals can send suspected VPD samples to State PH Lab for confirmation.Our ACS sri Rajeev Sadanandan IAS has taken a keen interest in developing infrastructure for the VPD Surveillance Lab & now it has become a prestigious lab division scoring highest marks in External Quality Assurance in VPD testing.

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Microscopic Agglutination Test(Mat) Test For Leptospirosis State PH Lab has developed a separate division for MAT Test after providing training for a scientific officer at Portblair institute at Andamans.It is a big achievement as the State PH lab has the maximum number of serovars for MAT testing. This would enable us to provide a lot of epidemiological information regarding Leptospirosis for its effective containment.

Histopathology Division in State PH Lab

Molecular Diagnosis Division of State PH Lab Started functioning in 2014 this lab is the first of its kind under the health dept.We are providing PCR test facility to various hospitals including medical colleges.the tests available incude neuro panel,respiratory panel,gastro panel,hanta virus, zika virus, Mers corona,Lepto, Leishmania etc. Being the APEX REFERAL LABORATORY of NVBDCP,DENGUE viral typing is also done by State PH Lab for the surveillance of Dengue and report sent to state and national level.

The Histopathology division of State PH Lab has started functioning in Dec 2018.Because of the sample overload there was a marked delay in obtaining histopath reports from Trivandrum medical college.Hence the histopathology division of State PH Lab is a relief to the patients from other govt hospitals in the DIST.

A JOURNEY

Overcoming the Nipah siege Dr Sarita RL Director of Health Services

ay 17th, 2018. It was the beginning of a battle in Kerala. A battle where losing was not even an option. It was against Nipah, a deadly virus about which Kerala had not even heard in the past. The state government and the public fought together and won the battle. As we take stock of the events, what we see is a community which came together to fight even without being asked to join. The Nipah control activities has placed the Government of Kerala on the international radar and all credits goes to the relentless team work. The highest degrees of political and administrative commitment, the kind that has never been seen before in the history of health department was what held the fort during the virus attack. Since day one, Honourable Ministers, MLAs and other elected representatives were there with us. The first information regarding a potentially deadly virus was reported as a phone call to the district medical officer, Kozhikode. The honourable minister for Labourand Excise Sri T P Ramakrishnan called and informed her about 2 people belonging to the same family in Changaroth panchayath contracting similar symptoms. As a responsible leader, he consoled the people at the Panchayat meeting on the very first

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day, the people who were crestfallen as the bad fate had struck. The Hon. Health Minister Smt. K K Shailaja Teacher cancelled all her programmes immediately and camped at Kozhikode, setting up a team to get to work. The fight against Nipah was something that we had no manuals or textbooks to follow, we just knew that it has to be dealt with extreme caution. Still the Hon Health Minister succeeded in coordinating all the activities with us. She ensured that the entire force worked together as a team. Sri A K Saseendran, hon. Transport minister, was also part of the daily review meetings, actively contributing to them. MLAs from Kozhikode, and all elected representatives always enquired about us, giving support in person and other wise. Sri Rajeev Sadanandan,IAS ,Additional chief secretary, Health and Family Welfare Department gave us all directions and guidance and also coordinated the research activities. He tried his best to bring experts, medicines and logistics from around the world to Calicut. He even made it possible to get the medicine from Queensland, Australia to Government Medical College, Kozhikode, in no time. Whenever the team had a concern, he made himself available to regain the control. The Calicut district

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administration department has done an excellent work under the leadership of Sri. U V Jose, IAS,,district collector Kozhikode. The order given by him to temporarily close Janakikkad, an echotourism spot in perambra shows the success of district administration in foreseeing the issue. He even coordinated with police force to take action against people who tried to spread hoax messages. His clear vision, efforts to have an in-depth study of the issue and planning were reflected in the work of district administration. The Kozhikode district health service team led by Dr Jayasree was doing the best since very beginning. Even in the early phase, when they were not aware of the causative organism, its virulence or the source, they had tried to close all the possible loopholes considering the possibility of a zoonotic, vector-borne or waterborne disease. Preventive measures like chlorination and fogging were done on the first day itself. Even before the organism was identified, Dr Bijesh and his team hadstarted working in the community. The medical team From Perambra Taluk Hospital had lost their colleague by then to the deadly virus and were facing isolation from the general public. Yet they were brave and

continued with their work. All hospitals and staff of the health service department, pledged to fight day and night, no matter whatever be the consequences. The determination shown by the students of government nursing college, Kozhikode to be part of the mission even when one amongst them was fighting with the disease shows that the future of health department , Kerala is safe in their hands. There were no treatment guidelines to follow in any of the text books, but the faculty members of government medical college Kozhikode came up with one quickly. Treatment protocol was made, isolation wards were created and what we witnessed was a magic. The crowded medical college transformed into an international centre with all facilities. The Staff was given training to improve their work because of which Nipah left us with 2 survivors. Itâ&#x20AC;&#x2122;s important to point out that the health care professionals working for the private sector, doctorsorganisations, professional and service organisations too worked withus. With their excellent clinical skills, the clinicians of Baby memorial hospital, Kozhikode had suspected Nipah infection after the second case and had sent

the samples for confirmation. Never before in the world has anyone suspected Nipah in such a short time span. The facilities for prompt diagnosis were arranged by Manipal Virus Research Centre. It was DrArunKumar G, the Head of the institute who did the historicalvirologicaldiagnosis which was later confirmed by the Nationalvirology Institute. DrArunkumar and Dr A S Anoop Kumar of Baby Memorial Hospital tried their level best to publish, the information related to Nipah containment in all print and visual media possible. It was another major challenge to prepare the list of contacts, get their details and to trace them. The team members of the health department knew the fact that most of the contacts in the list were their dear ones, yet they were determined to keep aside their emotions and work together for a great cause. The volunteers of â&#x20AC;&#x153;compassionate Kozhikodeâ&#x20AC;? deserves special mention for their commendable work in serving as a constant support to the health and revenue departments. We were gaining control over the situation when the issue of providing psychological support to the patients, relatives and general public came up. This was important in the background of the unexpected crisis and deaths. This task was taken over and beautifully performed by the district mental health program team members of Kozhikode with support from department of psychiatry, Government medical college Calicut and IMHANS, Kozhikode. Every Nipah related death was a heart breaking news in the Nipah camp. It was a difficult situation for the relatives as they were not able to see their dear ones for one last time and bid good bye before their final journey. The

staff of the primary health centres played an important role here in helping the grieving relatives come to back to their routine life. DrGopakumar, a health officer from Kozhikode willingly performed the last rites of many deceased patients whose relatives were not available. Sri Amit Meena, Honourable district Collector, and DrSakeena, the district medical officer, Malappuram played their roles well and worked as a team as soon as cases were reported from Malappuram. As part of an important department there were times when we had to be friendly as well as harsh with the media personnel. But this time it was a unique fellowship, perhaps a rare one. We could hardly see any negative reporting, unnecessary blaming or prejudiced versions. Instead they exhibited the true spirit of ethical reporting .They had an important role in providing important information to the public Many of them were even at risk of contracting illness and hence the Nipah cell had concerns about their health too. The efforts of these media personnel along with the support from district information officer helped the rest of the world know about the activities in our state.

this organism which came from somewhere and had frozen the normal life there. They were witnessing their loved ones falling ill and succumbing to the virulent microorganism, they knew that the rest of the world was observing them, still they stood together with the determination to fight. The restrictions imposed by the district administration was hard, still the people were determined to stick to it. They were even ready to give up many things which were dear to them for a better cause. They gave up their celebrations, entertainment, their daily outings, rituals and beliefs. And once they were sure that the threat is no longer there, they gathered in their city and expressed their love and gratitude to the government which made it possible for them to resume their life as before.

There are a lot many to be named. The ones who came and stood by our side to resolve our worries, the staff of private hospitals, different professional and service organisations, the helping hands from around the world which helped us to boost the government facilities, the team from the centre who came to Calicut and provided us with their valuable inputs. However in this occasion when we declare the state as free from Nipah virus, itâ&#x20AC;&#x2122;s important to mention the general public of the district. There was A JOURNEY

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Ockhi Rescue and Post Disaster Efforts Dr Anil V

Assistant Director

ery Severe Cyclonic Storm Ockhi was a strong tropical cyclone that devastated parts of Sri Lanka and India in 2017, and was the most intense tropical cyclone in the Arabian Sea since Cyclone Megh in 2015. On 29 november 2017 it reached coastal areas of Trivandrum district . to manage the mishaps due to ockhi the distrct health team alerted all the categories of health staff in the district . dircetions were given by the DMO to all peripheral institutions to get equipped with medicines and equipments to tackle the emergency. RRT was initiated at the district level. All the major hospitals were intimated regarding the disaster and and were asked to be prepared to receive the casualties on an emergency basis. Following this medical teams including all specialties were constituted at the major hospitals. KMSCL arranged necessary medicines and other consumables to these major hospitals on a emergency basis. The major hospitals like GH Trivandrum, DMH Perrorkada, CSH valiyathura, TH Fort were equipped in a short span with necessary medical and para medical personnel and medicines and equipments. Necessary directions were given

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JAMO Planning

to purchase blankets to rewarm the patients returning from sea. Adequate ambulance services too was ensured by arranging from other institutions and 108 and co-ordinating with private sector. Availability of freezers was ensured to keep the deadbodies. A control room was initiated at the the district level working 24 hours and in co-ordination with control room at the collectorate level and also with other medical colleges. At the DMO level each program officer was given charges of different areas in disaster management and also co-ordination with RRT. Post disaster psycho social care was initiated early by DMHP and DISA counselors. Medical team was even send along with costal guard authorities to the sea for providing first aid to those rescued from the sea. In order to provide medical care to those survivors who were airlifted medical team was posted to airports too. A major challenge for the district authorities was to release the dead bodies to the release as most of them were beyond identification due to decaying. To counter this necessary arrangements were made to collect the blood from the relatives of the dead by Rajeev Gandhi centre for biotechnology. Daily press release K E R A L A

was also arranged daily by the district . daily evaluation meetings were organized at the DMO office to review daily activities and also to plan next days activities in advance.

At the Relief Camps A total of 12 relief camps were started at various zones catering to the needs of evacuated and rescued victims. Medical teams were assigned duties to cater to the needs of these victims which included men, women, children, elderly. These teams visited the camps twice daily to ensure sanitation, medication to injured and sick, food and clean water and other consumables, sanitary latrine etc.. All the preventive measures to control water borne , mosquito borne diseases in the rescue camps. Behavior change communication activities were carried out at all the medical camps. Adequate number of Doxycycline tablets were procured by the KMSCL and was distributed to the medical camps. For those medical camps with more than 50 inmates, a health worker was posted to look after the health and health related needs.

District RRT and programme officers supervised the camps to ensure that the activities are going on as envisaged. District disaster cell maintained daily reporting to the state headquarters and collectorate. Special arrangements were made at the camps to deal with the special group of diabetics, hypertensives and cancer patients. State and district NCD cell made necessary arrangements to deal with NCD patients who had loss their treatment details. Essential antenatal care too was provided at the camps. Post disaster phase psychosocial intervention is very much essential to reduce mental stress of the camp indwellers who has been through huge mental trauma. District mental health team formed a special cell to provide psychosocial intervention to the victims. A special medical board was created by the DMO at GH tvm to categorize patients according to their injuries . this too was reported to the district collector and health secretary. Additional chief secretary Health Rajeev Sadanandan sir was instrumental in giving vital directions at that outset which helped the health services in planning and organizing the disaster activities in a phased manner.

A JOURNEY

Health System Response to KERALA FLOODS 2018 Dr Anil V

Assistant Director

Dr Juby

Dr Ajan M J

Jamo Planning

Nitheesh

Staff Nurse

isasters have always been posing insurmountable obstacles in the path of human development from time immemorial, and however developed the human race has become, the threat of a disaster is always a source of constant concern. As per the Indian Meteorological Department (IMD) data, Kerala received about 2346.6 mm of rainfall during 1 June 2018 to 19 August 2018 against the normal rainfall of 1649.5 mm, which was 42% above the normal for the time period.Floods affected 981 out of the 1664 villages in the state, claiming more than 480 lives. One-sixth of the total population in the state was directly affected by the flood, and nearly a million displaced people were residing in the 2700plus relief camps across the state. The landslides, and floods damaged 344047 houses, 2563 public buildings, and 285 schools. Around 3 lakh wells were affected, which in turn affected the availability of safe drinking water. To co-ordinate the health system efforts in the situation, a 24x7 Disaster Control Room was set up at the Directorate of Health Services on August 18th,

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2018. The state level decisions and advisories were communicated to the District level control rooms and channelized through nodal officers at Taluk levels. All activities were carried out in co-ordination with the local self-government institutions, Water Resources department, and the governmental and non-governmental Disaster Management and Relief teams. The Control room functioned under the direct control of the Director of Health Services, and the State Mission Director of National Health Mission. It worked in tandem with the special Disaster Unit at the Health Ministerâ&#x20AC;&#x2122;s office. The health minister K K Shailaja teacher and additional chief secretary Rajeev Sadanandan sir on a day today basis supervised this. The replica of the State Control room was constituted at the district level and activities carried out and monitored. All communications regarding the flood relief activities to the State control room from districts were being routed through the District control rooms by the DMOs, and who in turn were to report the field requirement of the districts in terms of money, material, and manpower to the

state team. District level nodal officers were designated for managing HR, Pharmacy and Transport. Nodal officers were designated at sub-district level for coordinating activities. On account of the severity of the floods, and widespread contamination of water sources, super chlorination was advised after the receding of flood waters. This was conducted after the removal of any visible waste materials and reducing the water turbidity. RO plants were brought in to flood affected areas of Alappuzha to provide drinking water. The health department issued guidelines for ensuring the safety of the food prepared in the relief camps. Also, liaised with the Food Safety department to ensure that soaked food materials from storages and stores in the affected areas were not brought into the food supply system. The training, and mobilization of health personnel were conducted district wise. Development, and dissemination of associated IEC material was done with the help of Training and Mass-media team, and NHM.

Any health-related advisory was only disseminated after getting approval from the State Disaster Management Content Approval Committee. Contents of all the disseminated material were verified by the Public Health Team. The field level activities were conducted in co-ordination with the LSGIs, Water Resources Department, Camp Officials, other supporting teams. Field reports were communicated twice daily to the state team through DMOs, analysis of which was done by the state team, according to which decisions were taken, and updated instructions communicated to the districts. Risk of vector-borne diseases like Dengue, Chikungunya, Malaria was high with the prolonged waterlogging. Vector control activities were carried out in the affected areas by the NVBDCP, in co-ordination with health system field staff, LSGIs, and Volunteer teams, as per the guidelines. Mosquito, and larval density assessment was to be carried out on the need basis at each ward, according to which fogging and other activities were to be conducted. An intensive sourcereduction campaign (for three ‘Dry Days’ per week), and IEC activities promoted the public participation in vector-control activities. Waste dumping sites were sprayed with insecticides by the District units, and field staff. On account of the crowding of the displaced population in the shelters, there was a higher chance of exposure of the susceptible population and consequent spread of communicable diseases like Measles. Considering this, the routine immunization drive was scaled up. STAGI meeting held at state level issued advisory for immunization of the population affected by the floods. A district

level action-plan was initiated for ensuring immunization coverage of the affected population. STAGI advised administration of MR (Measles Rubella) vaccine for all children of 6 months to 5 years of age, in the relief camps. According to this, all 6 to 9-monthold children in the relief camps were given MR vaccination, and this was marked as their ‘Zero’th dose of the MR vaccine. Tetanus immunization was advised for all who had sustained injuries, and those who were participating in rescue/relief and rehabilitation, irrespective of their immunization status.ORT (Oral Rehydration Therapy) depots were constituted at field level for every 10-15 houses, immediately after the flood waters receded, for reducing the mortality due to ADD.

in the first half of September 2018. In the second half, this was reduced to 153, and 214 cases respectively. Similarly, though the number of cases of other diseases like ADD, Chicken pox, and Hepatitis A were comparatively higher, it did not reach outbreak levels. Incidence of Dengue fever was much less than the previous years, pointing towards the effectiveness of the preventive measures taken.

Guidelines for Leptospirosis management was updated by the RRT, based on the assessment of the reports from districts, and inputs from NIE (National Institute of Epidemiology) and other expert consultants. All cases with fever, and myalgia with history of exposure, were to be considered as suspected Leptospirosis, and presumptive treatment with Doxycycline was advised. Leptospirosis prophylaxis drive was strengthened ‘Doxycycline Corners’ were opened, in all institutions from PHCs and above, wherein the relief and rehabilitation volunteers could avail the prophylaxis without waiting in the patient queue. Death-auditing of Leptospirosis deaths were to be conducted.

To expedite the surveillance, there was sensitization of the Private Health sector, on the reporting of the health events under surveillance. The state also received support in this endeavour from the Special Surveillance Medical Officers (SMOs) appointed by the WHO, and Public Health teams from other states, especially Tamil Nadu. An online reporting format was developed using a software application called ‘KOBO tool’ to aid in the surveillance. On the initial days of flood, the conventional surveillance mechanisms were strained in many places due to infrastructural loses, and other technical reasons. At that time, the Media Surveillance helped to bring in event -based surveillance data, which supplemented the Public Health surveillance mechanism and the Health System as a whole to prioritize areas to act upon on an emergency basis. The alerts created by the Media surveillance team helped the drugs and Logistics team to quickly track down places having shortage of drug/medical supplies and redirect the supply chain accordingly.

Following subsequent measures to strengthen the prophylaxis, and management of the disease, the department was able to reduce the incidence, and mortality due to Leptospirosis. 685 confirmed, and 1401 suspected cases of Leptospirosis was reported

An emergency meeting of State resource group was held and a Protocol for NCD treatment during Floods at Camps and primary care centers was developed and disseminated to the flood affected districts. A team from National Institute of epidemiology, A JOURNEY

Chennai was assigned the task of conducting an epidemiological surveillance of NCDs at the Flood affected sites by directly interacting with the medical officers, field workers and administrators on NCD Surveillance and prompt reporting. Special IEC materials for NCD control at disaster cell was developed and disseminated to districts. The module for NCD management was also developed and distributed. Instructions were sent to strengthen stroke clinic and dialysis clinic anticipating the increase in their load in the post flood scenario and thereby preventing the worsening of complications.

to support them. A WhatsApp group was created in each district including all posted doctors for easy dissemination of training materials, information and urgent notices. The temporary additional health facilities operated for 15 days and catered to around 73,000 patients in the flood affected areas. In the wake of flood, the routine Drugs and Logistics support system of the state run by DHS and KMSCL had to be augmented, for which a team was constituted at the State Disaster Control Room.

