1. Access and Barriers to Care within the Indian Healthcare System Observership at Christian Medical College, Vellore, Tamil Nadu, Southern India. June-July 2014 Lauren Andrus, University of Kansas School of Nursing Population: 1,103,956,000 Area: 1, 269,221 sq miles Languages: 14 including English and Hindi Religions: Hindu, Muslim, Christian, Sikh, Buddhist, Jain, Parsi Life Expectancy: 63 GDP per capita: $2,600 USD Literacy %: 60 GDP spent on heath care: 1.4% Health care expenditures: 74% out of pocket Population: 1,103,956,000 Area: 1, 269,221 sq miles Languages: 14 including English and Hindi Religions: Hindu, Muslim, Christian, Sikh, Buddhist, Jain, Parsi Life Expectancy: 63 GDP per capita: $2,600 USD Literacy %: 60 GDP spent on heath care: 1.4% Health care expenditures: 74% out of pocket (National Geographic, 2014)

2. To assess the issues that surround access and barriers to public healthcare in India.  Identify populations that utilize private vs public sector care and relative access to care  To study the barriers to care in India, such as economic status, language, and geographic location.  To evaluate maternal care in rural/economically disadvantaged communities and observe quality and access of care for the expectant mother.  To study emergent care in India, access to care, and emergent situations that are requiring immediate care.  To explore recommended broad methods for improving care access that may be applicable or appropriate to this particular healthcare setting. Objectives: A Community Outreach Nurse checks a blood pressure during a rural patient home-visit. June 2014

3.  Government healthcare is low cost, but has limited reach and underfunding causes serious barriers to care. Government care is seen as inferior and more difficult to access (Chang, et al., 2013).  22 official languages, which can affect communication between patient and provider (Narayan, 2013).  22-27% of the population lives in extreme poverty, making healthcare unaffordable, especially in rural areas (68.84%) despite government reforms to increase access (Ghosh, 2014).  High out-of-pocket costs for care and prefers private for-profit institutions, compound the issue of affordability of care for the poor. (Chang, et al., 2013)  India has 1/5 th of the global burden of absolute maternal deaths (Montgomery et al. 2014).  Poorest and more rural states have highest maternal mortality rates (397 per 100k) vs richer, urban states (119 per 100k) (Montgomery et al. 2014).  Unintentional injury is the cause of 7% of all deaths in India, 27% being vehicle accidents. 80% of unintentional injury deaths occur in rural areas (Jagnoor et al., 2012). Background. A slum in an urban area of Vellore. July 2014 Treatment room at the Low Cost Effective Care Unit, Vellore. June 2014.

4.  Well-respected private hospital and training facility for health-related professions  Founded as a single- bed institution in 1900 by Dr. Ida Scudder who recognized the need for accessible care for urban and rural patients in need.  Long-standing tradition of community outreach, free clinics and efforts toward the improvement of accessibility of healthcare to the less fortunate. CMC and Peripheral Clinics. CMC provides care on all three levels, primary, secondary, and tertiary. Mission is to provide accessible, quality, affordable care for the people of the surrounding area, both urban and rural. Developed several initiatives to work with the community, and partner with government programs to provide care to those in need. Firsts at CMC First College of Nursing in India (1946) First reconstructive surgery on a leprosy patient (1948) First successful open heart surgery in India (1961) First Rehab unit opened in India (1966) First Kidney Transplant in India (1971) First Bone Marrow Transplant in India (1986)

5. CONCH – College of Nursing Community Health initiative. Nurse-run clinic provides primary care in the surrounding villages and underserved urban areas. Medication is provided to patients who cannot afford it. CHAD – Community Health and Development Clinic has 120 beds Lower cost care is available here. RUSHA -- Rural Unit for Health and Social Centrally-located 69 bed rural clinic serves the outlying populations. Also houses a community college that helps to train students to have a career to fight unemployment. LCECU – Low Cost Effective Care Unit 46 bed clinic serves over 20,000 in the urban area of Vellore. Extremely low costs to those in need. Demand for these services is high, and only 250 patients can be seen a day CMC Hospital – Tertiary care facility and 2,632. bed hospital, with outpatient facilities to serve over 2.1 million patients a year. 39 Operating rooms. 19 ICUs. CMC & Clinics Tertiary & Emergent Care CMC Hospital CHAD, RUSHA (limited services available) Secondary Care LCECUCHAD, RUSHA Primary Care CONCH, LCECUCHAD, RUSHA The waiting room to be seen by a medical professional at RUSHA. June 2014.

6.  Private care preferred by all populations in India. Private staff seen as competent, better trained, and care is of higher quality despite out of pocket cost (Chang, et al., 2013).  Government health care is underfunded, understaffed, poorly accessible (find quote).  CMC utilizes profits from paying patients via private rooms and elective procedures to find care for the economically disadvantaged  Holistic care with their programs that serve all economic, religious, and social backgrounds.  CMC partners with government initiatives to meet healthcare quality improvement goals.  Community outreach clinics focus on primary interventions to improve overall health for their patients, helping to prevent illness.  Emphasize the importance of patient teaching and management for long-term illnesses such as diabetes, hypertension, high cholesterol and heart disease. Populations that utilize private vs. public sector care. Diabetes management class at LCECU Vellore. June, 2014. CONCH nurses give a presentation on intestinal parasites at a government school. July, 2014.

