A PHC in a remote Kerala village shows where there is a will, there is well-being

Fifty-five-year-old Jose Thomas made a living working as a salesman at a spices shop at Mananthavady in Wayanad district of Kerala. In the January of 2021, however, his life turned upside down when he fell from a tree and injured his spine. The spinal injury left Jose paralysed waist-down.

“He remained in a private hospital for over a month paying Rs 6,000 per day. When the treatment was over, physiotherapy followed. We did physiotherapy for a few days in that hospital, but we could not afford it after a point,” Jose’s nephew Amal told The Federal.

The family took Jose home but he still could not move and was in need of physiotherapy. It is then that neighbours and a few distant relatives suggested that the family could take Jose to the Family Health Centre (FHC) in Noolpuzha panchayat.

So, to begin with, the family wasn’t convinced. They reluctantly took Jose to the centre only to find that the Noolpuzha FHC is the top choice for patients who need physiotherapy not just in Kerala but also the neighbouring states of Tamil Nadu and Karnataka. Within months of treatment Jose not only began to walk but also returned to work as a salesman in a nearby shop. Jose is just one among the many of those who come on wheelchairs to Noolpuzha FHC but go back walking.

Among the many who have benefitted from the treatment at the Noolpuzha FHC is 51-year-old NK Hairunnisa, a native of Vythiri in Wayanad.

Hairunnisa suffered a stroke in September 2021 which led to paralysis.

“The left side of the body was completely paralysed. She underwent treatment for more than a month. Though she came back to life, we had little hope that she would recover completely,” Hairunnisa’s daughter Fasna told The Federal.

Being a daily-wage labourer, each day away from work meant no money. After being treated at a private hospital, Hairunnisa got admitted at the Noolpuzha PHC for a 30-day physiotherapy session.

“She started working again recently. Though she is not as healthy as she was before the stroke, she still manages to earn a living,” Fasna said, adding that her mother’s recovery was like a miracle for the family.

Noolpuzha FHC: Preventive healthcare

The Noolpuzha FHC, which was a Primary Health Centre (PHC) until 2018, stands out not just for the remarkable physiotherapy it extends to patients but also because it provides quality medical services in a tribal area with state-of-the-art curative and preventive healthcare facilities. Tribal communities constitute 50 per cent of the total population of Noolpuzha panchayat.

When one thinks of a PHC in a rural set up, the picture that comes to one’s mind is of a poorly-maintained, dilapidated facility with dirty toilets and lack of doctors and other healthcare officials. The Noolpuzha facility, one among the many upgraded as a FHC by the Kerala government, stands in stark contrast. PHCs in Kerala have been upgraded to FHCs under the ‘Aardram Mission’ to make the public healthcare system more efficient and people friendly.

While PHCs generally remain open up to noon, FHCs are open from 9 am to 6 pm. PHCs had just one doctor, while FCHs had about three doctors and a larger number of nurses, lab technicians. FCHs come with modernised labs, lifestyle diseases clinics and workout spaces.

A visit to the FHC at Noolpuzha makes it hard to believe that it is not a full-fledged hospital. It is this feat which has since 2018 ensured the Noolpuzha FHC wins the National Quality Assurance Certification with an impressive score of 98 per cent. A functioning out-patient department till 6 pm with two doctors, an in-patient section with 10 beds, laboratory with facility for 40-odd tests, an exclusive unit for physiotherapy with in-patient facility, dental clinic and speech therapy centre for children are only a few among the many services provided at this FHC.

The Noolpuzha model of primary healthcare has set a unique example of how to establish a system which successfully caters to the needs of the community. Kerala has over 700 PHCs upgraded as FHCs

One need not necessarily be sick to visit the FHC. There is a gymnasium and fitness centre, a play area for children and a banyan tree corner for senior citizens to gather with a snack bar. The OPD has a well-furnished large waiting area for the electronic display of token numbers for consultation. “We are trying to make the atmosphere people friendly as best as possible, primarily because this is a tribal panchayat,” says Sanu Chandran, the technical assistant at the FHC.

Welcoming feel

The FHC administration realised that people of the tribal communities find hospitals very unwelcoming for the costs involved and the overall treatment they get because of their social moorings.

“The tribal people are generally scared of hospitals. They find the hospital atmosphere intimidating. We understood this and thus decided to make the atmosphere as friendly as possible,” said Dr Dahar Mohammed, medical officer who is said to have taken the lead in making the FHC people friendly.

The FHC is not just for people who are sick because the very concept of primary health care in Kerala is prevention, not cure. “Our field workers do regular visits and closely monitor the health of the tribal population, especially women and children. Anaemia is a very common health issue identified among the tribal people,” says Dr Dahar.