To meet the additional HR requirements of affected districts, various organizations including the Defence- military & paramilitary forces, various state medical college Teams, Teams under Govt of India & IMA, who expressed their willingness to serve as volunteers through ACS- H& FW, were contacted and our requirements were communicated. Latter half of the HR management was more focused towards major hospitals of affected districts. Further, need of pharmacists during the latter half was met by deploying 141 M Pharm students of Govt medical colleges based on the list received from DME by the HR wing.

Due to the co-ordinated efforts of the various teams and district units and as a result of the tireless co-operation from the general public the state of kerala was able to avert the much anticipated mortality following flood due to communicable disease, non communicable diseases and mental stress.

It was also decided to start temporary additional health facilities in selected flood affected panchayaths manned by a medical PG student and a staff nurse to support the existing health facility in place in anticipation of increased requirement for health care services. 244 panchayaths were selected. Each additional health facility was provided with a drug and equipment kit worth 1,30,000. Two JPHNs from the parent institution were also posted at the additional health facility T H R O U G H

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Arogyajagratha

erala experienced an unprecedented increase in many communicable diseases during the year 2017. Morbidity and mortality due to the various common and uncommon diseases increased to a very high level during this year. In this context, the Health Services Department has decided to strengthen and accelerate its annual communicable disease control activities, keeping in mind all the lessons of 2017, aiming to prevent such epidemics in subsequent years. With high political commitment and the advent of the “NavaKerala Action Plan” and “Aardram Mission”, we hope to achieve greater stakeholder coordination to achieve the target of a healthy and safe state for all its residents. Arogyajagratha is a yearlong campaign by the Government of Kerala for prevention and control of communicable diseases.

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Activities • Systematic surveillance mechanisms for identifying communicable diseases at the earliest • Implementing control measures including treatment without delay • Surveillance of vectors • Outbreak investigation • Food and water safety • IEC/BCC

Action Plan The comprehensive action plan is broadly based on the following strategies: • High Political and Administrative will • Interdepartmental collaboration at state, district and block levels • District epidemic control committee under the leadership of District Collector with DMO(H), DPM, DSO, Standing committee chairpersons of Panchayaths, Urban local bodies and other stakeholders - to prepare, execute and evaluate activity plans

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Dr Meenakshi V

Dr Sukumaran

Additional Director, Public Health

State Epidemiologist

• Reviving Sub center based disease control measures, coordinating WHSNCs and NGOs - Suchitwa mapping and hot spots finalization

procurement plan

• Strengthening of Ward health Sanitation and Nutrition Committees - utilizing them for continuous activity in the respective wards • Intensive & Time bound vector control measures- Fogging, IRS and ISS along with other Integrated Vector Management components like Vector surveillance • Source reduction activities utilizing community participation • Mass cleaning campaigns- with support from LSGD and ULBs along with Traders association • Dry Day observation, Source reduction. Frequency and timing to be decided as per seasonality pattern • Ensuring the safety of drinking water by respective authorities, Water Quality Monitoring. Campaigns for protecting drinking water source • Ensuring all logistic support at all levels, need assessment and

• National Health days – These days will be observed ensuring full community involvement • Healthy Kerala Campaignperiodic and targeted • Training of all service providers – Government and private doctors on Protocol based case management • Cascade type training of all Field level workers on disease surveillance, prevention and control measures • Intensive Monitoring and Supervision by state level and district level program officers, (independent evaluation by Academic institutions, if needed) • Short and long-term research plans, KAP studies and midcourse corrections • Need based and area-specific IEC materials- production and distribution, utilizing appropriate dissemination methods • Strategies for motivating sociopolitical organizations to own the disease control measures • Integration of CD control with NavaKerala Mission elements, wherever possible/feasible

Ashwamedham LCDC Dr Padmalatha Kurup Deputy director Public health& SLO

erala achieved elimination status for leprosy in December 2005 with a prevalence rate less than 1/10000 population. Since then the prevalence rate of our state has always been below 1/10000 population district and panchayath wise. But the grade II deformity rate, grade II deformity percentage, percentage of child cases and Multi Bacillary cases are above or at par with national level. This is indicative of leprosy cases still occurring in the community and the detection capacity does not correspond to the level and intensity of disease occurrence. By 2005, National Leprosy Eradication Programme was integrated with General Health services. State decided to implement comprehensive leprosy Awareness and Detection Campaign in order to attain Sustainable Development Goal in leprosy by 2020 which was implemented on 2nd October 2016. A strategy was evolved to detect leprosy case among children through active search in all government/ Aided /unaided schools & also from Anganawadi after mass awareness campaign in the community. Contact survey of the detected cases and special group approach for migrant & tribal population were the other activities done to find out the

hidden cases and augment case detection. Through this SDG leprosy2020 we were able to detect 236 cases out of which 71 were child cases (report as on March 2019) . As per the epidemiology of leprosy the major source of infection in the community is an untreated case, ie a hidden case of leprosy lying undetected in the community. Early detection and treatment of the same will lead to depletion of infection in the community and also will break the transmission chain. As per the direction of Central Leprosy Division MOHFW 8 districts with Grade II deformity more than 2/ (as per the annual report March 2017) were selected for active case search â&#x20AC;&#x201C;Leprosy Case Detection Campaign (LCDC). Districts selected (Tivandrum, Ernakulam,Thrissur, Palakkad, Malappuram, Kozhikode, Kannur, & Kasaragod). Activities done prior to LCDC 1. Coordination committee for different levels, 2. Training to different Health functionaries and search team, 3. Micro plan preparation. 4. The most important part of campaign â&#x20AC;&#x201C; IEC activities to make community aware that leprosy still exists in our community and their participation. A JOURNEY

Leprosy Case Detection Campaign (LCDC)

purpose which are filled by search teams and supervisors. • After the completion of the campaign the post LCDC evaluation also carried out through independent evaluators. The most important challenge was to make people accept the fact that leprosy is still prevalent in the community and early detection and treatment are the only ways to eradicate this disease from our State in the coming years.

• LCDC as a flagship activity of NLEP is unique in its approach • Various committees are formed at each level i.e., National, State, District, Block to plan & implement the LCDC.

IEC –State level -To make people aware of the disease, the department decided to tap into their cultural imaginations.

• Intensive IEC activities, through various media before and during LCDC. • Under this Focused training of all health functionaries from District to Village level was conducted. The teams herein are being trained to have a a high index of suspicion in persons with skin lesions. .

• Leprosy Case Detection Campaign (LCDC) is fight against leprosy.

• House to house visits by a team including one Accredited Social Health Activist (ASHA) and male volunteer i.e. Field Level Worker (FLW), conducted during LCDC days as per micro-plans prepared for local areas.

• In Kerala we named our LCDC as “ASHWAMEDHAM” Leprosy Case Detection campaign. We are fighting to conquer leprosy

• Supervision of house to house search activities were done through identified field supervisors. • Continuous, systematic collection and compilation of reports is being done through the formats designed for this T H R O U G H

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1. Film actor Mohanlal, singer K S Chitra, Magician Gopinath Muthucaud and famous play back singer Shri. G. Venu Gopal have been speaking to the people about leprosy. An entire episode in “Uppum Mulakkum” a popular family entertainer telecasted though Flowers TV was dedicated to the disease.

State saw, • Football match devoted to leprosy awareness in Malappuram. A great kick start to the goal of leprosy free Kerala • Deep Sikha Rally and Cricket match by Trivandrum • Song carrying LCDC messages was written and sung by Junior Health Inspector. He performed this in all important places where people used to assemble in Thrissur. • Kite runner competition in Kannur • Hot air baloon, Kalarippayattu, Cricket match and Flash mob in Kozhikode • Traditional dance and Chendamelam in Palakkad • Ashwamedham LCDC Horse Rally in Ernakulam • Mobile LED wall showing LCDC messages in all districts.

Mic announcement etc.

Outcome “ASHWAMEDHAM” was conducted successfully in 8 districts in coordination with our Stake holder Departments – LSGD, Education, Tribal, Social Welfare , Associations like IMA, IADVL, & QPMPA and NGOs. Screening was done in 26509984 population. out of that 49313 were taken as suspected cases . 194 turned to be positive for leprosy and treatment was started for all of them (MB-129, PB-65, Child-20, Gr II deformity-15). Ashwamedham LCDC was conducted in rest of the 6 districts from April 29th (for 2 weeks) and the results are awaiting. The great achievement of Ashwamedham Campaign is that 114 persons are saved from deformities due to leprosy highlighting the adage Prevention is better than cure.

• In addition to all these innovative activities Social media highlights and forwards are breaking new ground in spreading awareness. • We also designed posters, hoardings, folders with various messages, hand book for ASHAs, Street play, skit competitions,

2. Special news bulletin on LCDC in all prominent channels

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Observations about a Flagship Leprosy Control Programme in Kerala Dr. N. Manimozhi NLEP Consultant (CLD), AIFO Director Medical Bangalore

n all the three districts evaluated it was found that all the activities planned had taken place in order and the campaign concluded.The Leprosy Case detection campaign is been carried out first time in the state – and the campaigns was named as “ASHWAMEDHAM” meaning fight leprosy and conquer, which had a positive impact for the campaign.Five blocks each from Mallapuram and Thrissur was evaluated, while Thiruvananthapuram only 2 Blocks could be evaluated due to sudden unrest in the State. Among a total of 3,476 family members of 718 respondents interviewed it was 561(16%) who were subjected to physical examination, while the rest were enquired for presence of any lesions suspicious of leprosy. It was noticed that the campaign had focused to reach people living at construction sites, locations outside of recognized settlements, mobile population, including high risk areas / underserved population in all the three districts. Most striking positive finding was that all the 718 respondents were aware of the campaign “ ASHWAMEDHAM”

“Ashwamedham”meaning fight leprosy and conquer – (which has history reference, a play and made into a movie which focused on community based spread of myths about leprosy – and the film was a box office hit in late 60’s) • There was a tremendous efforts by the Health Minister supporting the campaign – And each district had taken a competitive spirit in excelling each other • If there had been an extra effort for physical examination, there could have been an increase in the number of suspects and more leprosy cases could have been detected, is a major observation. • The strong view of the observer is that – this was one of the best LCDC programme observed, meticulous planning, execution involving most of the partners, public, celebrities and others in the programme. A commendable political commitment and involvement was clearly evident, well supported by the bureaucrat departments.

• Naming of the LCDC as

A JOURNEY

Progress towards LF Elimination in Kerala: A Success Story Dr. P.K. Srivastava

Dr Meenakshi V

Former Joint Director NVBDCP, New Delhi

Additional director Public health

ymphatic filariasis (LF) has been a major problem in Kerala as evident that Clerk in the 1709 described the elephantoid legs in Cochin as â&#x20AC;&#x2DC;Malabar Legsâ&#x20AC;&#x2122;. The first scientific study on the epidemiology of lymphatic filariasis done by M.O.T. Iyengar, during 1931 -1934 in Travancore revealed the prevalence of two filarial infections namely Wuchereria bancrofti and Brugia malayi.The control of lymphatic filariasis in Kerala was started in 1933 byestablishing a unit at Cherthala where the endemicity rate was above 48%. The unit mainly focused on control of Brugian filariasis. National Filaria Control Programme (NFCP) in Kerala: Since inception of theNational Filaria Control Programme in 1955 for control of lymphatic filariasis, 16 NFCP Units, 2 Filaria Survey Units and One Filaria Control Works Unit (Cherthala) were established in Kerala. The activities under NFCP were limited to urban areas through recurrent anti-larval work and detectioncum-treatment of patients. The burden of the disease, however,was reduced considerably over the years. These NFCP units in the State under integrated approach by National Vector Borne Disease

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Control Programme (NVBDCP) were renamed as District Vector Control Units (DVC Units) and restructured by establishing one DVC Unit in each district for entomological surveillance, filaria surveys and vector control activities. Elimination of Lymphatic Filariasis in Kerala: LF is targeted for global elimination. The resolution to eliminate LF by World Health Assembly in 1997 led the formulation of Global programme to Eliminate LF (GPELF) in 2000. The main intervention strategy is mass drug administration (MDA) with albendazole in combination with diethylcarbamazine (DEC) (or ivermectin in countries where onchocerciasis is endemic) to entire communities in districts where the prevalence of LF is equal or more than 1%, and morbidity management to alleviate suffering and prevent disability of those affected by the disease. Prior to GPELF, the piloting of MDA was done in India including two districts namely Alappuzha and Kozhikode of Kerala. However, with national launch of MDA in 2004, all the 11 endemic districts Kerala were brought under the MDA programme. With various challenges, the efforts started

showing encouraging results in Kollam, Alappuzha, Kottayam, Ernakulam and Thrissur. However, in Thiruvannanthapuram, Malappuram, Palakkad, Kozhikode, Kannur and Kasragod, the microfilaria prevalence remained above 1% in some areas indicating that desired target was yet to be achieved. By intensification of social mobilization and all required activities prior to MDA with the support of senior officers and administrators, more districts viz., Thiruvananthapuram, Kozhikode and Kannur and Kasaragod archived required target for undergoing validation test i.e.Transmission Assessment Survey (TAS). Transmission Assessment Survey (TAS): This validation tests are conducted among children of 6-7 years to assess whether the level of current transmission is below the threshold beyond which the transmission may not be possible and disease may die in due course. TASfor bancroftian infection was conducted in Kollam, Alappuzha, Kottayam, Ernakulam, and Thrissur in 2015. However, in Alappuzha, TAS for both brugian as well as bancroftian infection was conducted as some foci in the district showed Wuchereria

bancrofti and Brugia malayi infection. Further,TAS was conducted in Kannur, Kozhikode and Thiruvanathapuram districts during 2016 and in Kasaragod district, during 2017. All the above nine districts (Thiruvananthapuram, Kollam, Alappuzha, Kottayam, Ernakulam, Thrissur, Kozhikode, Kannur and Kasaragod) passed the first TAS and MDA was stopped. PostMDA surveillance activities are being carried out in these districts as envisaged in the national guidelines. Synchronizing with Sustainable Development Goal (SDG): In pursuit to achieve the goal of elimination and meet the SDG goal, during 2016 Kerala Government constituted 18 expert committees to set state specific achievable targets by 2020. This was under the guidance of Sri Rajeev Sadanandan, IAS, the Additional Chief Secretary of H&FWD, Kerala. Government also declared following 4 missions called Nava Kerala Mission based on achieving the targets of SDG. 1. Ardram Mission - directly related to health- People friendly hospital initiatives 2. Life Mission- Safe housing for all 3. Education Mission- Smart class rooms 4. Haritha Kerala Mission- Green & sustainable Environment The focus on LF elimination was prioritized under SDG No.3 which highlighted “Good Health and Well Being –Ensure healthy lives and promote wellbeing for all at all ages” especially under its target 3.3 which has indicated to end the epidemics of AIDS, TB, Malaria and Neglected tropical diseases & combat hepatitis, waterborne diseases & other CDs by 2030. In pursuit to achieve the

said goal, Kerala Government reinforced to eliminate LF from Kerala by 2020 and sustain efforts to prevent reintroduction.The main objectives are reducing Mf prevalence below 1% in all districts by 2020 and ensuring availability of recommended minimum package of care for all patients with lymphoedema, acute attack and hydrocele by 2020. Situation analysis of LF in Kerala-2017 The progress on LF elimination and current situation was being monitored by technical Directorate as well as by administrators at various level especially by Sri Rajeev Sadanandan, IAS, the Additional Chief Secretary of Department of Health & Family Welfare, Government of Kerala. Implementation of MDA in 11 endemic districts of Kerala since 2004 has shown that the overall mf rate has come down from 0.8% to 0.1% in 2014. Nine out of eleven districts have successfully cleared TAS resulting in stoppage of MDA and further to ensure no recrudescence in these areas, the second round of TAS have also been cleared in these 9 districts except Alappuzha which requires validation for two parasite W. bancrofti and B. malayi. TAS for B.malayi is only pending in this district. Third TAS was also found successful in Kollam and Kottayam districts. Third TAS in 5 districts of Thiruvanathapuram, Ernakulam, Thrissur, Kozhikode and Kannur is planned during February, 2020. The monitoring during his tenure (Shri. Rajiv Sadanandan, IAS) was so strong that slight increase of mf rate during 2015 (0.4%) in Palakkad district due to high transmission was immediately noticed. The analysis revealed various reasons for poor drug consumption, however, the alert issued resulted in improved drug

consumption than the previous years, especially in the hot spot areas. Another district of concern has been Malappuram which even with drug coverage above 65% and overall Mf rate below 1%, indicated mf rate above 1% in Thanur and Ponnani areas. These areas were considered as hot spot and under his guidance; it was decided to undertake MDA in high mf prevalent Taluks by pooling resources including HR for improved supervised drug administration. Post MDA activities have been strengthened including entomological surveillance (Larval & adult mosquito collection, Infection rate, Infectivity rate, mean mosquito infectivity etc). Migrant screening and treatment to all mf positives have been intensified. Morbidity management: The second pillar of strategy has also been intensified in Kerala and listing of Lymphoedema&Hydrocele cases are continuous process to update the data. Morbidity Management and Disability Prevention (MMDP) training conducted for 6 batches of Doctors and Staff nurses (30/ batch). MMDP Clinics were established in 82 centers (DH/ GH/THQH) in all 14 districts. MMDP training is going on in the state.Morbidity management kits are made available to the patients registered in these clinics. Training to Health workers and ASHAs for home based morbidity management is also continued in the district/sub district level.

of ELF in Kerala. Thanks are also due to State Mission Director, National Health Mission and Director Health services, Kerala for their continuous support giving boost to the programme. The technical advice and support provided to programme by Dr A.S Pradeep Kumar, the former SPO is also thankfully acknowledged. The continuous effort taken by Dr.V.Meenakshy, the present SPO is also gratefully acknowledged. The contributions done by Dr. Dilip Kumar, former Asst. Director was remarkable. Such a big campaign is successfully accomplished with the support of political leadership especially Hon’ble Health Minister which is also acknowledged with great thanks. The acknowledgement is due to all health functionaries at state, district, Taluk and periphery for their significant contribution in this endeavor. The support during evaluation by Dr.Reghu, Joint Director, NCDC, kerala Unit and during MMDP training provided by Dr.T.Suma, Prof and Head, Internal Medicine, T.D medical College, Alappuzha has helped the state in advancing on implementation of morbidity management which also acknowledged. Last but not the least, the technical and programmatic guidance provided by NVBDCP has been a great support to entire state team of Kerala during entire journey towards ELF.

