In 2004, Tamil Nadu had been battling stagnant infant and maternal mortality rates for a decade. A shortage of skilled doctors and nurses as well the lack of emergency transportation services and blood bank facilities prevented the state from reducing these mortality rates further. Vulnerable groups, especially remote tribal populations, did not have good and affordable medical care near their homes, nor did they know where these services might be available. And although non-communicable diseases such as breast cancer, cervical cancer, diabetes, and hypertension were on the rise, the public health system did not screen for these four major diseases. District and sub-district hospitals were in a state of disrepair and needed more equipment and trained staff to meet the growing numbers of patients. Management and policy decisions were hampered in the absence of a system for collecting performance data. These issues contributed to a state health system that was performing far below its potential.
To bring down the infant and maternal mortality rates, 80 hospitals – two in each district - were designated as Comprehensive Emergency Obstetric and Neonatal Care Centers. These centers, open 24 hours a day, were provided with skilled doctors and nurses, new equipment, and improved blood bank facilities. A public-private partnership bought and equipped ambulances to provide free emergency transportation to ferry patients to medical centers within 30 minutes from anywhere in the state. The project helped bring quality healthcare closer to vulnerable groups, especially remote tribal communities, through partnerships with non-governmental organizations and private sector groups.
A program to screen and treat cancer of the cervix and hypertension was piloted in four districts. On its successful completion, the pilot project’s scope was widened to include breast cancer and diabetes. This is now being expanded across Tamil Nadu to address the state’s growing burden of non-communicable diseases. A web-enabled information system is being set up in 270 project-supported hospitals to improve management functions and accountability, and better inform policy decisions, and 12 hospitals are being prepared for certification from the National Accreditation Board of Hospitals to ensure that their procedures and performance meet acknowledged standards of quality.
Moreover, some 270 community health centers, district and sub-district hospitals now have web-enabled hospital management systems to improve managerial decisions and accountability. Doctors, nurses, paramedical staff and community health workers have been trained to improve their clinical and administrative skills.
Altogether, these efforts have helped the women and young children of Tamil Nadu in a number of ways:
- Thanks to the network of 80 obstetric and neonatal care centers and free ambulance services, over 99.5 percent of deliveries in Tamil Nadu now take place in medical facilities;
- This has, in turn, helped reduce the infant mortality rate in the state from 41 per 1,000 live births in 2004 to 28 per 1,000 live births in 2009;
- The maternal mortality rate has also fallen, from 109 per 100,000 births in 2004-05 to 79 per 100,000 births in 2008-09;
- As of September 2011, 432 well-equipped ambulances are providing free emergency transportation services. These services have proved especially beneficial for expectant mothers who can now reach medical facilities in time for their deliveries. Of the 130,880 emergency cases transported by these ambulances between October 2010 and September 2011, about 21 percent were pregnancy-related;
- Between April 2008 and September 2011, a total of 399,423 complicated obstetric cases were admitted at the 80 Comprehensive Emergency Obstetric and Neonatal Care Centers. Almost 40 percent of the women admitted were from the Scheduled Castes/Scheduled Tribe communities, indicating equity in access to improved health facilities for vulnerable groups;
- Remote tribal communities and other vulnerable groups have benefitted from free weekly medical outreach vans. Doctors at these vans treated 512,416 tribal patients between May 2008 and March 2010. In addition, some 2,300 tribal patients were provided free inpatient care at hospitals run in partnership with non-governmental organizations (NGOs). Some 15,730 tribal people were screened for sickle cell anemia, of which 1,618 patients diagnosed with the condition were placed on treatment;
- The state has scaled up the screening and treatment of breast and cervical cancer, diabetes and hypertension. Between November 2006 and September 2011, 518,000 women between 30-and-60 years of age were screened for cervical cancer, with a detection rate of 5.5 percent. In addition, a total of 1.2 million people were screened for hypertension between October 2007 and March 2010. Of these, almost 150,000 people who were found to have the condition were placed on treatment;
- To date, the new health management information system is operational in 270 project-supported hospitals, while the web-based hospital management system in online in 126 project-supported hospitals;
- Two district level facilities have been accredited by the National Accreditation Board of Hospitals;
- Repairs and renovations have been carried out in 270 project-supported hospitals. These hospitals have also been supplied with the necessary medical equipment to improve the quality of health services. Additionally, between January 2005 and September 2011, most of the doctors, nurses, paramedical staff and community health workers mapped to these 270 health facilities have been provided clinical, administrative and skill-based training to improve the level of service provided by them.
International Development Association (IDA) supported the Government of Tamil Nadu with funding of US$97.5 million. In September 2010, additional financing of US$117.7 million was approved and the project was extended for a further three years.
Within the Government of Tamil Nadu, the Department of Health and Family Welfare, has been the Bank’s implementing partner for this project. The project also works closely with its two critical arms—the Department of Medical Services and the Department of Public Health. Procurement of all medical equipment and pharmaceuticals is performed by the Tamil Nadu Medical Services Corporation and procurement related to information and communications technology is being handled by the Electronics Corporation of Tamil Nadu Ltd.
Toward the Future
By the end of the first phase, the Tamil Nadu Health Systems Project had begun to integrate project-supported activities with the routine health services provided by the state. Tamil Nadu is now making enormous efforts to sustain and carry forward the investments made through the project in the widespread provision of obstetric and neonatal care, bringing health care to remote tribal communities, the establishment of health management information systems, as well as for accreditation of hospitals and the training of staff. This is reflected in an increasing state budget for health, with funds being allocated for taking over project-supported activities as the IDA funding for their recurrent expenditures is progressively reduced.