The health workers of Noolpuzha go to the tribal settlements, conduct blood tests, particularly for women and children. “We prepare the list of people with haemoglobin less than 10. They are generally hesitant to take medicines. Hence, we provide injections for those who have acute iron deficiency,” said Sanu Chandran. Women and adolescent girls are given special care with an intention to break the chain of hereditary transition of anaemia.

The doctors and health care workers at the FHC believe that a primary health care centre caters to holistic needs of the community. The latest to make to the list of people friendly projects of the FHC is the refreshment centre for highway passengers, especially women.

This refreshment centre named ‘Penma’ (womanhood) has a neat and tidy rest room with comfortable sofas for four to five people at a time and a washroom. A separate feeding room for breastfeeding women also exists. “Anybody can use this building, patients, bystanders or highway passengers. We welcome any woman who passes and is looking for a neat washroom or a private space to feed her baby,” says Sanu.

People’s thumbs up

The Federal met 55-year-old farmer Verghese while he was waiting in the crowded OPD area. Despite the rush and the long wait, Verghese had no complaints waiting for his turn.
“Lot of ordinary people like me trust this PHC. I am ready to wait because they provide services on a par with any private hospital that too free of cost. When a lot of people depend on this centre, it is natural that we have to wait,” he said.

Many others who were waiting for their turn also expressed the same view – happy and contented with the service provided at Noolpuzha FHC. “Even if you go to a private clinic for a normal fever, you will have to spend at least Rs 300 to 500. Here we get very good service free of cost,” said Fatima, who was at the FHC for regular consultation for diabetes arguing that the long queue and the waiting time are minor issues considering the services extended by the staffers.

The first thing that one notices while entering the facility is an electric autorickshaw in blue and white parked in the corner. This vehicle is used to carry senior citizens within a 5-km radius from their homes to the FHC if required. When there is a need, they are also dropped back home. Like all other services, this commutation is also provided free of cost.

The transformation

How can an institution at the primary level extend such facilities to patients? Where does the money come from?

The team at Noolpuzha has developed a sustainable model for that.

“This PHC was, like any other, was suffering from a lack of human resource and infrastructure. All that began changing in 2016,” says Sanu Chandran. That was the year Dr Dahar joined. Sanu and all other healthcare workers unanimously hold the view that the PHC got a rebirth under his leadership.

Since then, Dr Dahar and his team did not miss a single project both under National Health Mission as well as the state government. “We conceptualised several projects, prepared proposals and won financial support from several corners. Individuals and organisations came forward to support us too,” says Dr Dahar.

The government’s Aardram scheme helped bring about the drastic transformation of the Noolpuzha PHC to a FHC. In the first phase, the PHC received Rs 1.80 crore for maintenance and development from the panchayat, which is part of the Local Self Government (LSG) funds for healthcare. Kerala implemented decentralisation in 1997-98 with devolution of 35 to 40 per cent of state plan funds to LSGs.

There are eight categories under which funds are granted to FHCs by both the Centre and the state governments including general purpose grant, financial commission grant and development fund (as ST/SC development fund).

The Physiotherapy Centre, one of the most prestigious projects of Noolpuzha FHC, was completed with the help of the Corporate Social Responsibility funds received from Cochin Shipyard. Member of Parliament Elamaram Kareem provided a substantial amount of money from the MP fund for the equipment needed in the Physiotherapy Centre.

The Physiotherapy Centre has more than 20 modern equipment providing specialised services. Electrotherapy machine, Adult Rehab Treadmill and Paediatric Rehab Treadmill, imported robotic hand therapy machine, KINECT XBOX Video Game Therapy, shockwave therapy and different types of walking aids are some of the services available in this Physiotherapy Centre.

All it costs is Rs 150. “Even that is exempted for physically/mentally challenged, BPL card holders and tribal people among others. So, only about 20 per cent of those who avail the services have to pay for it,” said Sanu.

High achiever

The 2019-20 report of the Union Ministry of Health and Family Welfare explains how Noolpuzha FHC got the National Quality Assurance Standards certification. “The overall score of health facility was 98%. Department wise scoring was: 98.7% for OPD, 95.6% for Laboratory, 97.3% for national Health programmes and 98.2% for general. The score obtained for different area of concern was: service provision 96.8%, patient rights 96.2%, Inputs 98.6%, Support service 99.7%, clinical service 97.7%, infection control 99.4%, quality management 91.0 and outcome 100%.”

Noolpuzha FHC has other unique achievements too. It is the first such centre to introduce an e-health programme. Under the programme, the data of the all members of households in the area is digitised which makes the services more efficient.

There is an e-health kiosk near the OPD registration counter, if a patient revisits the hospital within one month, there is no need to go to the registration counter. They can use the old OPD number to get a token number for the consultation.

It is efficient systems like these that make the wait at the FHC for people like Verghese less troublesome and healthcare within reach.