Acknowledgements: Towards elimination of Lymphatic filariasis in Kerala, the personal interest, continuous guidance and innovative decisions taken by Shri. Rajeev Sadanandan, Additional Chief Secretary (Health) is greatly acknowledged and will be remembered forever in history A JOURNEY

Morbidity Management and Disability Prevention (MMDP) For Lymphatic Filariasis as an SDG Goal

The Kerala Story

Prof. Dr. Suma T. K

Prof of Medicine & Head, Filariasis Research unit Govt. T. D. Medical College, Alappuzha

Introduction

nsuring availability of the “recommended minimum package of care” in all implementation units with known cases of lymphedema and hydrocele in Kerala by 2020 1. GOAL: 100% Geographical Coverage of recommended minimum package of care. To attain this there should be at least one health facility designated for MMDP services per Implementation unit (IU). Delivery of these services should be through the health system at the appropriate level, and the services delivered should be of quality. SDG 3.8 envisages that these services should be provided under the framework of Universal Health Coverage (UHC), with the aim of ‘leaving no one behind.’

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2.2. Availability of MMDP services To have 100% geographic coverage of MMDP, each implementation unit should have at least one facility providing minimum package of care ie., lymphodema management, treatment of acute attacks (ADL) and surgery for hydrocele. 2.3. Readiness and Quality of MMDP services In addition to development of facilities, it is important that the service provided should be of good quality. It is mandatory to have an assessment of quality done in 10% of the designated facilities of the State using the Direct Inspection protocol.

2. Strategy

3. Activities:

2.1. Assessment of disease burden

To achieve the goal the most important activity considered is Capacity building. There had been developments in knowledge regarding the pathogenesis and pathology of the disease and management. In order to fill the knowledge gap capacity building is

The estimates of number of lymphedema and hydrocele cases per implementation unit (IU) is important for proper planning and to decide on the number of facilities T H R O U G H

to be provided per IU, allocation of funding, assessment of success of the program etc.

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essential. It was recommended by the Additional Chief Secretary that a team of health care providers- a doctor and staff nurse- from each Taluk Head Quarters hospitals should be given training in MMDP so that they can train others in their facility and also provide the services to the patients.

3.1 MMDP training: Director of health services and team have selected the health facilities (THQ and CHCs) from every district, including the nonendemic districts, which were included because presence of patients with LF clinical disease have been reported from theses districts.where the ‘recommended minimum package of care’ should be provided. Doctors and nurses were selected for the training from these hospitals. The training on MMDP was inaugurated by the Additional chief secretary Shri. Rajeev Sadanandan on 5th June 2017 at Govt. T D Medical College, Alappuzha. The training was given to a total of 184 health care providers in 6 batches of 3 days each by the Filariasis research unit, Govt. T D Medical College, Alappuzha Dates of training and number

of healthcare providers trained are given in table 1. The training was imparted as per the WHO certified training module which has components detailing background, clinical and Programmatic aspects of LF. The objectives of the training are 1) to understand the background, requirement and current status of global program to eliminate LF (GPELF); 2) to understand LF clinical disease focusing on Lymphedema and hydrocele, Acute attacks (ADL) and recommended minimum package of care; and to 3)know about the various aspects of the GPELF program such as situation analysis, development of health facility to impart MMDP services, assessment of quality of services, reporting of activities. The training started with a pre - test to assess the background knowledge of participants and also to assess their achievement at the end of the training by the post test. The training included interactive sessions, photo quiz, interaction with patients having lymphedema including history and physical examination and hands on training on limb hygiene measures and details of lymphedema

management. The participants were divided into groups according to their institutions and given a group work to develop a proposal to start the MMDP services at their own hospitals. All participants were very enthusiastic about this and all the groups have presented good proposals for imparting services to patients with LF. This included appraising their Superintends and DMOs about the need for initiating the MMDP services, training of the other health care providers in their own hospitals, infrastructure modifications, procurement of necessary materials for management of lymphedema and acute attack– availability of antibiotics and other drugs, antiseptic, antifungal ointments and other items and necessary materials for limb hygiene measures. Other important points discussed are IEC activities and maintenance of documents and reporting.

3.2Post training activities On returning after the training, the participants had discussions with their Superintendents and DMOs, organized training program for doctors, nurses and health care workers and carried out IEC

activities also. Government has allocated funds for the LF MMDP activities at every district and all the districts have started MMDP clinics in areas known to have patients with LF clinical disease. It is always better to get the situation analysis and assessment of disease burden done before the development of health facility to provide minimum package of care. But here proper burden assessment was not done districts before establishing the MMDP clinics. The trainees had a feeling that they have not been taking adequate care of LF patients because of the lack of awareness and lack of facilities. After the training, they have realized the knowledge gap and that with the newfound knowledge they are capable of providing quality service to the LF patents which is very easily affordable and definitely improving the quality of life of patients. The interaction with the patients and hands on training have made them more confident to manage these neglected patients and also become champions to train others so that the MMDP program could be integrated with primary health care. Through this activity 82

MMDP clinics have already started in the State as part of the SDG program and there are on an average 5 facilities per district. WHO’s MMDP program envisages integration of MMDP activities into the primary health care system of the country for its sustainability also. Kerala is the first State or the first place among the endemic countries, to achieve this. Kerala’s success in imparting MMDP services to LF patients all over Kerala is being recognized by the international community on NTD as the “Kerala story”.

Way Forward A clear and scientific burden assessment of LF disease should be carried out in all districts. Quality of the facilities also should be assessed as part of GPELF. In case of LF the recommended minimum package of care, lymphedema management, ADL treatment and Hydrocelectomy should be provided under the framework of Universal Health Coverage, through the primary health care system with the aim of leaving no one behind. To attain this, the MMDP services should be included in the essential package of services of UHC. A JOURNEY

FIGHTING TB:

Story of A Model Achiever Dr Sunil Kumar

Dr Shibu Balakrishnan

State Consultant RNTCP

Consultant WHO

n late nineties, when Revised National Tuberculosis Control Program was launched in India after a pilot test in five districts across the country, Kerala was in the forefront to join hands with the national leadership in setting high standards. It was on of the few states to achieve state-wide scale up; to have all fourteen districts implementing the revised program by early 2000. Today, the state claims to practice the best management strategies; acknowledged by national and international authorities including WHO headquarters, Geneva, with the lowest and rapidly declining estimated incidence of tuberculosis, accelerating its journey towards elimination of public health burden due to the deadly disease. While the National End TB target is to reduce TB incidence to 40/100000 by 2025, a few of Kerala districts have already moved closer to the destination. However, the journey to this stature was not seamless. Akin to the geographic terrain of the state, there were ups and downs in the program performance, but never backward. What gave strong footing to RNTCP to stand high among many national programs T H R O U G H

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across the country, are bold and farsighted decisions with locally appropriate customizations of national guidelines. One among such many, a prime decision was to integrate program implementation with general health system, against its conceptual verticality. While RNTCP had provisions to hire TU key staff like Senior Treatment Supervisors and Senior Laboratory Supervisors on contract, the state health services decided to deploy existing regular Treatment Organizers and Senior Laboratory Technicians for this purpose. Later, Medical Officers for Tuberculosis Control (MOTC) were deployed from peripheral health institutions beyond the TU headquarters, sparing the busy clinicians at HQ. These important decisions have bonded RNTCP with the general health system in Kerala while in many places it continued to be vertical for a long time providing unsolicited evidence for a limited government stewardship. The state always had the lowest TB notification rates compared to others. It raised concerns locally, nationally and internationally. In a tuberculin survey conducted K E R A L A

in 2006 with the help of NTI Bengaluru, the state government has established very low levels of TB transmission in Kerala. The highest ever TB notification (27500 cases) in Kerala was achieved in 2009. Since then the public sector notification was declining steadily with a figure of 19000 in 2018. During the same period, sale of adult anti-TB drugs in open market also has declined. In 2012, anti TB drugs sufficient to treat 17,000 patients were sold in the market; sale during 2017 was just enough for 10,000. Paediatric drug sale had even steeper decline. Pharmaceuticals reported sale of kid formulations for 16,000 during 2006, while 2017 sales figures were for 1600 indicating a decline by 90%. Proportion of TB patients with MDRTB is the lowest in Kerala. Among new it is less than 1% and among previously treated it is 3.5%. Reported recurrence is less than 5% and long term follow up confirms low recurrence. The age specific notification of TB in Kerala has shifted towards right with the highest notification rate in the age group of 55 to 65 years. There is a decline in age

specific notification by 35% below 35 years; complementing the conclusion of low transmission by the 2006 tuberculin survey. Government of Kerala has taken a bold decision in 2017 to take advantage of the declining TB burden and announce the state TB Elimination Mission with a theme of “My TB Free Kerala”. The mission is envisaged as a peoples’ movement against TB under the leadership of local self-governments. Theconsultative workshop of local, national and international experts conducted in February 2017 with support from Government of India and World Health Organization developed Kerala TB Elimination Mission strategy document to achieve sustainable development goals and accelerate impact for TB Elimination. Subsequently the government issued an order to implement TB elimination mission under the leadership of local self-governments with the theme “My TB free panchayat/ municipality/corporation”. TB elimination taskforces were formed by all LSGs for locally appropriate interventions. A few of the interventions worth mentioning.

Mapping of TB vulnerabilities of the entire population is a novel strategy that would enable the state to forecast, prevent, detect and treat TB with precision and effective deployment of resources. Complete population coverage is a herculean task, but the state health department has achieved a coverage of 87% with only a part of the urban areas spared. Early reports hint that approximately 17,00,000 individuals were mapped with various TB vulnerabilities. The state’s plan is to screen them on a quarterly basis; a novel method for active surveillance. Sooner the country would head towards diagnosis and management of Latent Tuberculosis Infection (LTBI) when the vulnerability database would enable the state to filter out individuals eligible for LTBI management. Attempts to engage private sector in fighting TB and enhance TB notification from private sector often tumble over the concerns on customer loyalty, confidentiality, complex documentation and the limited capacity of health service staff to engage with other sectors. Kerala has implemented a novel intervention called STEPS (System for TB Elimination in Private Sector) wherein all TB services including diagnosis, follow up, RNTCP drugs, contact tracing, universal DST, direct transfer of patient benefits (NikshayPoshan Yojana), household AIC kits, treatment adherence support and long-term follow up are being provided in an ‘after-sale-care mode’ by the private hospital through a single window named STEPS centre. It could enhance notification and compliance with Standards for TB Care in India (STCI and customer loyalty on the other. Early results show increase in notification and improved treatment adherence in private sector.

RNTCP in Kerala had been implemented with high level of government stewardship. Political and administrative commitment as mentioned as the first and most important component of DOTS strategy was clearly visible in each government decision. From the decision to completely integrate RNTCP with the general health system to the latest decision for phased implementation of TB elimination mission, the commitment was demonstrated to the highest degree. As the goals were reset from TB control to TB elimination, the stewardship was more visible and impactful. Kerala’s achievements were acknowledged and appreciated at national and international fora. Dr.Soumya Swaminathan, Dy. Director General, World Health Organization recently declared that the state should prepare to accelerate TB elimination activities including LTBI diagnosis and management during her visit to Kerala. Kerala TB elimination mission document is being utilized as a resource document by a few states in India and a few countries. The state is considered as a model achiever. It is a result of effective administrative and management strategies. Shri. Rajeev Sadanandan IAS, during his long tenure as the Secretary, Principal Secretary and Additional Chief Secretary to the Government of Kerala Department of Health and Family Welfare, was in the lead role to empower Kerala health system to fight TB. A visionary to lead is the key to the success of Kerala as a model achiever in the fight against TB.

A JOURNEY

Taming the NCD Dragon Dr Bipin Gopal

Assistant director & State Nodal Officer NCD

he state of Kerala is unambiguously placed at the highest epidemiologic transition zone which had exerted drastic effects on the morbidity and mortality tables of the state. The rampant urbanization and modernization which had infiltrated even to the grass root levels of the state, irrespective of the region and economic strata, influenced lifestyle of the population making the state fertile for Non Communicable diseases

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to flourish. The mortality and morbidity due to lifestyle diseases soon began to surpass those due to communicable diseases & RCH issues combined. The available studies on prevalence of these diseases indicate high trends of NCD placing the state in the top spot of prevalence chart. The study conducted by Achuthamenon Centre for Health Science Studies in 2017 was a shocking revelation into precarious position of the state with findings pointing that

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one in five of the population being diabetic and one in three being hypertensive. This along with the poor control rates and high out of pocket expenditure for the management of this diseases made Kerala the hub of Non Communicable Diseases in the country. The strategic thinking on controlling the epidemic of Non Communicable Diseases started in the first decade of this century with a handful of localized projects

and government sponsored pilots in selected districts of the state. But it was after the introduction of the centrally sponsored National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) programme in 5 districts in 2010, that a structured programme for control of NCDs was developed . The political leadership had shown a responsible stand in favour of NCD control activities on a broad frame work. It was

the visionary leadership of the Principal Secretary of Health Shri.Rajeev Sadanandan that shaped the evolution of NCD programme in the present form. With the thrust of fund allocation shifting towards NCD control form CD control and RCH, the programme gained momentum and had started spreading its wings. When the rest of country restricted the programme to the limited districts under NPCDCS, the state of Kerala expanded the scope of the programme to the entire state covering all primary health centers, Community Health Centres and Subcenters utilizing the sate plan fund money making the state the first one to implement the programme at all level of health care. The subcentres which were once on the verge of neglect were rejuvenated and soon became the focus of public attraction , with the introduction of NCD clinics and service which included NCD screening , follow up and medicine distribution.

Protocol based management was introduced for management of Diabetes & Hypertension with the help of National & State level experts . With scientific &structured programme rolling in the entire state the programme became well accepted among the general public with more than 60 Lakhs people getting enrolled as beneficiaries. Over 12 Lakhs new Diabetes and Hypertension patients were detected through camps and clinics conducted across the state through fixed clinics, camps, mobile clinics, work place intervention etc. The entire work force were capacitated with regular trainings. The programme after stablisation at the primary care level as stretched to cater the requirements of secondary and tertiary care levels. NCD clinics were established in district and sub district hospitals & special clinics to manage complications of NCDs like CVD management,

Stroke management, Cancer care, CKD management, Retinopathy management, COPD management, Diabetic foot care were also introduced. The most significant feature of Shri. Rajeev Sadanandan as the leader of NCD team was the hand picking of state, National, International experts in the concerned areas and involving their expertise for the development of each programme. As a transformational leader he also transformed the programme officers to their highest potential level to yield the optimum output to his desired level. An attempt is made to re visit his contributions in the management of NCDs through the eyes of the experts who have been supporting him hand in hand.

A JOURNEY

India Hypertension Management Initiative Prof. Dr. Suma T. K

Dr Branch Immanuel

Prof of Medicine Govt. T. D. Medical College, Alappuzha

Background of the initiative: More than 200 million adults in India have high blood pressure, yet just 1 in 7 has their disease controlled. Studies suggest that in rural areas in India, only one quarter of people with hypertension are aware of their condition, and only around 10 percent have their blood pressure controlled. In urban areas, around 40 percent of people with hypertension are aware of their condition, and only around 20 percent have their blood pressure controlled. In order to meet the Government of India target of a 25% relative reduction in the prevalence of raised blood pressure by 2025, it is estimated that approximately 5 crore additional people will need to have their blood pressure effectively treated.

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CVHO

With the increased prevalence of Hypertension and reduced control rates, State of Kerala adopted the India Hypertension Management Initiative. Hypertension is a major public health problem in India. According to WHO estimates, the prevalence of hypertension in adults aged 18 years and above in India was 22.9% during 2010, and had gone to 25.4% in 2014. Hypertension is a silent killer leading on to cardiovascular disease, cerebrovascular disease, chronic kidney disease and other serious vascular problems. K E R A L A

Realising the importance of this issue the Additional chief secretary Shri Rajeev Sadanandan had discussions with Director General, ICMR and vital strategies during August 17.The objective of the initiative was to improve hypertension control rates among people with hypertension , by managing them at primary health care level. . The 5 essential components of this initiative are use of standard drug and dose specific algorithm for management of hypertension; ensuring the regular and uninterrupted supply of quality assured medications; task sharing like health workers who are accessible to patients can distribute medications already prescribed by the medical officer;Use of other patient-friendly approaches such as easy access, 3-month prescriptionsfree drugs, BP measurement at the subcentre or by ASHA etc., and also implementation of monitoring systems and documentation systems that will give reliable, timely information on the hypertension control rate in order to measure progress. As per advise and initiative of the additional chief secretary

the first step was to develop the standard algorithm for management of hypertension to be used at Primary health care in Kerala. A consensus workshop was held under the chairmanship of ACS on September 19, 2017. The members present for the workshop were the experts and heads of departments of Medicine and cardiology of various Medical colleges of Kerala and other experts, external experts from other States, doctors from primary health care and members of NCD team, Govt. of Kerala. The workshop was attended by representatives of WHO and vital strategies also. After deliberations an algorithm for management of hypertension with just three specific antihypertensive at different doses was prepared.

India Hypertension Management Initiative (IHMI) In November 2017, Ministry of Health and Family Welfare (MoHFW), Government of India and Indian Council for Medical Research (ICMR) officially launched the India Hypertension Management Initiative (IHMI). The IHMI is a collaborative project of MoHFW, ICMR, WHO, State Governments and Resolve to Save Lives Initiatives of Vital Strategies. Its main goal is to reduce the morbidity and mortality due to cardiovascular diseases (CVDs) by improving the control of high blood pressure. The project also aims to strengthen the cardiovascular disease component of the National programme for Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS). In Kerala,

IHMI aims to improve the quality of the hypertension management through effective diagnosis, treatment and monitoring of hypertension in primary care level.

Implementation of IHMI project: Government of Indiahas selected four districts (Thiruvananthapuram, Thrissur, Kannur and Wayanad) to implement IHMI. Each district is provided with a cardiovascular health officer (CVHO) and four Senior Treatment Supervisors (STS) covering 120 facilities. The idea was to implement screening, early diagnosis and management of hypertension at the PHCs/ FHC level and then to roll it over to other levels of health system including tertiary care centers.

