Community Health and Development (CHAD)

While we spent last week at the bustling main hospital, today Moriah and I started at CHAD, where we see the other side of the cost support coin, the patients whose medical care is mostly paid for by the patients who pay for private rooms at the main hospital. The facility is located righty next to the medical college campus, on the outskirts of vellore proper.

It is a small hospital in comparison, only about 80 beds, but it is attached to an extremely busy outpatient clinic. We, however, spent the day with the traveling general medicine and maternal fetal medicine clinic. Five students, three nurses, a community health aid, an intern and one physician piled into an ice cream truck sized traveling clinic equipped with an examination table, medical supplies, and a pharmacy.

We stopped at two villages where the locals had gathered. One of the nurses was kind enough to patiently explain the system to me. Each of the villages had one person assigned to be the part time healthcare worker, for which they received a little bit of money. This person was responsible for getting all the people in the village with medical conditions to meet at a certain place every month to receive care from the traveling clinic. They were also trained to recognize common medical issues (cough, leg swelling, blurred vision, etc) and have these people come to the clinic as well. Each person is responsible for brining their medical chart, in this case a single piece of paper with a list of each encounter they had at the clinic, each one taking no more than two or three lines of scrawled physician notes.

The part time health care workers reported to the community health aid, a full time employee who had more substantial organizational and medical training who traveled with the clinic. She reported to the area registrar, the physician in charge of the program at CHAD. Tried to get an idea of the budget but the people on site weren't familiar with the actual figures.

So the part time healthcare worker assembles her villagers in need of care at the site on time for the ice cream truck converted into a clinic. The villagers come carrying their children and their chart, and are seen by the intern, only a year out of medical school. He sees all of the old patients with chronic illnesses first (lots of hypertension, diabetes and COPD) and then will see anyone with new medical complaints.

About 30 patients were there to be seen, and he moved quickly, seeing all of them in around an hour and a half (3 minutes per patient). Despite over a week in India I remain unable to speak Tamil and was able to help him by taking the patients vital. To my surprise, he only wanted blood pressure on the patients who were being seen for hypertension. Screening was not the name of this game, we were here to efficiently manage chronic illnesses in these villagers, and that meant ensuring they were adherent to their treatment plan and that it was working. After being seen they would go to the pharmacy in the truck to receive their medications. If the patients had new medical complaints or if they showed worsening symptoms in spite of medication increases, they were asked to come to the CHAD main campus for more detailed evaluation. If they required more than just basic laboratory evaluation, even something as seemingly simple as a chest x ray, they would have to go to the main hospital.

Once again Moriah and I found the details of cost very interesting. CHAD provides low cost, not no cost medical care, to the majority of its patients. Only the extremely poor receive their care for free. I was curious how this was determined, as I saw no social worker going through pay checks or w2s to determine income level, and it seemed like patients could lie about their income in order to avoid paying 10 Rs for their medications. It turns out the part time healthcare workers are also responsible for determining which patients should be able to pay for their medical care, and how much they can afford, and they report this information to the community health care worker.

Moriah spent a great deal of time with the maternal-fetal medicine clinic. There pregnant women were quickly assessed for symptoms and a rapid physical exam was performed. If it was their first visit, they were screened for HIV and hepatitis b. though most of the patients were termed low risk, she did come across a particularly interesting high risk patient, who was married to her uncle. Turns out this is not uncommon in the rural villages.

Another interesting note about the maternity care in India; determining the sex of an fetus before it is born is illegal. This into prevent abortions of female fetuses, which is probably related to the cost of providing a dowry. Dowries are now illegal in India and are starting to disappear, but this remains a serious public health problem.