7.  Underutilization of government system  Underfunded government health system  Extreme poverty  Reduced Rural Access  Language barriers  High-out-of pocket costs Barriers to care. CONCH Equipment Kit used during rural visits. June 2014. A girl awaits care with her mother at RUSHA. June 2014.

8.  CMC wards have a “free” bed, that doctors can use for a patient that is unable to pay.  Programs are in place to help offset the cost of expensive treatment dispensed by committee on an as- need basis.  Nurse-run clinics – CONCH perform house calls daily in rural villages to help those that cannot afford travel to CMC.  Assessment includes a record of the family, main health complaints, occupation, the quality of the dwelling -- updated with every change within a family.  RUSHA – Rural clinic is more accessible to patients, and also performs visits to outlying areas.  CHAD serves a “block” of 82 villages of the Kaniyambad area(250,000 pop.), holds doctor and nurse-run clinics  Community liaisons are used to coordinate clinics, address language barriers Local Strategies to Address Improved Care Access. Keeping costs low to help make care more affordable: CMC registration fees: Hospital: 120 Rs CHAD: 60 Rs LCECU: 20 Rs (one time fee). Rural & Home Visits via CONCH, CHAD: No cost.

9.  “Financial inability was cited as one of the most predominant reasons for not seeking care by the rural and poor population. The situation seems to be further worsening for the poor and rural population (Ghosh, 2014)”.  High out of pocket costs have made care unaffordable for the poorest (Gill et al., 2013).  Government ambulances are available for free to help transport women to the hospital for birth.  Government scheme to implement free generic medicine schemes in Tamil Nadu (Chang, et al., 2013) to reduce costs. System Strategies to Address Improved Care Access. System Strategies to Address Improved Care Access. Patient records at RUSHA. June 2014. Some government agencies incentivize rural caregiving (Gill et al. 2013). India spends only 1.4% of GDP on government health (vs 5% global average). Increased funding for government system a priority to attain global median of 24 beds per 10k pop (Jehani, 2012).

10.  50% of deaths occur at home, 13% in transit to health facility, 25% of these deaths are due to maternal hemorrhage (Montgomery et al., 2014).  Institutional births are encouraged to reduce complications. CMC has partnered with the government system to bring antenatal care to women in rural areas  Utilization of birth cards that track gestation, and the post-partum condition of the child including vaccinations and growth.  CONCH performs home visits, well-baby and well- woman check ups post partum.  Vitamins and medications provided to support women during pregnancy  Education provided on breastfeeding, diet and care for infants. Community and Local Strategies to address Maternal Mortality Rates Overall maternal mortality rate has decreased by ~50% and was reported at 200 deaths per 100,000 live births as of 2010. Tamil Nadu has reached the Millennium Development Goal of a maternal mortality rate ratio less than 109 deaths per 100,000 live births (Chang et al, 2013). CONCH nurse arriving to conduct an antenatal health clinic in a rural community. June, 2014.

11.  Level I emergency & trauma services  First nurse-run triage in India.  Walking triage implemented to assess patients that may have heart attack and stroke that may be waiting in line.  Developing separate ED for chest pain.  7 bed Resuscitation Bay for stabilization of immediately critical priority 1 patients.  Trauma Bay for trauma patients that are stable and awaiting emergency surgery or further assessment.  Recognized as an International Training Centre for Accident and Emergency Care by the WHO. The department trains and awards the WHO Training Certificate to health professionals of South-East Asia.  Cost for registration set at 200 RS ($3.32 USD) to make it accessible to most patients, but no patient ever is turned away. Community Strategies to Address Emergency Care. The line outside CMC Hospital’s Emergency Department. June 2014.

12.  Complete access to care across the lifespan, primary, secondary, tertiary, maternal and emergency is imperative to the lifelong health of the population and ideas for improvement should be examined.  Government is improving affordable access to care but change is slow. Expansion of funding and extension of universal insurance is necessary.  CMC is working to bridge the gaps between government care, and unaffordable private care in the emerging country of India.  CMC is successful at supporting and partnering with government care programs to improve access.  Possible to have the needs of the people met efficiently and affordably between the private and public systems. Conclusions. An urban clinic run by nurses in an area close to Vellore, India. June 2014. A slum in a semi-urban area of Vellore. June 2014.

13. The most important clinical experience I had in India was not all at once, but a process throughout my entire time there. What I learned was how to rely on more than words to connect and communicate with patients. I could not speak the language, and it was incredible to be able to experience human interaction on the most basic of levels, through gestures, touch and body language without speaking, but still being able to ask a patient where it hurts, to give comfort, or to reassure when a patient is afraid or in pain. I believe the ability to connect on this level takes a great deal of practice and is difficult to master. This skill is something I can use throughout my entire career to improve the connection I can make with my patients. Clinical Experiences. A ceremonial funeral wreath. June 2014.

14. This observership at CMC was incredibly rewarding and rich because it was a very immersive experience. As such, I was able to experience the culture in a way that was real and immediate. I did not visit CMC as a tourist. I was a part of the culture and the way people lived. I ate the same food, used the same transportation, went to the same stores, wore the same clothes and haggled for my rickshaw rides like any student at CMC would. I saw how people lived, and I was welcomed into their homes. I saw and the challenges and benefits of life in India first hand. It was incredible to experience the culture of India this way, and I feel it would never have been possible by simply visiting. Cultural Experiences. A brightly painted house in a village. June 2014.

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