The plan: Screening for hypertension: Hypertension or raised blood pressure (BP) is defined as systolic blood pressure equal to or above 140 mmHg and/or diastolic blood pressure equal to or above 90 mmHg. The screening is done with different methods. 1. Population based screening Screening for Hypertension in all individuals aged ≥30yrs at all PHCs/FHCs of the selected 4 districts ASHA workers/JPHN should do house to house visit and those people found to have BP >140/>90 mmHG will be sent to nearby FHC/PHC for diagnosis of hypertension. Medical camps and Camps at workplace to be orgnised by JPHN/ASHA in consultation with medical officer to cover the population of the area. 2. Opportunistic screening

All patients aged ≥18yrs attending the hospital for any reason should be screened for hypertension by checking the BP. If the BP is found to be >140/90 mmof Hg, the patient should be sent to the medical officer for diagnosis of hypertension. Those with normal BP should be checked at least once an year.

Diagnosis Hypertension is diagnosed when Systolic BP ≥140 mmHg and/or diastolic BP ≥90 mmHg on two different occasions 1-4 weeks apart.

Management: Management of hypertension is as per the algorithm developed during the consensus workshop. As per the algorithm there are only 3 drugs, Tab Amlodipine 5mg, Tab. Telmisartan 40 mg and Tab Chlorthalidone 12.5 mg. The procurement of these drugs are given priority.

Capacity building: To implement the process the important requirement was training of all the stake holders including medical officers, nurses, health care workers, pharmacist and others. The program is going on in all four districts with the unflinching support and the constant guidance from the Additional chief secretary Shri. Rajeev Sadanandan. The hard work and coordination by the Medical officers, nurses, and other healthcare workers are commendable which are ably supervised by the DMO. The CVHOs and STSs also involved in full strength to make the program a success

Services under the Initiative: • All patients 18 years and above visiting any PHC or CHC is subjected to BP measurement • Patients whose BP values are more than or equal to 140/90 are referred to Medical officer for treatment initiation, in which lifestyle modification is the first modality of treatment followed by pharmacological management as per the decided treatment protocol. • Patients initiated on treatment are registered under the program with a Treatment card maintained for every patient at the facility level and a patient pass book at the patient level.

• Details of Patients registered with treatment card are documented in a Hypertension facility register to facilitate cohort monitoring after 6 months of treatment initiation. • Cohort monitoring of patients registered under the Initiative after 2 quarters of registration and treatment initiation. • Identification of defaulters and ensuring tracking of defaulters through field workers. • Regular supportive visits to Health facilities and on-site capacity building from CVHO and CVH-STS to ensure smooth implementation of the program. • Regular reviews by ACS and State Nodal Officer-NCD.

Preliminary results of the program. District

Controlled

Uncontrolled

Defaulters

Wayanad

34.4

29.1

36.5

Thrissur

36.1

37.3

26.3

Kannur

45.8

36.2

18.0

Thiruvananthapuram

35.1

40.2

24.8

Way forward The preliminary results are not optimal we have to assess the training needs of all stakeholders and necessary training should be imparted. Improvig the health education to patients and relatives in various ways to make awareness regarding the importance of control of hypertension

A JOURNEY

State Nodal Officer NCD recieving the recognition for IHMI Programme as the Best and Replicable Practice at National Summit, Kaziranga

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Message From Thomas R. Frieden, MD, MPH 100 Broadway 4th Floor New York, NY 10005 T +212-500-5725 www.resolvetosavelives.org

t has been a distinct honor to work with Shri Rajeev Sadanandan over many years. His tireless contributions to public health span everything from tuberculosis control to hypertension treatment. His passion and dedication to implementing programs, not just on paper but in reality, has led to lakhs of lives saved and improved. Most recently, I have had the pleasure of interacting on the India Hypertension Management Initiative (IHMI). which was launched in November 2017.Kerala was one of the initial states to launch this program. One of the reasons Kerala was chosen to launch the IHMI in South India was the dynamism and sense of urgency that Mr Sadanandan would bring to the programme. He was quick to see the value addition that this programme would bring to the State that already had an NCD control programme. The IHMI has been recognized and shared as a best practice by the Government of India, and Mr. Sadanandan has been a key driving and supportive force for progress of this program in Kerala. During 2018, the IHMI programme had two interruptions â&#x20AC;&#x201C; the Nipah virus outbreak and then the devastating floods. We read in the news reports how efficiently the outbreak was contained and health relief was mobilized rapidly to reach the affected population. The IHMI programme was back on its track much sooner that we had expected. This is eloquent testimony to his deft handling of public health crisis with mission-like approach. I thank Mr. Rajeev Sadanandan for his many valuable years of service, and wish him well in his future endeavors. Sincerely,

Thomas R. Frieden, MD, MPH President and Chief Executive officertfrieden@resolvetosavelives.org

A JOURNEY

Message From Dr. Salim Yusuf, DPhil, FRCPC, FRSC, O.C

KIRAN

Palpating The Vague Underlying Burden Dr Bipin Gopal

Dr Vijaya Kumar K

Assistant Director & State Nodal Officer NCD

Former HoD, Dept of Community Medicine, GMC Trivandrum

ven though there is a vivid picture on the catastrophy due to the rising NCDs in the state, there still is an obscurity regarding the prevalence of these diseases and its leading risk factors. This is basically due to the heterogenic characteristic of the population and the multivariate etiology of these diseases. The prevalence studies done to determine this burden in the state threw some light in to the facts, but the actual pictures needs more clarity as the sample size and proportionate representation of the population was limited. The estimation of the underlying disease burden is inevitable for health planning and allocation of resources based on the disease burden.

in this field was conducted and finally an epidemiological study in the form of observatory was designed with the technical support of the renowned , global, public health expert Dr.Salim Yusaf of McMaster University, experts from Achutha Menon Centre for Health Science Studies, Community Medicine Department Medical College Trivandrum, KUHS etc. Even though a successful pilot study was conducted, the report remained unpublished as the project was abandoned due to some unfortunate controversies. The Additional Chief Secretary shouldered the responsibility of getting through these issues and pitched back to proceed the study in 201819, entrusting Achutha Menon Centre for Health Science Studies to lead the study. Thus the mammoth study -KIRAN (Kerala Information on Residence Arogyam Network) was coined, which is expected to display the first glimpse into the real picture of NCD burden 2019-20.

In 2013 the Principal Secretary to Health Shri. Rajeev Sadanandan voiced the importance of developing a health observatory by doing a systematic surveillance of a representative population covering all districts, which is potentially enough to bring out the existing prevalence and the risk factors of the population. A series of discussion with the experts T H R O U G H

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May 22, 2019

would like to wish Rajeev Sadanandan the very best on his retirement from the Government of Kerala.

I was introduced to Rajeev about 5 or 6 years back and I was struck by his dynamism, open-mindedness and his deep desire to do good and constructive things to improve the health of people in Kerala. His very direct and no-nonsense approach has not only been effective, it has certainly earned the respect of many people in Kerala and beyond. We were first introduced over the phone when I was visiting India and he asked me why I had not done more in Kerala and I indicated that to work with the government I needed a reliable partner within the government. He immediately offered to work with me and the Population Health Research Institute (PHRI) to develop programs to help Kerala. One of the biggest challenges that Kerala faces is the lack of proper health information, details on the health behaviours, as well as their impact on people’s health. Having such information makes a huge difference to health policy, location of resources, deployment of physicians and other health workers, as well as prevention – all of which are critical to improve the health of people of the state. We jointly came up with the idea of a state wide large, representative survey that would serve the Government’s needs to improve the health care of Kerala. This would form the foundation and improve future health strategies and investments. I don’t have to say that while the idea was met with considerable enthusiasm from academic leaders and medical leaders in Kerala, there was some unfortunate obstacles put by some individuals with little interest in improving the health of the people. Nevertheless after several years these obstacles have been overcome with the support of senior Ministers within Kerala, senior leaders in the Government of Kerala and the able leadership at the Achuta Menon Centre in Trivandrum under the leadership of Dr. Asha and Dr. Raman Kutty. It is gratifying that this very important survey is well underway due to the able capabilities of Dr. Pradeep, Dr. Vijay Kumar, Dr. Thankappan and Dr. Bipin Gopal. I am optimistic that Rajeev Sadanandan’s successor will carry on his good work and will if anything build on it and enhance it. In this regard it is my hope that the state wide survey will provide a platform for evidence-based health policy for the entire state for a long time to come. I look forward to continuing to contribute to improving the health of people in Kerala, supporting the Government and working with the excellent colleagues at the Achuta Menon Centre. At a personal level I have always enjoyed my social and personal interactions with Rajeev and I know we will continue to keep in touch and hopefully work together in the future. Rajeev, the people of the State of Kerala owe you a great deal of gratitude for your tireless and selfless efforts. For the few of us who are fortunate to have worked with you, we will always carry with us deep admiration and respect for your tireless efforts. Thank you. Best wishes for your transition into new roles and I am sure they will be successful.

Dr. Salim Yusuf, DPhil, FRCPC, FRSC, O.C. Distinguished University Professor of Medicine, McMaster University, Executive Director, PHRI, Chief Scientist, Hamilton Health Sciences, Heart & Stroke Foundation/Marion W. Burke Chair in Cardiovascular Diseases Past President, World Heart Federation I N

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KIRAN- A Unique Project to Support Long Term Health Planning for Kerala

Dr. V Raman Kutty M D, M Phil, M P H(Harvard), FIACS Professor Emeritus, AMCHSS, SCTIMST

he Kerala Information on Resident’s Arogyam Network – KIRAN for short, is a project which attempts to collect information on one million residents of the state, which will serve as a baseline for tracking the residents’ health over the long term. Most advanced countries have periodic health surveys which generate information on a large sample of residents. This is used as a resource for planning, as well as for assessing the progress of the health status of the citizens. The US and Korean health examination surveys are examples. These surveys also serve to identify trends of the

emergence of unusual diseases or new health problems. Though at the national level we do have surveys that capture health information such as the NSSO and NFHS, Kerala has a unique health profile which is more similar to more industrialized nations. More people die from NCDs such as heart disease and diabetes in Kerala than from the infectious diseases. Thus, we have problems which are distinct, and these need to be identified early and tracked. KIRAN is a project that fulfills this task. KIRAN was conceptualized and initialized during the tenure

of Sri Rajeev Sadanandan as health secretary. He had a great role to play in getting health experts from different organizations to get together and come up with a workable plan. Though it went through many initial hurdles, it has taken off recently, and about a third of the field work has been completed. The project is supported technically from the Achutha Menon Centre for Health Science Studies of the SCTIMST; the field work is done by staff of the Kerala Health Services department, with the help of the e-health initiative. Sri Sadanandan also has tried through his good offices to get technical and

statistical support for the project from internationally acclaimed experts. The information from the KIRAN project, which could be put to good use in the future for planning health services in the State, is a major initiative of the Kerala Health Services Department

A JOURNEY

DIABETES CONTROLMelting the Sugar Berg Dr R. Chandini

Dr Bipin Gopal

Prof. Dept of Medicine GMC Kozhikode

Assistant director & State Nodal Officer NCD

Kiran Kesav

ASTRA ZENECA

Dr. Rontgen Saigal Regional Coordinator NCD

360 Metabolic Centre Of Excellence At Government General Hospital Ernakulam

iabetes is a chronic disease that requires continuous medical care and ongoing patient education to prevent acute and chronic complications. Optimal glycemic control is the main stay of diabetes management and critical to controlling disease progression which may otherwise lead to micro and macro vascular complications. A patient centered approach that takes into consideration individual patient needs, preferences, disease state are pivotal to better patient outcomes. The traditional methods of caring for Diabetic patients have their shortcomings, as have been discussed earlier. The percentage of patients who are aware they have diabetes, and are uncontrolled (HbA1c > 7.0%) are different as reported by several studies, varying from around 57.6% to as high as 66.7% [6] and 70% . In India, with our diverse and large population and varying levels of access to healthcare, it is typically

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the access and affordability of medication that are blamed for our poor health indices. In this light, a holistic, 360⁰ care for Diabetic patients can help in ensuring the right medicines is combined with the right care to achieve treatment goals. This 360⁰ System of Care has been modelled under a single roof, has been inaugurated by the Hon Minister Smt K K Shylaja Teacher and is fully functional at Govt General Hospital, Ernakulam.This center of excellence at Government General Hospital Ernakulam cater the need for hundreds of NCD patients every day.The Center of Excellence (COE) has been established as joint partnership between AstraZeneca, Directorate Health Services (DHS), Kerala and General Hospital, Ernakulam in 2018. As part of the partnership, AstraZeneca provides state of the art infrastructure at the hospital for comprehensive management of Type-2 Diabetes patients. The main objective of establishing the COE was to address unmet needs K E R A L A

of diabetes patients with regards to access of medical facilities for early diagnoses, appropriate treatment and prevention of complications. The center primarily receives patients who have been referred from the Medicine dept. at the hospital while some patients are also direct walk-ins.

The Concept has been Outlined in the Sections Below. a) Components of the 360⁰ Metabolic treatment centre The main components of the centre are as below: i. Treatment protocols and practices Standardised treatment protocols approved by leading diabetic experts and bodies, that will help patients get the best treatment ii. Hardware and devices to diagnose and treat patients

Equipment and in-house diagnostics to accurately measure patients’ progress and aid better treatment, which may include (but not limited to) Blood Glucose monitors, HbA1c tests, Body composition and fat analysers. iii. Cross functional treatment team Treatment goals would have to be holistic as well, and look out to not just treat the disease. This is where physicians and support staff / nurses can play an important role to help patients achieve their treatment goals. They can be enabled by providing adequate and appropriate training, either in private setups or by agencies that specialise in such training. They could compose of: • Physicians- primary care are responsible for Monitoring Patient health and Pharmacologic decisions, formulating personalized Treatment plans including daily glucose monitoring and how to

take insulin injections etc. • Specialists are responsible for Comorbidity Management (such as nephrologists, neurologists, ophthalmologists among others depending on the patient’s comorbidity profile) • Entities like Certified Diabetes Educators if part of the team can lead the Patient support, self- management and education using relevant tools and techniques • Nutritionists and Dieticians help draw Personalized nutrition plans • Fitness experts help drive maintaining an Active and healthy lifestyle [15] iv. Technology to drive and track patient performance • Technology is a great enabler when it comes to healthcare and its benefits can be maximised in the Metabolic centres. This can be done by:

• Uniquely tagging and tracking a patient’s progress – along with her vitals and other factors mentioned above, so that informed treatment choices can be made • Having personalised appbased coaches and monitors on smartphones that will again help patients stay healthy, as well as monitor things like their diet, calorie intake, exercise, medication adherence and compliance. b) Patient Journey in the Metabolic centre, and major differences With the above factors to help enable better treatment, the experience of the patient and her journey in the Metabolic centre will be different from a regular visit to the doctor. A typical visit to the metabolic centre may look like this: The main points of difference from a conventional way of treatment are:

• Ability to digitally track patients’ history and progress centrally for all patients • Qualified professionals who can educate and counsel patients at the centre • Treatment practices that are recognised and validated by experts • Readily available diagnostic facilities to find out the current status of old patients, and to quickly diagnose new patients suspected of being diabetic • Advanced and better data points to risk stratify and qualify patients for the right treatment • A digital solution to handhold a patient after the visit to the Metabolic centre, and remind them of their treatment goals, medication timings and continuously monitor progress c) Outcome improvement There is a growing body

After signing a historic document Sri. Rajiv Sadanandan with Mr. Gagan Singh, Mr. Atul Tandon, Mrs. Lucy Dance, Mrs. Jayasree Mapari, Mrs. Varsha M Das, Mr. Kiran P Kesavan of Astra Zenica and Dr. Bipin

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of research from across the globe comparing conventional diabetes management to a multidisciplinary approach. A few more outcome-related benefits of the program are as below: i.

Better informed patients, physicians and treatment decisions

ii. Enhanced Quality of Life iii. Reduced burden on patients and infrastructure Providers at such 360â ° Metabolic clinics could offer diabetes care and education options in a â&#x20AC;&#x153;menuâ&#x20AC;? format for patients, and steer them toward the appropriate treatments, diagnostic tests, and education based on their individual needs. With an increased understanding of the pathophysiology of diabetes and the mechanisms through which their therapies work, patients can have more say in, and ownership of, their treatment decisions thereby leading to better disease management and outcomes.

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Total of 4240 patients visited the clinic with a section visiting only for physiotherapy or dietary counselling. In the given population segment, higher proportion of female patients (2450) attending the clinic was observed compared to male patients (1790). In addition, the proportion of patients with a past-history of either Diabetes (DM), Hypertension (HTN), Dyslipidemia (DLP) was higher compared to those who were undiagnosed (3050 vs 1190). Of the undiagnosed cases, around 11% were diagnosed as new diabetics while the remaining were either normal or having other unrelated co-morbidities. In addition, it was observed that 1739 (40% of total cases) received dietary counselling while 815 (approx. 20%) of the patients received physiotherapy training. Average age of patients attending the clinic was approximately 56 years while the BMI was around 25. Hence, the average patient attending the clinic was usually middle-aged, overweight and with past-history of diabetes or related morbidity.

Management Algorithm for Diabetes Mellitus for The State of Kerala Focusing On the Primary Care R Chandni

HoD Emergency Medicine, Govt Medical College Kozhikode

s per the directions of Additional Chief Secretary (Health) Sri. Rajeev Sadanandanan algorithm was designed to addressthe issues which is cost effective and to reduce the number of drugs so that the supply would be continuous. There were one external and 30 internal members including doctors from PHCs to tertiary care centres. Later diabetes program was also included in the population based screening program and a state level ToT was conducted on population based screening of NCD from 1st February to 6th February 2018.

“Step Wise Approach to Airway Diseases (SWAAS)”: A structured Programme for COPD Control Dr Sanjeev Nair

Associate Professor Dept Pulmonary medicine GMC Trivandrum

on communicable diseases (NCD) are responsible for a considerable proportion of premature deaths in India. Obstructive airway diseases were poorly addressed among the NCD in India even though COPD is the second leading cause of mortality in India (GBD 2017). In addition to the mortality caused by COPD, it is also responsible for huge burden of morbidity, being the second leading cause for DALYs in India. Asthma is the twelfth leading cause of mortality in India. The burden of COPD (as measured by chronic bronchitis) is 3.5% in India as studied in INSEARCH study, whereas the burden in Kerala in the same study was 10% which ranked Kerala as the state with the highest disease burden. The 2017 burden estimates place Kerala as the fifth leading state in India in terms of COPD prevalence with a rate of 4.6% (5.7% in males and 3.7% in females) but when Asthma and COPD are taken together, then Kerala has the highest burden of disease in India (both together 9.4% in males and 7.9% in females). In the recent past, the National NCD Program decided to include COPD as one of the prime NCD to be addressed. Kerala was the first state to address Chronic

Respiratory Diseases as a public health program when it pilot tested the PAL strategy in a block area in Kollam district in 2014. However the PAL strategy was a sub-component of the STOPTB strategy and was piloted as a sub-component of the TB control program, with limited infrastructure, treatment services or reporting. A preliminary analysis showed that this strategy resulted in reduced use of antibiotics and steroid injections in the PHCs where this was implemented but its impact on COPD and Asthma was not clear. It was in this context that the State Health Ministry started formulating strategies to achieve the health targets of the Sustainable development goals. Under the leadership of Sri. Rajeev Sadanadan, efforts were initiated to set targets for Kerala for SDG and develop strategies for achieving these targets. Among the diseases identified was COPD. As a result of a series of consultative meeting, the first Public Health Program for COPD in India, the SWAAS Program – The Kerala COPD prevention and control programme evolved. The program aimed at identification of COPD in early stage of the disease and initiate preventive strategies, including

Dr M S Manu

State co-ordinator SWAAS

smoking cessation and to develop a structured programme for diagnosis and treatment at all levels for COPD and Asthma. Guidelines for the program were developed after consultative meetings with all stakeholders. After training of doctors and nursed, selected FHCs were provided facilities for diagnosis of COPD/Asthma by screening for symptomatic and performing mini-spirometry. Inhaled drugs were provided for a guideline based use; and pulse oximeters, nebulisers and oxygen concentrators were made available. Non-pharmacologic management including smoking cessation and pulmonary rehabilitation was also provided

compliance. Diagnosed patients were registered and followed up at regular intervals. Special campaigns were organised for increasing community awareness and interventions. Secondary and tertiary care centres were also strengthened for referral services. Of 10,123 patients screened in last 6 months, 5098 new cases of COPD were detected and put on guideline based interventions. SWAAS as an ideal model has shown that prevention, screening, diagnosis and treatment of COPD, one of the future epidemics, is feasible even at primary care level, another contribution to India by Kerala health System .

In the first phase, the programme has been implemented in 100 primary health centres covering population of 4,000,000 and 39 secondary and tertiary care hospital. About four hundred doctors, 400 staff nurses and multipurpose workers were trained on diagnosis and treatment of COPD. Trainings & capacity building focused on Tobacco cessation, prevention of indoor and outdoor air pollution, use of clean fuel, occupational health, performing spirometry inhaler technique, pulmonary rehabilitation and medication A JOURNEY

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CANCER CARE In Tussle with the Crab Claws Dr Bipin Gopal Assistant director & State Nodal Officer NCD

ancer continues to be the major killer in the state with more than 55thousand new cases getting reported every year. Efforts to demystify the myths about the disease have not etched out the fear and apprehension among the people about the disease. In the early decade of this century the treatment facility in Government sector for cancer was limited to 2 Regional Cancer centres at Thiruvananthapuram and Kannur along with 5 Government Medical Colleges. This had created difficulty in people residing at other districts as they had to travel a long distances for getting service which had affected them physically, financially and emotionally.

Since the cost of treatment in private sector was extremely exorbitant, the patients either had to discontinue treatment or forego all their belongings for uncertain management leading to the soaring of death rates due to cancers. In 2012-13, then Principal Health secretary Sri Rajeev Sadanandan designed a new model for cancer care which shattered the conventional beliefs in public health management even though it raised a lot of apprehensions. The idea was to decentralise the cancer management from the highly specialised sector to the lower levels of Health care by training the existing doctors in Health services on comprehensive cancer management. Winning the

confidence of Dr Paul Sebastian Director RCC and Dr Satheesh Director MCC, he pushed the project forward setting up district cancer centres in all districts using plan fund of Cancer care program. Committed doctors were trained at RCC and MCC on comprehensive cancer management including chemotherapy. In order to avoid hiccoughs in the initial run only follow up chemotherapy was offered through these centres. The rest is the dawn of a new era in cancer management as slowly cancer management including chemotherapy started in district centres giving a huge sigh of relief to hundreds of patients.

Now District Cancer care centres are functional in 23 institutions across the state and already more than 62000 chemotherapies have been given along with other supportive services like ascetic fluid tapping, blood and blood product transfusion etc. This has also reduced the unnecessary rush in the tertiary care centres. More than 3400 new cancer cases were detected through these centres which had marked 94% accuracy. This was followed by setting up day care chemotherapy wards in all District Hospitals which is another feather in his ever glowing cap.

DCCU DH Mavelikkara

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Taking Cancer Care To The PeopleGovernment of Kerala’s Vision For Distributed, Decentralized, Digitally Connected Cancer Care Model Dr. Moni Abraham Kuriakose

Director, Cochin Cancer Research Centre

In May 2018, under the stewardship of Sri Rajeev Sadanadan IAS, Additional Chief Secretary of Health and Family Welfare, Government of Kerala, for the first time in the country, released 2030 vision for cancer control. The primary targets were (1) Reduce the incidence rate of cancers amenable for prevention and early detection (cervix, oral and breast) to 15% and (2)Improve 5-year cancer survival to 70% for cervix, 65% for breast, 60% for oral and 50% for colorectal cancers by 2030. This needs a strategy that takes into consideration the prevailing health care system and health seeking behaviour of the Kerala population. Traditional method of managing cancer through establishing large comprehensive cancer centers are ineffective in developing countries. This is attested by the exponential increase of cancer of the state of Kerala during the past decade from 74 to 135 patients per one lakh population and cancer related mortality, which is one of the highest in the country. These larger cancer centers become victims of their success and attract increasing number of patients from distant places, overstretching the resources and increasing out-ofT H R O U G H

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pocket expenses for the patients. Increasing the number of cancer centers also is not effective as each unit by itself will not have the critical expertise to offer comprehensive cancer care. In addition, for sustainability and improved resource utilization, the cancer care needs to be integrated with the existing health care system.

serve as ‘community cancer clinics’. They offer diagnostic services, palliative and supportive care including palliative daycare chemotherapy. The Level 4 units are established as part of the primary and family health centers which provide the important task of cancer surveillance and improving cancer literacy for the public with people’s participation.

Government of Kerala is implementing an alternate, innovative model for distributed, decentralized cancer care that is integrated with the existing primary healthcare system, which was conceived by the Additional Chief Secretary of Health and Familywelfare. This is expected to meet the 2030 cancer control vision of the state. The distributed cancer care network propose to stratify cancer care in four levels. Level 1 would be three apex cancer centers with most advanced infrastructure and serves as quaternary centers and coordinate cancer care in three zones and focus on research and manpower development. The Level 2 cancer centers established at medical colleges and cancer centers in major private medical hospitals offer comprehensive cancer care and serve as tertiary cancer referral centers. Level 3 centers are located in the district and taluk hospitals,

These independent functional units and activities, unless coordinated, will not be effective. The government propose to constitute an apex cancer control body for the coordination of cancer care. In addition, integration of cancer care with the digitally connected health care system which is being rolled out through the e-health mission will improve the efficiency in the logistics of care delivery. The expected outcomes are down-staging of cancer, developing a resource stratified referral pathway that minimize treatment delay, ensure that the patients receive guidelines-based cancer care and more importantly provide cancer care within 90 minutes of travel and therefore lowering out-of-pocket expenses.

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CANCER CONTROL

Malabar Cancer Centre Dr. Satheesan.B

Director, Malabar Cancer Centre

is contribution to the growth and development of MCC is spread across the wide spectrum of empowerment to facilitation of implementation. The real essence of the title “autonomous institution” was demonstrated under his chairmanship of executive committee. The nobudge attitude resulted in cancer control strategy document. The keenness and the perseverance with which Standard Treatment Guidelines is developed is another example of administrative brilliance. The selection interviews we attended together were a training session for me and selection of quality staff under him really helped the institution to grow to this extent today.

Message From

Director RCC

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Integrating Non Communicable Disease (NCD) Control Program With Reproductive And Child Health Services (RCH) Dr Sivasankaran. S

Professor of Cardiology, SCTIMS&T, TVPM

here is a high incidence of obesity, diabetes and hypertension in Kerala and India1-3. In the last decade the incidence of obesity, hypertension, and diabetes between the ages of 29 to 36 years were 2%, 2-4% and 0.5 to 1% per year among women and men respectively. 2 25% of the Kerala population is now in the age group of 15 to 30 years and will be 30 to 45 years of age in the year 2030. The high incidence of asymptomatic non-communicable diseases (NCDs) in this age group has to be factored in the NCD control program. Approximately half of this population, being women in the reproductive age group can be covered in the reproductive and child health programs of the state health services. Gestational diabetes, and hypertension not only lead to neonatal problem but also is the fore runner of future cardiovascular disease in the

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mother and earlier onset of NCDs in the offspring.4 Recognition of life cycle approach for prevention of noncommunicable diseases gives a good window for evaluating the outcome of the control program by integrating the same with the well-established reproductive and child health services in Kerala. 1 Currently the prevalence of noncommunicable diseases in women in the reproductive age group is substantially high in Kerala with 15 to 20% prevalence of gestational diabetes,5 and 6to 12% prevalence of gestational hypertension. Polycystic ovarian disease(PCOD), yet another disease of civilization affects at least 10% of the adolescent girls in Kerala and is the commonest cause of infertility in the state.6 One third of the women in the reproductive age group in Kerala are obese, and vitamin D deficiency is universal.

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Hence effectiveness of implementation of control programs to targets (women and children) from the beginning, if proposed, (like the fat taxes, banning of junk food sales in and around schools and increasing physical activity in children, adolescents and young adults, facilitating health diet) can be evaluated at the comprehensive reproductive and child health data of our health services. Successful implementation of the control program should reflect as a decline in prevalence of gestational diabetes and hypertension and polycystic ovarian disease, and pre-gestational obesity in women, which have shown a clear increase in prevalence in Kerala over the last 3 decades. Further targeting the NCD control measures through the RCH program will have a mass appeal, good compliance and better penetration to family as a whole, especially in targets of good

diet and physical activity. Hence following targets are suggested which aims at approximately halving the current prevalence of these problems in prospective mothers. Achieving healthy parenthood should be slogan for this mass movement 1. Reduction in overweight and obesity in prospective mothers by 15% by achieving BMI<25 2. Decline in gestational diabetes to less than 10% of the mothers visiting antenatal clinics 3. Decline in gestational hypertension to less than 5% of the mothers visiting antenatal clinics 4. Decline in polycystic ovarian disease in adolescent girls to less than 5% in community or college surveys.

Crusade Against Transfat and Salt Dr Bipin Gopal

Dr Indu PS

Assistant director & State Nodal Officer NCD

HoD Community Medicine GMC Trivandrum

ravelling from North to the southern end of Kerala you can find the array of bakeries, restaurants, and street vendors with flocks of population rushing to grab their piece of mouth lingering food ,the new found dine culture which has eventually pushed the population to the pool of lifestyle diseases . The villain in the processed food is the form of additives, preservatives, fat, salt and trans fat, out of which trans form of fat is more dangerous and needs to be limited or excluded. Many countries have taken bold steps to control Trans fat from their processed food and healthy campaigns have encouraged food

manufacturers to produce food which are marketed as trans fat free. FSSAI has introduced a restriction for Trans fat below 5 % which is now amended to 2% lately but study on the locally and commonly available food in the country has shown the trans fat component up to 40%. It was ACS Shri Rajeev Sadanandan sir who took the initiative to control the trans fat and salt content in the processed food in the state. He entrusted the State NCD cell, Community Medicine Department and Food Safety authority to do a brain storming with the experts in the field of nutrition. Through his personal connections he engaged

the World Bank team, WHO, Vital Strategies and FSSAI who were already working in this direction to guide the state in this sector. The sate NCD cell arranged the consultative meetings which were chaired by the ACS and enriched by the presence of Experts including Dr Suresh Mohammed, Dr Eram S Rao, Dr. Rajani Chopra from WB, Ruchitha Guptha from WHO, Dr Roopa Shivsankar from Vital Strategies, Dr Swathi Bhartwaj from FSSAI participated in the meeting along with experts from the state .

demonstration workshop for all stake holders was also conducted to educate the industry on alternatives of trans fat. An yearlong action plan was developed and food safety authority jointly with Health department are moving ahead with activities as per the action plan.

This was followed by a sensitization workshop for Hotel owners. Pickle and food manufacturers and later a

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‘Fat Tax’ and Elimination of Transfat Kerala’s Unique and Innovative Interventions to Reduce NCDs

nder the proficient leadership of Shree Rajeev Sadanandan, the Government of Kerala has taken numerous measures to tackle noncommunicable diseases (NCD) in the state. Shree Rajeev Sadanandan had a great foresight to include primary prevention strategies such as ‘elimination trans fats in foods’ in the state’s NCD control measures. As in all preventive efforts, the impact of the efforts to eliminate trans fats will be seen many years later. This did not deter Shree Rajeev Sadanandan to take such measures at the tail end of his tenure.

Senior Health Specialist, The World Bank, 70 Lodhi Estate, New Delhi.

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Sadanandan as Additional Chief Secretary of the Health and Family Welfare Department and is a testimony to his foresight and vision. Though the ‘Fat Tax’ got subsumed within the overarching national tax policy reform of Good and Services Tax (GST), it succeeded in bringing focus on the role of fiscal policy in reduction of high fat, salt and sugar in the diets of people. The World Bank documented the evolution and implementation of ‘Fat Tax’ in Kerala as part of its Global Obesity Study. The efforts to reduce transfat by the Kerala Food Safety Commissionerate and the Kerala National Health Mission have picked up momentum in the past one year under the able leadership of Mr. Rajeev Sadanandan. A K E R A L A

Dr Roopa Shivashankar

Dr. Suresh K Mohammed

he increasingly high burden of noncommunicable diseases (NCDs) poses a significant challenge to the great success that Kerala has achieved in human development in the past many decades. The Government of Kerala responded to the challenge of NCDs through a multi-pronged approach. One of the innovative interventions of Kerala to control NCDs was the introduction of ‘Fat Tax’, a fiscal policy that aimed to disincentivize consumption of unhealthy foods by levying an additional tax. Another unique strategy focused on voluntary reduction of transfat by bakeries, restaurants, hotels and other food manufacturers with the aim of eliminating transfat from food products in Kerala. Both these interventions were implemented during the tenure of Mr. Rajeev

Message From

state level monitoring committee has been formed to oversee the reduction of content of transfat, salt and sugar in foods of which World Bank is a part. Further, World bank has been a technical partner to the Government of Kerala in its efforts to sensitize the Bakers Association of Kerala and the Kerala Hotels and Restaurants Association to adopt transfat free or low transfat oils and fats in their food products. We hope that the seed sown by Mr. Rajeev Sadanandan will bear fruit in the coming years and Kerala will become a model in the reduction of transfat for the entire country.

Kerala was the first state to start the monitoring of trans fats in oils and foods in the country and has provided leadership for rest of the state to follow. This would have been impossible without a clear vision and dynamism of Shree Rajeev Sadanandanji. He was quick to convert ideas into action, brought in all stakeholders under a single umbrella. He garnered the support of national and international organization through his connections and quickly formed an action committee for trans fats elimination in the state. We are highly appreciative of inspirational leadership of Shree Rajeev Sadanandan in the state of Kerala and wish him good luck in his future endeavours.

Dr Roopa Shivashankar Resolve to Save Lives

SIRAS Rejuvenation Therapy for Stroke Management Pathway Dr Bipin Gopal Assistant director & State Nodal Officer NCD

anagement of stroke is a complex modality which is a combination of specialised skill, technological intervention, sophisticated infrastructure, high potency drugs and most importantly time bound management. Combining these factors at a peripheral health unit was unimaginable which restricted the stroke management to a few specialised hospitals in the state. This made stroke treatment inaccessible for a large segment of population due to insufficient facility, high cost of management and difficulty in reaching the stroke treatment facilities within the golden period of 4 hours leading to high rates of mortality and morbidity. The stroke survivors were the worst affected since the

quality of life was compromised due to the residual paralysis and high dependency rates. Finding a solution to solve the impending problem was an uphill task as there was acute shortage of neurologists in the system and shortage of other services like diagnosing facility CT scan, 24 hour radiology support, Expensive thrombolytic agent TPA, trained staff, ambulance network , proper traffic system etc. It was the visionary planning of Sri Rajeev Sadanandan Sir as the Health secretary who meticulously planned a stroke management pathway for Health services which later revolutionised the super speciality care service in the state. His leadership brought together all

experts in the stroke management arena including experts from SCTIMST, Medical College etc around a table which set the carpet rolling for the program. Training was given to physicians under SCTIMST on stroke identification, management and rehabilitation which was followed by hospital based trainings for medical officers and staff nurses. Stroke clinics were set up utilizing the NCD funds and TPA was procured through KMSCL and distributed to Hoapitals. Dr Vivek Nambiar, Stroke specialist Amrita Institute of Health sciences proposed a tele -stroke model which offered 24 hour tele consultation with AIMS Neurology unit which was accepted by the NHM and the new system boosted the confidence

First Succesful Stroke Thrombolysis at GH Ernakulam. Patient Before And After Treatment

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of the physicians in stroke units. Overcoming some stiff challenges, the program pushed forwards amidst the apprehensions and finally the first successful stroke thrombolysis was done at GH Eranakulam by Dr Manoj, Dr Paul, Dr Haneesh and the entire GH Team. Now stroke units have been established in 8 District Hospitals and 68 successful thrombolytic treatments have been given in addition to other supportive cum rehabilitative services. The expensive treatment which was once available only at Apex Hospitals is now available at the nearest District Hospital totally free of cost and the impact is beyond expectation as mortality and long term morbidity could be averted in the golden hours. The Government has expanded the program to the entire state and Hon Minister Mrs KK Shylaja Teacher dedicated the program to the state as SIRAS (Stroke Identification Rehabilitation Awareness and Sensitization program).

Patient Testimony

Capacitating Health Services for Stroke Management

ast President, Indian Stroke Association, Honorary Professor,School of Nursing,University of Lancashire,UK ,Member of Educational committee,World Stroke Organization Stroke is a leading cause of adult disability and mortality .Providing good quality care to stroke victims is a priority as the major burden of stroke is borne by low and middle income countries. The challenges before us in stroke prevention and management are many, with regard to the availability of enough trained doctors, getting timely effective acute treatment and stroke rehabilitation. The comprehensive stroke care program at Sree Chitra

Tirunal Institute for Medical Sciences and Technology has been actively involved in stroke awareness programs,improving infrastructure for acute stroke treatment, training programs , community intervention in secondary prevention and stroke rehabilitation and stroke research.I would like to take this opportunity to express by heartfelt gratitude to Dr Rajeev Sadanandan, whose involvement in each of activities helped in timely and effective completion . For the last 4 years , we were able to conduct training programs for the primary care physicians and nurses at district and state level on acute stroke treatment and secondary prevention . Last 1 year , we had

Dr. P.N Sylaja MD, DM, FRCP Edin, FESO, Professor of Neurology, In-Charge, Comprehensive Stroke Care Program, SCTIMST

the opportunity to train more than 1000 health workers and the primary care physicians in health blocks of Trivandrum district on acute stroke care and care of a stroke survivor. Kerala has started the maximum number of stroke units in district hospitals under his leadership and this has lead to better acute stroke treatment and stroke care for patients with stroke.His sincere involvement led to a collaborative research with ayurveda physicians on randomized controlled trial on stroke rehabilitation funded by Indian Council of Medical Research which is ongoing and this project which involves 2 disciplines of medicine would not have materialized without his support.

am thilakarajan 45 year old autorickshaw driver residing at Elimullu, Konni. I had acute onset left sided weakness and balance problem early in morning july 2017.i had availed the benefit of this treatment.i got full recovery from my deficit.i resumed my work 2 weeks later.iam indebted to dr stanley george.sincere thanks to heath department kerala for timely action and my new life.

With Dr Stanley George Neurologist GH pathanamthitta who has done 23 stroke thrombolysis so far. T H R O U G H

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Diabetic RetinopathyPreventing Blindness Through Technology

ORNATE INDIA: A Government of KeralaUK Collaboration Professor Sobha Sivaprasad

UCL and Moorfields Eye Hospital, London, UK

rogramme was set up across Thiruvananthapuram district and within 2 months, we have acquired data on 1200 patients with diabetes that clearly show that this project will reduce the numbers of people with diabetes who present with severe visual loss. His patriotism to Kerala Health oozed an aura around him when he gave an update of the success of the set-

up of the project to the International Advisory Board of the ORNATE India grant. It filled me with immense pride when he announced that there was clear evidence already that the pilot project is successful and that the Government of Kerala will integrate the diabetic retinopathy service into the NCD programme and scale it up to 14 districts in Kerala in the first instance.

Achievement So far 3814 patients were screened out of which 929 had diabetic retinopathy and other eye diseases. The gradability of images is 89.4%

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Nayanamritham Project Dr V Sahasranamam

Director ,Regional Institute of Ophthalmology, Thiruvananthapuram

Dr Simon George,

Additional Professor, RegionalInstitute of Ophthalmology, Thiruvananthapuram T H R O U G H

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he incidence of diabetes in the adult population in our country is increasing alarmingly and it is found that Kerala has the highest incidence of diabetes in India. Studies have shown that about 20 % of the adult population in Kerala are diabetic. Diabetic is the most common cause of blindness in diabetes. Early detection and timely treatment of sight threatening diabeticretinopathy can reduce the risk of blindness.To achieve this objective, the Nayanamritham project was inaugurated in

November 7, 2018 as a pilot project in 16 Family Health Centres in Thiruvananthapuram District. This is the first project implemented in the public health system in Kerala for diabetic retinopathy screening and treatment. Mr Rajeev Sadanandan, Additional Chief Secretary (Health) Government of Kerala has put tremendous efforts in the planning and designing of this project. His constant supervision and guidance helped overcome the initial difficulties in its implementation. Screening for diabetic retinopathy happening at the primary health care facilities will definitely pave way for the early diagnosis and management of diabetic retinopathy. Evaluation and treatment of diagnosed diabetic retinopathy patients is planned appropriately at the secondary and tertiary care institutions. Once the pilot project is successfully completed, it can be extended to all the districts in Kerala as a part of â&#x20AC;&#x2DC;Kerala model â&#x20AC;&#x2122; in health care delivery system. This project initiated by Government of Kerala will play an important role in reducing blindness and visual disabilities due to diabetes in Kerala.

Continuous Ambulatory Peritoneal Dialysis (CAPD) in a ‘Resource Limited’ SettingIs It Viable And Sustainable? Dr Krishnadas T

Nephrologist DH Palakkad

idneys are major excretory organ of our body.As the function of kidneys declines due to various illnesses there will be accumulation of waste products and disturbances in other functions. Kidney diseases are broadly divided into Acute Kidney Injury (mostly reversible) and Chronic Kidney Disease which is not reversible.Medical Care has scientific basis, it has social, economical, psychological and political aspects also. Management of ESRD depends on these aspects more than of any other illness

Scientific Aspect ESRD patients has three mode of treatment available 1. Conservative Treatment by medications- very poor survival benefit 2. Kidney TransplantationExcellent survival benefit, best treatment modality available but not affordable to most patients 3. Dialysis- Hemodialysis (HD) or Peritoneal Dialysis (PD) In India only less than 1% of ESRD patients are receiving kidney Transplantation. Dialysis is the next best option but only

10% are getting this. These services are given largely by private sector and tertiary care centers. Various studies proved patients on CAPD have better survival and Quality of Life than on Haemodialysis.

Political Aspects There is increase in demand for Dialysis from the community for the past 10 years. The Govt. of Kerala planned to start Heamodialysis Unit in all the Dist. Hospitals and Taluk hospitals. Each dialysis machine can only be used by a maximum of 6-8 patients. There is deficiency of Heamodialysis facility to cater all the patients number of patients requiring dialysis is on the rise. So community participation is needed for Dialysis. CAPD may be the solution for that issue. Since CAPD is done at Home by patient and their family members it has no limit allocation of treatment.

Social Aspect The treatment option of any illness, more so in CKD, is influenced by friends and relatives. What they demand is continue education to do usual job, freedom for attending family,

religious and social functions,. Heamodialysis require hospital visit 2-3 times per week. So their social life is disturbed. As CAPD is done at home by self at their own convenience patient and family have social freedom.

Economic Aspect Renal Replacement Therapy is a luxury for majority of our patients. To set up a Heamodialysis Unit having 8 machines approximately 1 crore rupees is required as initial investment. A space of 2000-3000 sq.ft , un interrupted Water and Electricity supplies is also required. But to start a CAPD unit it needs only an area of 400 sq.ft, minimal water and electricity and Rupees10-15 lakhs as investment. Human resource required for HD unit is 10 times as that for CAPD unit. In our Hospital estimated expenditure for Heamodialysis is ₹25000-27000 and for CAPD is ₹23000-25000 per patient per month. Hospital visit is 1-2 per month for CAPD compared to 8-12 per month for HD patients. Hence CAPD saves a large amount in terms of travel expenses and work lost by patient and caregiver.

Psychological Aspect Patients when diagnosed as End Stage Renal Disease they pass through following emotional stages. Denial of the illness and treatment, become angry towards self and the society, started bargaining for illness and treatment, go into a depressive stage and finally accepts the issue and agree for treatment. What we can offer is a treatment which is incurable. require repeated admissions in the hospital and RRT in the form of Dialysis(HD or PD) and Transplant. But extend the lifespan and improve Quality of Life, patients’ demand is complete cure normal activity, normal sleep, unrestricted food and water intake, normal sexual activity and a freedom for social life. Renal Transplant may satisfy many of the above demands, but only 1% is getting kidney transplant. Among dialysis modality CAPD offers more psychological and social freedom.

A JOURNEY

District Hospital, Palakkad

8. Higher authorities are un aware of such modality of treatment.

544 bedded Hospital having 15 specialties. Heamodialysis Unit was started in 2011 with 2 machines and two patients. The unit expanded to 8 machines and started functioning round the clock by 2014. We are doing 500-600 HD per month. We also do Emergency Dialysis for patients with Acute Kidney Injury. We started our PD program in January 2015 and now completed 129 procedures. Acute PD procedure is done for more than 200 patients. Till 2014 we have only patients imported from other centres for Maintenance Heamodialysis.. Those on follow up at CKD stage IV-V are counseled regarding Renal Replacement Therapy. If they have plan for Transplantation we refer them to higher centers. If no plan for transplantation they were considered for CAPD. If there is anatomical, Social or Economical Barrier for CAPD they are counseled for HD and AV Fistula creation. In cases of emergencies we take them for Intermittent PD or HD then give counseling for long term dialysis. CAPD is offered followed by HD.

Problems we face for PD first Policy 1. Anatomicaly not suitable for CAPD 2. ‘No House’ or Proper House. 3. No facility for Hand Wash 4. Relatives don’t want to take responsibility 5. Fear of Peritonitis. 6. Other Nephrologists said “it’s a second class treatment”

Advantages of CAPD 1. Home Therapy 2. Less costly done compare to HD 3. Promotes patients Autonomy. 4. Less travelling for patient and bystander 5. Better survival and Quality of Life. 6. Less use of Water and Electricity. 7. More community Participation. 8. There is no limit for number of patients.

Government Initiative

onsidering the recurring expenditure for the patient and the delay due to high volume of patients for Hemodialysis, ACS sri Rajeev Sadanandan took a path breaking decision to promote CAPD which is more comfortable for the patient and with a lesser economic burden. He called for a consultative meeting of all experts at NHM conference Hall and laid the guidelines for initiating CAPD in District Hospitals. Fund was allocated from NHM to DH Palakkad, GH Eranakulam and GH Thiruvananthapuram for setting up CAPD unit under NCD Control program. On the basis of the success in 3 districts the program has been expanded to 14 districts in 2019 -20.

Challenges of CAPD 1. 1)Multiple barriers to Home Care 2. High technique failure rate. 3. Peritonitis

Training on CAPD at GH Trivandrum

4. High use of consumable in Home. 5. High Exposure of Glucose. We do all dialysis modality almost free of cost. Funding for the expenditure is met from Karunya Benovolont Fund, RSBY, ESI, ECHS other reimbursements. We also have support from LSGD Paln fund and some donations from organizations and individuals. NHM provides part of Human Resources. If implemented properly CAPD is scientifically better, economically cheap, socially acceptable, psychologically comfortable procedure of choice for patients with ESRD and politically correct. And we should work very hard to offer transplantation to all.

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TOBACCO CONTROL Curbing the Noxious Smoke

Fight against Tobacco with a Legend in Public Health

Dr Bipin Gopal

Saju Itty

Assistant director & State Nodal Officer NTCP

obacco use was once a symbol of heroism and an essential commodity for alternative thinking, writing and a fad of modernisation and this anti hero brought in diseases specific to tobacco to significant section of society irrespective of the age and sex. The state became a hub for oral and lung cancer –the only attribute being tobacco, still tops the cancer prevalence chart. Other diseases like COPD and other chronic respiratory diseases have claimed its presence in the state in a big way. The state Health department took the reign of tobacco control activities when Shri Rajiv Sadanandan sir assumed charge as health secretary. He along with the team in DHS led by Dr AS Pradeep Kumar laid the foundation for the anti tobacco activities supported by VHAI and TFK the NGOs working in this sector.

Dr M S Manu

State co-ordinator NTCP

Under his leadership Kerala banned Gutka products, E Cigarettes and became the first state to declare as tobacco advertisement free at point of sale. The Education institutions became 100 % tobacco compliant and all government Institutions were declared tobacco free institutions. In the GATS 2 survey the prevalence of tobacco in Kerala came down from 21% to 12% which is due to the concerted effort of the Health Department in association with other line Departments. Pharmacotherapy for tobacco addiction, Yellow line campaign around 100 yards of schools, Tobacco cessation cells in District Hospitals and FHCs were other major achievements. In 2019 May before his superannuation Rajeev sir released the Government order for FCTC2.3 which is inented for controlling the tobacco industry Interference in Government sector and this land mark order hailed by all at national and International level.

Executive Director KVHS

n behalf of Kerala Voluntary Health Services (KVHS) I met Mr.Rajeev Sadanandan Sir in 2012 immediately after the Judgment of Kerala High Court in the Public Interest Litigation filed by KVHS on violations of film rules. He read the judgment and directed me to organize a round table to discuss the implementation of the judgment. The round table discussion held on June 2012 and he took personal effort to conduct state level coordination to ensure the implementation of the judgment. He took the judgment as a tool to control tobacco epidemic in the state. In the same time using the comfortable political situation he initiated to ban Gutka and chewing tobacco products in the state. Kerala is the second state to ban Gutka in India, but our order is the best in the nation. His keen look in the minute details is the result of the good order. Tobacco companies railed behind him to withdraw the order. But his commitment to the public health

was visible by the state as the form of strict enforcement. Then the tobacco companies went to Kerala High Court to squash the order. As a leader he took the challenge and personally gave briefing to public procedures who attended the case. He directed Kerala Voluntary Health Services to implied in all cases. The battle he made a landslide victory to Government and Kerala High Court squash all petitions filed by tobacco companies. There after several times tobacco lobby approached him in several disguised way , as beedi workers, petty shop owners, retail merchants etc, but his commitment to public health made them ashamed in all times. The Kerala’s GATS’ data which released in 2018 is a Crown to Mr.Rajeev Sadanandan sir. With out him Kerala could not have the best performance. Off course his retirement will make a huge vacuum in Kerala’s Public Health. Sir… Kerala is really overwhelmed by your contribution, commitment and care. We thanks to you sincerely. A JOURNEY

Contribution to Tobacco Control in Kerala Dr. KR Thankappan

Professor Department of Public Health and Community Medicine Central University of Kerala at Kasaragod, Periye, Former Professor and Head, Achutha Menon Centre for Health Science Studies, SCTIMST, Trivandrum.

hri Rajeev Sadanandan, additional Chief Secretary Health and Family Welfare, Govt. of Kerala was a Champion in tobacco control. He understood the importance of tobacco control in prevention and control of non-communicable diseases in Kerala, the most advanced Indian State in epidemiological transition. In his capacity as the chief administrator of the health department, he provided the leadership in coordinating all the related government departments such as Police, Excise, Education, Taxation and several others within the State Government and national government Institutions located in the state so that there was a concerted effort in implementing tobacco control in Kerala. He also provided

leadership in coordinating several non-governmental organizations involved in tobacco control. Smokeless tobacco ban, e-cigarettes ban, implementation of the cigarettes and other tobacco products act in educational institutions, smoke free homes in Kerala were some of the major successes during his time. As a result of all these activities, Kerala state recorded the largest reduction in tobacco use among the major Indian states as per the Global Adult Tobacco Survey (GATS)1 conducted in 2009-10 and the GATS -2 in 2016-17. Relative reduction in smoking was 30.6% and that of smokeless tobacco was 49.5% between these two surveys in Kerala.

Cricketer Sanju V Samson as Brand Ambassador for Tobacco Control

Yellow line Campaign Inaguration by District Collector Ernakulam Sri. Mohammed Y. Safirullah, IAS T H R O U G H

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Mental Health InitiativesOne Of Its Kind Dr Bindu Mohan

Dr Kiran P S

Additional Director Medical

SNO Mental health

treamlining of Mental Health Programme in Kerala started in the year 2016-17, by bringing MHPs in all districts (previously under Plan Fund, NHM, IMHANS) under a unified guideline funded by State Budget. It was completed by 2017-18 and now functioning as the backbone of Mental Health Services in the entire State. Reports and data started to be reviewed in SMO Conferences, based on which interventions were planned and implemented. Subsequently mental health began to be reviewed in DMO Conferences in all districts. As a result of this, Mental Health has become more integrated into general health system. At present around 25,000 mentally ill patients are given treatment (Pharmacotherapy, Psychotherapies, Social therapies including Rehabilitation) in 272 Monthly Mental Health Clinics by Mental Health Programme. In addition to this, 536 patients are given day care, free medicines, counselling, occupational therapy and recreational activities through 29 Day Care Centres under DMHP. Mental Health Programme aims for Mental Health Services through Primary Care and achieves

this through a) Information Education and Communication (IEC) activities for general public to create awareness and reduce stigma, b) Training for Doctors, Nurses, Pharmacists and Health Workers for Integration of mental health into primary care, c) Targeted interventions(Substance abuse prevention, suicide prevention, geriatric mental health, stress management) and d) Community based Rehabilitation. From 2017 three targeted interventions were launched under MHP in ARDRAM Mission namely ‘Aswasam’, ‘Sampoorna Manasika Arogyam’ (SMA) and ‘Amma Manass’, each one the first of its kind in the country. i. ‘ASWASAM’-Depression management in Primary Care was started on April 7 World Health Day 2017 in 170 Family Health Centres across the state. In the current year it is being extended to 500 more FHCs. Health Workers and Staff Nurses are trained in Screening Depression among general public using PHQ9 questionnaire, while Doctors are trained in diagnosis and management of Depression

at Primary care. Staff nurses of the FHCs are trained in Psychological First Aid and Psycho Social Intervention. Referral Protocol for cases to be seen by DMHP is included in the programme. ii. Sampoorna Manasikarogyam -For finding the undetected mental health case burden by involving community level workers (ASHAs) in detection, management and follow up of cases and Integration of newly detected cases to Family health care system. Till date it has been implemented in 206 FHCs, 5885 ASHAs were trained as part of the programme and 9567 New cases were detected from these 206 panchayats. A total of 13574 cases were given treatment as part of the programme and integrated into Comprehensive Primary Care by which they will continue to get treatment & psychotropic medicines from their nearest FHC iii. Maternal & Infant Mental Health Programme started by the name ‘AMMA MANASS’ by which screening for A JOURNEY

SDGs on Mental Health is in the process of implementation. These include:

Stress, Depressive Disorder, Anxiety Disorders And Other Mental Health Issues are done during antenatal ( 1st, 2nd& 3rd trimester) and post delivery period ( 6th wk , 14th wk & 9th month ). Training is given for JPHNs, Staff Nurses, Primary Care Doctors, Gynaecologists & Paediatricians.

‘Pariraksha’- Post Flood Psycho Social care - In the context of flood and landslides that occurred, Govt of Kerala constituted Mental Health Disaster Management team , under DMHPs on 18th August 2018 , in districts and directed to coordinate all mental health services in the disaster affected

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areas under these teams. Special attention was given to the problems of children and elderly . ASHAs were included for grass root level work and were given training in all the affected panchayths from 28th August. 384 training programmes were conducted in the most affected 10 districts through which 17,643 ASHAs and volunteer counselors got trained. They visited 717 camps and conducted 1,30,999 house visits,

Strategy/Intervention

Early detection of emotional and behavioural problems in children School mental health programme

To reduce high suicide rate

To reduce morbidity due to depression

To reduce treatment gap

To reduce treatment dropouts

Integration of mental health in primary care

Rehabilitation of mentally ill

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‘ASWASAM’ programme

‘Sampoorna Manasikarogyam’ (SMA)

thereby provided Psycho Social Intervention to 2,12,797 persons in need . In addition 1543 persons who needed further intervention were given mental health treatment by Mental Health teams thereby ensuring mental health service to all the survivors . Vimukthi -De-addiction Centreswere started in all 14 districts in the stateduring 2018-19. These centres provide de addiction treatment to alcohol, cannabis and other substance use disorders With the extension of SMA, Aswasam and Amma Manass programmes to all FHCs and CHCs, and with implementation of newer targeted interventions like Tribal Mental Health, Coastal Mental Health, Suicide Prevention and Stress Management programmes in the current year, MHP will be able to achieve its goal of ‘Mental Health for All’.

‘Sneha koodu’ and ‘SMA’

Palliative Care Programme

alliative Care Programme was initiated in Kerala in 1994 by Non-Governmental Organisations. By the year 2002, this programme became a community movement through NNPC (Neighbourhood Network in Palliative Care). The astounding success of this programme inspired the local self governments who in turn started supporting NNPC Units. Medical Professionals and hospitals also started involving in this programme and Kerala Government declared Pain and Palliative Care policy in 2008 .The policy clearly mentioned the sufferings of bed bound, home bound and chronically ill people in Kerala and stated that home based care should be the corner stone of Care Programmes for these groups. Government also declared that they would develop their own system to take care of these patients through their Local Self Governments and Health Institutions with the support of community based organisations and volunteers. National Health Mission also started supporting the programme in terms of human resources and funds in 2008. Director of Health Services issued circular for implementing the palliative care programme through Government Health Institutions in 2009 which was revised in 2012 and 2018.Local Self Government department issued circular in 2009 which was revised in 2012,2015 and 2019. Government Palliative Care Programme aims to

establish the primary, secondary and tertiary care facilities for all the bed ridden incurably ill and dying patients in Kerala with community participation. The strategy was to facilitate the development of palliative care programs through Local Self Government Institutions while taking care to maintain the spirit of community participation in the program. Focus of the program was on sensitization and capacity building among various strata of the society and also health care professionals at the primary, secondary and tertiary level health care system. The Primary level Palliative Care Programme is implemented by Panchayath Raj Institutions through respective Primary Health Centres. Home based care is provided through a trained community nurse. The Medical Officer of the PHC is the implementing officer of the project and is well informed about each patient through the community nurse. Out Patient facility is also provided. The Program is closely monitored by the Palliative Management Committee (PMC), comprising of representatives from respective PRIs, health institution, volunteers etc. All the 941 Grama Panchayats, 87 Municipalities and 6 Corporations in Kerala are having well established primary palliative care programme. The Secondary level Palliative Care is implemented at two levels. 1. Through major hospitals of district (Taluk, General and District Hospitals) with the

Dr Mathew Numpelil State Nodal Officer, NPPC

support of NHM. The patients who need specialist care, referred from Primary level palliative care programmes like patients with end stage cancer, colostomy, tracheotomy, end stage systemic diseases etc. are catered. The home Care is done under the leadership of trained Staff Nurse appointed through NRHM and also by doctors trained in Palliative Care. Secondary units are also providing specialist inpatient and outpatient services to the needy patients. Morphine and other palliative care medicines are given to the needy patients through secondary OP, by a Medical Officer, trained in Palliative Care. The secondary units are also co-coordinating and monitoring the activities of primary palliative care units in their area through training and quality improvement programmes. The secondary services are being provided through 102 hospitals. 2. Through Community Health Centres. Form 2017-18 onwards we have started long term care programmes in 232 Community Health Centres for providing specialist care for patients with NCD, Mental Health issues and issues related to old age. For this we have appointed one staff nurse trained in Palliative Care and one Physiotherapists in each CHCs through NHM. These units are giving specialist nursing care and physiotherapy home care programmes, medicines for patients through Special OP, training for improving the quality of primary services and also inpatient care for physiotherapy

and special nursing needs. The Tertiary level Palliative Care focuses on various trainings for professionals (doctors and nurses) as well as students and volunteers. Besides, the secondary level program is also implemented in the tertiary unit. The tertiary units are in charge of overall co-ordination, monitoring and quality improvement of primary and secondary level units in the District. For this purpose each tertiary unit is having a team of trained medical officer, staff nurse and co-ordinator. Physiotherapy is also provided for the required patients by trained physiotherapist. All the fourteen districts in Kerala are having established tertiary level palliative training centres. There are also about 500 NGO/CBO involved in palliative care services in the state. They are involved in providing psycho social support, nursing and medical care. Government is giving training and technical support for the doctors and nurses in NGO sector who in turn are playing a major role in improving the care of patients with the involvement of the community. Most of us go throughlife trying to do a good job which to us means walking well through a beaten track. We keep the system going; but perhaps that does not pave the way for positive change.

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Positive Change Demands Pragmatism Dr. M.R Rajagopal Chairman, Pallium India, Director, Trivandrum Institute of Palliative Sciences (WHO Collaborating Centre for Training and Policy on Access to Pain Relief)

ositive Change Demands Pragmatism - the quality of dealing with a problem in an appropriateway that meets the relevant conditions, rather than following fixed theories, ideas, or rules. I think that is what made Mr Rajeev Sadanandan different – pragmatism coupled with the ability to realistically analyse the status quo, decide on what he could change within a reasonable period of time and work hard towards that objective. His job would have been easier if he were in a country where health care received the attention that it deserved. But he did not. He belonged to India where we spend only about 1.25% of GDP on health care as against an average of 5% in any civilized country (including many developing countries). And he belonged to Indiain which health care institutions and professionals were overburdened with unbelievable demands on the system and unrealistic workloads on each employee. He could not change it all during one term as the head of the executive of health care in a state.

could possibly assume massive proportions. And during the third recent term as the head of health care in Kerala, he faced two of them. First came the Nipah outbreak. Astute doctors pointed to identification of the problem; but they themselves could not possibly have contained the outbreak without excellent governance and without Mr Rajeev Sadanandan’s pragmatism. The second was the massive floods that the state saw. The people of Kerala were phenomenal; but they needed the leadership that Mr Rajeev Sadanandan’s administration could provide. The fact that the much-dreaded aftermath of the floods – an outbreak of contagious diseases – could be avoided is indeed a feather in his cap. As a palliative care activist, I had several occasions to seek his help; and was lucky to get his pragmatic support each time. I wish him all success in his future career. I do hope his best is yet to come.

I think he looked for what he could indeed change. Like the Ardram mission. And many other aspects of primary care. And as typically happens in any system that is inadequate to meet demands, each crisis T H R O U G H

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HRIDYAM

new newborn screen program in 43 public sector delivery centers;

An Initiative For Reduction For Infant Mortality In Kerala

• An Echocardiography training program for pediatricians to diagnose children with CHD was launched in December 2018;

Jackie Boucher, MS

• Clinicians throughout the state were trained to educate parent to care for their children preand post-hospital discharge;

President, Children’s HeartLink

n 2017 Children’s HeartLink had the privilege to begin, a very productive, partnership with the Government of Kerala’s Department of Health and Family Welfare to help achieve a reduction in infant mortality in Kerala, which is one of the targets of Sustainable Development Goal 3. From the very beginning, we were impressed by the Government of Kerala’s ambitious goal of reducing infant mortality from 12 to 8 by 2020. More importantly, however, we were impressed by the clarity and vision for how to achieve this change: by addressing mortality and morbidity from congenital heart disease (CHD) among children in Kerala. By enhancing the public health system to provide early detection, diagnosis, referral and improved treatment options for children with CHD, today we are certain that Kerala is well on its way to achieving this goal. As often it has been acknowledged, Kerala is leading the way and breaking new ground in improving access to health services for its people. This achievement is in no small part due to the outstanding commitment, vision, and leadership of Mr. Rajeev Sadanandan, Additional Chief Secretary, Department of Health and Family Welfare, who recognized that early detection of congenital heart defects is

integral to enhancing outcomes for children in Kerala. During his tenure, in collaboration with Children’s HeartLink, Mr. Rajeev supported capacity building efforts for clinicians in the state’s referral pathway to ensure appropriate and timely screenings, counseling for families, and appropriate and timely referral. Under his leadership, the Department of Health and Family Welfare secured dedicated funding for treatment of congenital heart disease and the creation of Hridyam, a first of its kind state-wide electronic system to identify, register and refer for treatment children with heart disease. Congenital heart disease is complex and requires the coordination of efforts across all levels of the heath system. We were lucky that Mr. Rajeev understood these challenges and took the right actions.

• Clinicians and emergency medicine personnel were trained to better stabilize and transport children with CHD in February 2019; and • Since Feb. 2019, 15 weekly eLearning sessions were held providing pediatricians and pediatric PGs with skills in screening, identifying and referring children with CHD for treatment. On average, 180 participants joined the weekly eLearning sessions. The innovations that Mr. Rajeev has supported are being noticed by government officials nationally. At the Kerala Child Health Summit (February 2019), 466 officials from the National Health Mission and delegates had

the opportunity to learn of Kerala’s efforts to address CHD in over 14 educational sessions. Based on this and other opportunities, government officials from at least 6 states have expressed interest in replicated the efforts Mr. Rajeev led in Kerala. His support and leadership will truly impact children throughout the Indian nation for years to come. On behalf of Children’s HeartLink, we would like to recognize Mr. Rajeev for his outstanding commitment to the wellbeing of the children in Kerala. We could not have wished for a more committed, authentic and expert leader and are grateful for his leadership and the hard work of his team for contributing countless hours to the goal of enhancing access to pediatric cardiac care for children in the state. Children’s HeartLink is a proud partner in this collaboration and is looking forward to supporting future efforts that will continue to build Kerala’s pediatric cardiac system so that all children born with heart disease will have access to quality cardiac services.

During the period 2017-2019, the following was achieved: • 603 radiologists and OBGYNs were trained on prenatal screening techniques; • 262 pediatricians were trained on CHD, timely referral and family counselling; • Over 85,000 children were screened for CHD since June 2018, following the launch of a A JOURNEY

Maternal and Child Health in Kerala Dr.V P Paily

State Coordinator, Confidential Review of Maternal Deaths, Kerala

erala has an unassailable lead in maternal and child health indices compared with other states in India. This has not happened by accident. Several factors have contributed to this achievement. The most important among them are the high literacy, presence of large number of health care institutions, good transport and communication facilities and roads and a public willing to spend for health. Private institutions cater to about 70% of deliveries in the state. The government has maintained a network of health care institutions that serve the poor and socially deprived segments of the society. The government of Kerala has been giving leadership and co -ordinating various activities that help to reduce maternal and newborn mortality and morbidity. This has been more visible in the last 15 years during most of which Sri. Rajeev Sadanandan was the health secretary. During this period different political parties ruled the state but the commitment to maternal and child health was unwavering. It was seen that contributions from government of India through the National Health Mission was fully utilised. Support from the private sector was solicited. Professional organisations like Kerala Federation of Obstetrics and Gynaecology (KFOG) and Indian

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Dr. Sandeep K

Deputy Director FW

Academy of paediatrics (IAP) joined hands with govt. of Kerala to achieve the goal of low maternal and infant mortality.

Practicing obstetricians, nurses and to some extend nursing assistants are trained to provide safe obstetric and new born care.

In safeguarding the maternal health Sri Rajeev Sadanandan recognised the importance of the work started by KFOG in 2004 with support from government of Kerala and World Health Organisation(WHO). This was the confidential Review of Maternal Death to identify the real causes of maternal death and the steps to be taken to prevent such deaths in the future. He invited the NICE International based in the United Kingdom to work with government of Kerala and KFOG to chart out steps to improve maternity care. The project “Quality Standards in Obstetric Care” was piloted in eight centres and helped in reducing maternal deaths due to haemorrhage and hypertension. The concept was later expanded to other major causes of maternal deaths like sepsis, haemorrhage and pulmonary embolism.

Audit is the scientific way to realise the causes of maternal deaths. KFOG has pioneered the confidential audit process in maternal deaths. The emphasis here is to take away the blame game that is usually associated with enquiries. The same process in now extended to include confidential audit of near miss cases. The government of Kerala and KFOG have recently decentralised the audit of near misses to the district level where obstetricians from all delivery points, private and government, come together every month to review the maternal deaths and near misses and learn lessons for day to day practice. Our aim is to learn lessons that will help to avoid all avoidable maternal deaths.

The importance of training and updating the practising obstetricians and nurse midwives was recognised and many training programmes were initiated. Emergency Obstetric Care and Life Support (EMOCALS) was one such project initiated by KFOG and is now spread out to all districts.

A target of Maternal Mortality Ratio (MMR) of 30 by 2020 and MMR of 20 by 2030 has been declared by the government of Kerala. KFOG is actively partnering with government of Kerala in achieving this goal. Our motto- “ zero tolerance to all avoidable maternal deaths”.

Labour Room Quality Improvement Initiative (LAQSHYA) in Kerala Dr. Harikumar S

District Programme Manager NHM Kollam

erala is the leader in India towards achieving the Sustainable Development Goals related to Health, especially so with regard to Maternal Mortality Ratio and Infant Mortality Rate. Due to the sustained efforts over the years, Kerala’s MMR stands at 46 per 100000 live births and IMR at 12 per 1000 live births in 2014-16. In its stride towards achieving targets at par with developed countries Kerala has reiterated its commitment in this area by announcing specific SDG targets as follows • To reduce MMR to 30 by 2020 & to 20 by 2030 • To reduce IMR to 8 by 2020 A concerted effort involving Health Services Department, Medical Education Department, National Health Mission, private institutions and KFOG is underway in line with achieving the targets with available resources. At the core of this activity is the LAQSHYA which aims to adopt a holistic and comprehensive approach at all levels of care to

improve and strengthen Quality of Care (QoC) during intrapartum and immediate postpartum periods. The programme brings together standards of care, capacity building of service providers at all levels, facility ownership, accountability and respectful maternity care. The specific goals of the programme include • Reduce preventable maternal and newborn mortality, morbidity and stillbirths • Improve Quality of care during the delivery and immediate post-partum care • Enhance satisfaction of beneficiaries • Apart from providing necessary infrastructure, the processes towards LaQshya certification include

• Setting up Facility Level Targets • Competency trainings through skill labs • Onsite mentoring & running 6 rapid improvement cycles • Verification of achievement of facility level targets by district coaching team and SQAC • External assessment by National Assessors 43 institutions have been targeted to achieve LaQshya certification across the State including Medical Colleges, W&C Hospitals and Taluk Hospitals. Of these 2 institutions, namely W&C Hospital,Kozhikkode and Beach Hospital, Kozhikkode have already been LaQshya certified.

• Formation of District Coaching team • Formation of Quality Circles in Labour Room and Operation Theatre in selected institutions • Internal Assessment and Peer Assessment using NQAS checklists A JOURNEY

Helping hands to the Differently Abled Dr Bindu Mohan

Additional Director (Medical)

PMR Units

hese units function in 22 institutions. These units provide state of the art care to patients with spinal injuries, paraplegia, stroke, myopathies, cerebral palsies, posttraumatic care and differently abled. Facilities include IP,OP care, Exercise therapy, wax therapy, ultra sound therapy, infrared therapy, laser therapy, electrical nerve stimulation and interventions like botulinum toxin injection to relieve spasticity . Step trainers, finger trainers, continuous passive movement equipment, scanning are . during last financial year funds were provided to GH TVm for care of paraplegic and head injury patients.

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Limb Fitting Centres At present, we have 8 limb fitting centres. In these centres artificial limbs, calipers, braces, spinal jackets, slings, mcr chappels etc are provided free of cost to bpl patients and at rates prescribed by government to apl patients. These ubits work as part of physical medicine and rehabilitation units and has staff in the following categories. Foreman, orthotic technician prosthetic technician, leather technician(cobbler). Gh tvm, dh kollam, DH kozhenchery, gh aleppey, gh ernakulam, dh palakkad, dh kannur, . 6 more limb fitting centres will be set up by 2020

Oorumithram Project Dr Nita Vijayan SPM RCH

Dr Manjula Bhai SNO Tribal Health

The widely accepted success of Kerala Model of Development across various socio-economic indicators in our state has unfortunately not yet transended to the most vulnerable communities among us – the indigenous SC & ST people. The first hand witnessing of the grass root situation in a district with a greater proportion

Dr Mathew Numpeli

Head Social Developement NHM

of our tribal population – Wayand, has reinforced our dire need to address this gap in enabling quick and efficient healh care to this underprivilaged community and resulted in the introduction of Oorumithram. Oorumithram project is a special initiative by the State

government to improve the health status of tribal people in all districts of Kerala. The project started initially at Wayanad, Idukki and Kannur districts. It mainly focuses on the vulnerable communities i.e. Paniya, Kattunaika, Oorali, Adiya, Muthuvan, andCholanaika. Oorumithram (Hamlet ASHA) is a female health worker who

coordinates and works as a linkage between the Health Services Department and the people residing in the colony. The conception of this project can be traced back to the explosive Cholera outbreak in July 2011, which claimed 5 lives – all in the Tribal settlements and the

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infection was fast spreading to the general community. The Principal Secretary at that time, Dr. Rajiv Sadanandan, and a fantastic team at Wayanad were able to identify the biggest issues aggravating the deteriorating situation – lack of sufficient manpower, infrastructure deficiencies and many other roadblocks. The immediate requirements and a long-term action report were presented and thus started the project along with the many accompanying proposals. One of the initial infrastructural interventions was building toilets with running water to put an end to the endless water borne diseases – which were undertaken by Nirmithi. The good army of my team in Wayanad monitored this too and the completed constructions have provided happy users. One of the many project proposals that we created was a Sahayi project – an empowerment project that is similar to ASHA, but with added skills and equipment. This project could be rolled out only in 2015, after Dr. Sadanandan’s return to Kerala health and his support for the project resulted in a revised proposal based on reknowned models. This followed into a review of the SEARCH project in Gadchiroli, operated by Dr.AbayBangh and Dr.Rani Bhang – a research/ specialty hospital center run according to the wishes of the Gonds in Dhandakaranya,remote Maharashtra’s dense forest belt. The success story from the SEARCH project with drops in MMR, IMR and Malaria deaths was surprisingly initiated by a simple intervention – skilling a tribal volunteer to deliver accurate and defined services. The review of SEARCH functioning revealed that the tribal volunteer, Arogyadooth, even though barely literate was given skill-based trainings for field health requirements and certified qualified T H R O U G H

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by AIIMS examiners. The team identified that the single largest factor for success of the project would be the apt selection of the tribal volunteer. Another roadblock for introducing this project was that the concept was considered only for the North and North Eastern States andnot for Kerala, which had a different yardstick for GOI. An ASHA review by Dr. Rajani Ved from NHSRC Delhi opened an opportunity to pitch in our SDG goals - our MMR IMR program and the niche areas where we still could not reach, despite the advances in Health Care. Maternal and child health, TB, Leprosy, NCD Control are some of the key areas the State is focusing on. A revised and thoroughly studied proposal with foolproof selection, customized modules and 3 Pilot Cases are underway. It was implemented as a focal intervention program in vulnerable segments of the population, to achieve the declared targets of sustainable development goals primarily in the domains of Maternal Mortality and Infant mortality reduction. The 3 Pilot districts are as yet fledglings and starting to make a difference. Now we are in the process of saturating remote, difficult to reach hamlets with an ASHA worker of their own– trained, skilled, equipped and demanding. This promising project will have 283 trained volunteers to deliver ANC,PNC, child care and track NHPs they are our Oorumithram. A committee headed by the ward member, the JPHN/JHI/ Kudumbasree worker, ASHA worker, tribal promoter, Anganwadi worker, CSW will convene an oorukuttam to motivate an “Oorumithram” to come forward with two volunteers who will fulfill the following criteria • A lady married into the community with a child K E R A L A

• Must be able to read and write • Committed to serve • Must have leadership skills The family members of the volunteer should be supportive of the volunteer working if required at odd hours. Two names from each identified settlement will be sent through the Panchayath and Medical officer to the District Nodal Officer for this program. A twoday “Sensitization cum Assessment workshop” will be held locally in the districts and the most competent person will be selected from the two. If both volunteers are found wanting after a second level training no one will be selected and a fresh recruitment will be done. Now the program is being expanded into ten more districts excluding Alappuzha which has a negligible tribal population. Three regional training of trainers have been completed to facilitate Oorumithram selections, at Trivandrum, Ernakulam and Kozhikode respectively and the number of Hamlet ASHA’s selected in these districts is 137 and waiting for induction training in June 2019. The new ward health review is set to be done so: • Chaired by the ward member with the JPHN/JHI the conveners and the AWW, the Kudumbasree, the volunteers. The committee will first define their universe of each segment in the ward: • The No. of infants and children and the high risk among each cohort. • The No. of mothers expecting and lactating - • The No. of young couples planning or yet to complete their family

• The adolescents 6-18 • The Productive or Reproductive group • The elderly > 60 • The super elder > 85 A monthly health review of these aforementioned indicators will be conducted and services to the vulnerable or the prioritized in each cohort are non-negotiable. We have already mobilized a large number of field functionaries and with further motivation and adequate training we can assign one to many so that no one in adversity is left alone to fend for themselves. For we are Keralites – the land that has shown the world that the best place to die with chronic illness is here – Gods Own country with a world known Model of Development.We have a point to prove to the world and to the underprivileged amongst us.

Medical Education In Kerala... How It Faced The Challenges In The Last Decade. “An Over View - On The Eve When It’s Most Dynamic Health Secretary Bids Farewell”. Dr. Remla Beevi A

Director of Medical Education

he medical education in Kerala though started well ahead of half a century , has been experiencing ups and downs for the last so many years . Five years back we had only 5 medical colleges in government sector at Thiruvananthapuram, Kozhikode, Kottayam, Alappuzha and Thrissur. The last government had embarked on a ambitious project of starting government medical colleges in all the districts in Kerala and took initiatives to start medical colleges at Manjeri , Idukki , Paripally , Kasargod, Vayanad , Haripad , Thiruvananthapuram and Konni making use of the central government relaxations in the area of land needed, requirement of own running hospital and faculty members. However Manjeri and Paripally GMCs have only suceeded in mobilizing required infrastructure and faculty members and in getting MCI sanctions for hundred seats each. The Thiruvananthapuram GMC was dropped half way through because of strong opposition from different quarters. Similarly the proposed Medical College at Haripad also wound up due to lack of fund even though it was planned to run with government privet participation

and the land was handed over to director of medical education (DME ) . The GMC at Idukki though got sanction to admit100 students , could not move forward because of inadequate hospital facilities , lack of hostels for students , in sufficient quarters for doctors and NGOs and low faculty members. The students were send to other medical colleges after they completed first year examination , during the time of clinical posting because of poor teaching materials and due to lack of experiencd faculties. Eventually the medical college teaching program was temperorly suspended and now the Idukki GMC is running with a principal and skeletal staff . However the process to get MCI sanction is under steady progress For the Kasargod GMC the hospital building construction was inaugurated by chief minister at Kasargode in January 2019. The construction of college and Hospital building partly completed for the Konni GMC .The Wayanad GMC site is not finalized yet Along with this the two Medical Colleges running in cooperate sector was taken over by the government and handed over to DME .The Ernakulam GMC was taken over in 2013 and the

regularisation of staff and faculty members and their absorption into government pay role after scrutinizing their certificates completed only recently. The government order to hand over Pariyaram Medical College to DME was issued only 2 months back. Thus the number of medical colleges under DME have increased from 5 to 9 running medical colleges and 4 proposed medical colleges. Now the single most important requirement in running the new medical colleges is the faculty. For that enough posts have to be created on a warfooting and all the hurdles in PSC posting to be removed with a special government order . Now there have been an inordinate delay in getting PSC hands in medical colleges in the right time, even though the new generation post graduates are very much keen to join medical college services. The local MLA and MP should work hand in glove with the superintendent and Principal of their GMC to meet the demands and should go to any extend to get the fund sanctioned , posts created and faculty and staff posted as per the requirements of the MCI The other important requirements are infrastructure facilities and academic background improvement. Sri Rajeev Sadandan

sir as Health secretary took great interest and very keen initiatives to correct all these pressing needs of medical education. Let me list out the very important achievements he could bring to the medical education in the last decade From 2010 on wards there has been an effort to increase the number of seats in the existing medical colleges . Thus 50 seats respectively increased in Alappuzha, Thrissur , Kottayam and Kozhikode. With addition of 100 seats each of Pariyaram , Ernakulam, Manjeri and Paripally GMCs now the total number of medical seats under DME have gone up to 1300 . My association with Sri Rajeev Sadanandan sir started in the year 2011. when I was Principal at Alappuzha GMC. He has given me continues support to all my activities at Alappuzha. He was a gentleman with very high level of energy and enthusiasm , always surging with new ideas and goals . He has a peculiar efficiency to stimulate the subordinate to brings out the good in them and always willing to correct them with words of encouragement and appreciation . He is an up an right person with high standard of integrity and inter person relationship . At Alappuzha GMC we could start DM cardiology PG course A JOURNEY

which remarkably changed the cardiology care and able to embark on primary angioplasty treatment patients admittedly with acute heart attack.

A master plan for Thiruvananthapuram GMC has been approved and an amount of 56 cr was sanctioned for first phase . Multi speciality block at GMC has been made functional with his effort

Central government fund for tertiary cancer care , NABARD assistance for maternal and child health center , fund for residential quarters for PGs and new administrative block were sanctioned during that time.

Apart from the above infrastructure improvements he has taken special interest in patients care services like A. Implementation of E - health program

At Thrissur GMC , NABARD assistance for new academic block and hospital block were sanctioned . At Kottayam GMC fund for new causality block ,PG resident quarters and college of pharmaceutical science were sanctioned . The construction works of Super speciality blocks under Primeministerâ&#x20AC;&#x2122;s Swasthaya Sureksha Yojana (PMSSY ) project at GMC Alappuzha and Kozhikode have gained great momentum with his initiative and nearing completion.

B. OP transformation under Ardram project C. Remodeling of casualties in all the medical colleges . The leadership role he played in the management and containment of Nipah out break in Kozhikode is remarkable and appreciated world wide .

At Ernakulam GMC with his timely intervention we could complete the integration process of faculties and staff after the take over from CAPE. With his initiative we could prepare a master plan for the Ernakulam medical college. Fund has been sanctioned from KIFBY for construction of superciality block. Super speciality departments for nephrology, cardiology and neurology were started and new cardithoracic block with cath lab started functioning with his effort . Cochin cancer centre in Ernakulam GMC campus is another major achievement during his tenure With his continuous support we could get the permanent recognition from MCI for hundred admissions at Manjeri GMC .

The continuous medical care to the flood affected victims in camps and timely intervention in preventing water born diseases are co ordinated with his timely advices. Research activity in the various medical subjects is one of his great passions and with his effort ICMR has given fund for starting multi disciplinary research units (MDRU) in GMC Kozhikode, Kottayam, Thiruvananthapuram and Thrissure This is just a birds eye view of the contributions and interventions he has made for improving the medical education sector in Kerala . I think majority of his dreams concerning the medical education have been materialised.

New Multi Speciality Block at MCH Trivandrum

I wish him good health and happiness

New cathlabs sanctioned at Parippally and Manjeri GMCs are because of his special interest only. T H R O U G H

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Dental department: Special Initiatives Dr Simon Morrison Deputy DHS (Dental)

elicham Programme conducted in Wayanad district with 61 Dental screening camps at CHCs & PHCs, 8 Oral Cancer screening camps & IEC activities were conducted with help of Malabar Cancer Centre Thalasserry. There were Oral Cancer awareness classes with audio visual aids , Oral Cancer awareness street play by students, interactive Talk show with cancer victims and Oral Cancer Awareness Rally. 30 numbers of Geriatric camps were conducted and we could fabricate and deliver 1500 full Dentures for the poor and needy Elder Citizens of our State under “Mandhahasam” Project.

Punchiri Programme A successful Massive Dental Screening Programme for the School Students of Kannur district deserves Special mention. About the programme (Punchiri) the School Dental programme is an initiative of National Health Mission Kannur. This programme aims to improve Oral and Dental Health of School Children by quality intervention of RBSK Nurses and Dental Surgeons under NHM through awareness classes, Health Education and Screening Camps at Schools and Weekly Clinics at BPHC/CHC/TH/District Level Hospitals more than 45000 School Students were covered in this programme.

ational Rural Health Mission in Kerala has been able to initiate many schemes and activities which are mostly tailor made to the unique features of the state of Kerala. One among such initiatives is the implementation of ASHA programme. ASHA’s are the trained female community health activist and are providing health related services to the deprived sections of the population. They are a major source of support for strengthening the public health system, and are providing valuable services to the community, especially women and children. The key functions of ASHA’s include playing lead role in the Prevention & Control of Communicable diseases, in Mosquito control, to identify regional health issues and work in coordination with Ward Health Sanitation Committee, to eradicate them and to make health services available to pregnant women and children. In Kerala ASHA workers were redistributed as ‘One ASHA per Ward’ and ASHA as the Coordinator of Ward Health Sanitation & Nutrition Committee. Government Order issued for Ward Health Review organized by ASHA with support of members Anganwadi workers, ADS members of Kudumbasree. In the review ASHA will present the ward health report followed by discussions and the JPHN/ JHI in charge of ward will give the technical inputs.

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Community Engaging Activities Under NHM To make it function a community mechanism was required. Three day course was announced for health volunteers from each Municipal/Corporation/ Panchayath wards. This training programme will be given to two volunteers on first come first basis. They should be doing some activities in the health field and they should have the interest to learn. Earlier experience on introducing such schemes in the community helped the State a lot. For that a State ToT was done in December at Trivandrum with officials like Deputy District Medical Officers, District Palliative care coordinator, District ASHA Coordinators, District NUHM Coordinators, two persons from Health Inspector wing and two persons from PHN wing. All these initiatives will be effective with the introduction of monthly ward health review and monthly panchayath health review which is started from May.

which includes all the field staff and medical officers including AYUSH doctors. The third step is ASHA training for 5 days. It is a participatory hands on training at Panchayath/PHC level and two days are allotted for AYUSH (one day at Ayurveda hospital and other day at Homeo dispensary). As of March 2019 we have completed training of 16217 ASHAs on Module 8.

We have started a state specific module called ASHA Module VIII. The module has two part , the first part is a revision of previous seven modules and the introduction of Aardhram. The second part is AYUSH which is an introduction to all the systems under AYUSH for ASHA workers. It is first time ASHA workers are trained on AYUSH. As part of these, we have conducted training of master trainers from all the 14 districts. As the second step, have conducted cluster training T H R O U G H

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Pilot intervention of ward health facilitation centres under supervision of ASHA and digitalisation of ward health data @ Rs.6.25 lakhs for 5 districts â&#x20AC;&#x201C; We are proposing one Panchayath each in 5 districts (Trivandrum Ernakulam, Thrissur, Malappuram & Wayanad). ASHA is preparing monthly Health Status Report (HSR) of each ward. We are planning to give one Tab for each ASHA in these Panchayath, so that the HSR can be digitalized. We also plan to start a health facilitation centre in each ward of these Panchayath. This will be managed by the ward health team consisting of ward member, Anganawadi worker, Kudumbasree chairperson, Arogya Sena and ASHA. ASHA will coordinate the facilitation centre and it will be a point for coordination of the field activities. The centres will be having Digital BP Apparatus, Glucometer, & Weighing Machine.

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Dr Mathews Numpeli

Head Social Development NHM

Aardrakerala Puraskaram :

erala is giving recognition to the best performing Local Self Governments since 2012. It is aimed at improving involvement of LSG in health and health related activities. This year as part of Aardhram Mission, we are giving more importance to primary health care with the active support of Local Self

Seena KN

Senior Consultant Social Developement NHM

Governments. LSGs are taking projects for improving facilities in the institutions transferred to them to make them patient friendly and also for improving public health activities. This year also we are planning to recognise best performing Panchayath/Block Panchayath/ District Panchayath/Municipality/ Corporations in the banner of Aardhrakeralapuraskaram.

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Infrastructure Development in Health Sector to Improve Patient Amenities Anila C J CE, NHM

ational Health Mission is a nodal agency in implementing development works in Health sector. The Engineering Wing of NHM is entrusted with works such as, Construction/ Renovation/ Re-construction of MCH Block, District Hospital, Taluk Hospital, CHC, PHC, Sub Centre, Training Institute, Isolation Ward, Vaccine Store, Labour Room Strengthening as per LaQshya Standards, ICU, DEIC, SNCU,NBSU, Skill Lab, Burns Unit etc. Engineering works under National Ayush Mission are also entrusted to engineering wing of National Health Mission. Moreover the implementation of Aardram Project and Flood Renovation works were carried out through engineering wing of NHM. AardramMission is one of the programmes implemented under Nava Kerala Mission in Health Sector. The major thrust under the scheme is making the hospitals patient friendly and providing quality services to the patients who depends the hospitals in Govt. Sector. As the implementation of the Aardram mission is expected

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to carry out in a time bound manner, it is proposed to do the implementation of the programme, through National Health Mission Kerala. The works under Aardram Scheme were got implemented in8 Medical Colleges, 17 District Hospitals, 14 Taluk Hospitals and all PHCs in the State. With the implementation of the Aardram Projects Patient Friendly Amenities such as Patient Waiting Areas, Queue Management System in the OP, Pharmacy & Lab providing adequate seating facilities, Drinking water and toilet facilities, proper signageâ&#x20AC;&#x2122;s, LED TV in the waiting area, PA system etc.to the patients are provided.

Likewise, when Kerala faced unprecedent floods during 2018, he has taken efforts to revamp the various institutions and tried to get sponsors for various institutions. The central Government public undertakings came forward to sponsor a number of works, only because of the efforts put in by the Additional Chief Secretary. The Technical advice, guidance and Support provided by Shri. Rajeev Sadanandan, Additional Chief Secretaryare greatly acknowledged.

The Additional Chief Secretary Health and Family Welfare Department has evinced keen interest in giving necessary directions to formulate proposals for various works and he has monitored the implementation of schemes at various stages. In a nut shell, only due to the timely guidelines and intervention of Additional Chief Secretary the implementation of above schemes were materialised.

KSACS A major activity conducted during (July to October 2017) was the Baseline Assessment 170 of Blood Banks in Kerala. The assessment was conducted under the guidance and leadership of Sri. Rajeev Sadanandan IAS, Additional Chief Secretary, Govt. of Kerala

The study was technically and financially supported by WHO. 28 Transfusion Medicine experts from our state was trained in carrying out the study. These trained assessors visited and assessed 170 Blood banks in Kerala.The data was analysed with the help of a Data Manager. Based on the observations, the assessors were divided into 6 working groups to come up recommendations to tide over the deficiencies identified. First recommendation is Donor Management –this was to provide safe and 100% Blood transfusion through Voluntary Blood transfusion by increasing the number of Outreach VBD camps, awareness through effective IEC and Uniform

Dr Ramesh Rairu PD, KSACS

Donor selection criteria. Another recommendation was the Standardization of collection, processing, storage and inventory management in blood banks, to ensure quality consumables and reagents, Effective supply chain management, Uniform data management/biomedical waste management, Adequate man power/work space/equipments ,Calibration of equipment’s and AMC . They recommended the Formation of Hemotherapy Cell under KSBTC to monitor and improve transfusion practices, Redistribution of Blood banks and Blood Storage Centres to ensure Blood availability, Temperature trackers to ensure Cold Chain maintenance of Blood Units and Periodic training of Clinicians on rational use of Blood through NACO/SBTC. Strenghthening of Immunohematology by Automated /semi automated platforms for screening procedures and ensuring EQAS programs and Auditing of Blood Banks including Human Resources was the other recommendations.

There are 61 Targeted Intervention (TI) projects functional in the state which include 20 projects addressing Female Sex Workers (FSW), 13 for Men having Sex with Men (MSM), Five Injecting Drug Users’ (IDU) projects, Six Transgender (TG) projects, 15 Migrant Projects and Two Trucker Interventions. Many activities were done of which an important one was the State Level Workshop conducted by the directions Sri. Rajeev Sadanandan IAS, Additional Chief Secretary, for the Re-Strategizing Out Reach among Female Sex Workers.

level work shop was organized in January 2018 at Trivandrum. The intention of the workshop was to explore the dynamics of sex operations and identify alternative programme strategies in Outreach for FSW TI Projects Kerala. Following to this, wide Community Consultations were done. Case Studies, In-depth Interviews & Focus Group Discussions were conducted. Expert Consultations to explore possible alternative strategies was also held.

Commercial Sex Operations and Sex Networks has undergone paradigm shift. FSWs are no longer visible in open streets to solicit clients. Intrusion of mobile phones and diverse new media, have replaced physical to virtual solicitation spaces. Diverse modes of sex operations too have been adapted over time, thus hindering the conventional outreach strategies for HIV prevention services. Based on these assumptions, a two day State A JOURNEY

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