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Role of "Aardram Mission" in delivering public health care services in the

State Background

Conference Paper · November 2022

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Role of “Aardram Mission” in delivering public health care services in the
State
Syama U S, Research Scholar, Lincoln University College-Marian Research Centre, Kuttikkanam,
Peerumedu P O, Idukki, 685531
[email protected]
Dr.K.V. Thomas, Professor and Head, Research and PG Department of Commerce, Marian College
Kuttikkanam (Autonomous)-685531, Kerala.
E mail; [email protected]
Background:
Public Health care programmes help to keep people healthy, increase life expectancy, reduce
infant mortality rate, reduce or eradicate communicable disease etc. Kerala's successes in
social development despite its dismal economic performance, the state gained special
mention in the first Human Development Report (HDR) published by the United Nations
Development Project in 1990. Even if the government take hard effort to realize the objective
or aim of the public health programmes, it is not sure whether the programme would be
capable of or efficient in improving the public health care system. Hence, it is very important
to analyse the progress and effectiveness of ‘Aardram’ mission on ground of improvement of
public health care system and accessibility of Family Health care Centres to the people. The
role of Public Health care systems in Global health has high relevance. The findings of this
study will throw light upon how effectively the grass root level health care institutions
decentralize in imparting health care services to the individuals. Family Health Centres are
part of new public health care programme launched by the State Government of Kerala with
an objective to revamp and revitalize the Primary Health care system in 2016. Five years down
the lane how far this programme has achieved its objective is a major area under concern.

Literature Review

Soter Ameh (2015) presented a study on “The relationship between structure, process, and
outcome as a measure of quality care in an integrated Chronic Disease Management model
in South Africa”. Taking patient and operational manager satisfaction in the dimension of
care, and using patient satisfaction values to assess the relationships between the structure,
process, and outcome components as a measure of quality of care in the ICDM model, a
precisely associated goal. The basic components of the ICDM model include delivery of critical
medicines and equipment, pre-packaging of medicines and equipment, training of referral
defaulters, and an appointment system. A cross-sectional study was carried out in the
Bushbuckridge sub-district, which consist of 38 PHC facilities out of which 17 are ICDM model.
The study population was the patients belonging to the category of chronic diseases like
hypertension, HIV, and diabetes. The Donabedian model of quality care was used for the
study in unidirectional, mediation, and non-recursive pathway. Four hundred and thirty-five
responses were taken and adjusted 10% for non-response. The study of patient satisfaction
was done on a five-point Likert scale .The study found that operational managers rated
satisfaction with respect to 16 dimensions of care. Patients reported satisfaction in 14
dimensions of care. Operation managers and patients were dissatisfied with patient wait
times. The current study uses a 3-point Likert scale for patient satisfaction.

Alia Almoajel, Ebtisam and Alshamrani (2015) conducted a study on “The patient satisfaction
with Health care in Jubail City, Saudi Arabia”. Study objectives included assessing patient
satisfaction with various aspects of primary health care and assessing the availability of the
health education program. For the study, a sample of 200 patients was drawn using a random
sampling method. This was a cross-sectional study which involved collecting the details of the
socio economic back ground of the patients. Patient satisfaction was measured with the help
of dimensions like accessibility, continuity, comprehensiveness, communication, health
education, and overall. The collected data were statistically evaluated using chi-square test,
t-test and ANOVA. This study found that patients responded well to their general level of
primary care. In the present study, many of the variables used in the study were used to assess
patient satisfaction.

Anitha and Thimmaiah (2013) presented a study “Satisfaction from primary health care; A
comparative study of two taluk in Mysore District.” The objectives were to explore the
utilization rates of PHC services in study area, compare the utilization between two taluk, and
to determine the possible reasons behind the satisfaction with respect to PHC services. Out
of the two-taluk selected one was developed, Mysore taluk and the other was
underdeveloped H.D Kote taluk. Sixty randomly selected respondents were surveyed using a
well-structured questionnaire. The study variables involved socio-economic factors, distance
from PHC, and the health status of the respondent, health insurance, awareness of
government programmes and utilization pattern of the PHC. The tools used for the analysis
were t- statistics, Likert scale etc. The results turned out was the underdeveloped H D taluk
shows a higher utilization pattern compare to Mysore taluk. While Kota taluk has a lower
satisfaction when compared to that of Mysore taluk.

Anitha and Thimmaiah (2013) presented a case study on “the extend of utilization of PHC in
rural areas and to track the causes which hinder the accessibility of PHC services”. For the
study, Kurakula PHC in Mysore district has been chosen. A random sample of 50 respondents
was taken for the study. Chi-square test, dummy regression and correlation analysis has been
used in this study as assessment tools. .It is finally established that there exist the accessibility
of PHC to the local about 82%. The inhibiting factors of access are income, educational level,
and distance. Among these reasons, distance holds the primary reason.

Põlluste, Kallikorm et.al (2011), this was a cross-sectional study titled “Satisfaction with
Access to Health Services: The Perspective of Estonian Patients with Rheumatoid Arthritis”
The aim of the study was to understand the rationale behind the satisfaction of patients with
rumatoid arthritis. The variables used for the study involved waiting time, doctor-patient
relation, waiting time, and travel cost. The result showed that the majority of Estonian
rheumatoid arthritis patients were satisfied. However, long wait times and higher
transportation costs had a negative impact on satisfaction.

"Patient Satisfaction in a Primary Health Facility in a West Bengal District: Are Our Patients
Really Satisfied?" is a study conducted by Avantika Bhattacharya et.al (2006) to evaluate the
satisfaction of the patient visiting the PHC. This was a cross-sectional study conducted at
Guskara PHC in West Bengal. The PHC was a ten bedded centre which covers a population of
28000 populates. The sample was selected accordingly from the population. A total of 422
people were interviewed. The questionnaire was divided into three parts: socio-economic
factors, reasons for patient satisfaction and reasons for patient dissatisfaction. Tests included
unpaired t-test and one-way ANOVA. The study showed that greater satisfaction was
observed in the 18-20 age group. Men were more satisfied than women with quality care and
literate people showed more satisfaction than illiterates. The main reasons for dissatisfaction
were long queues, inadequate seating, lack of cleanliness, unavailability of toilets and the
behaviour of the doctor.

“Patient Satisfaction at a Primary Level Health care Facility in a District Of West Bengal: Are
Our Patients Really Satisfied?” is a study done by Abantika Bhattacharya et.al (2006) to assess
the satisfaction of the patient who visited the PHC. This was a cross-sectional study undertook
in Guskara PHC of West Bengal. The PHC was a ten bedded centre which covers a population
of 28000 populates. The sample size was calculated using a formula (N = Z2pq/e2.). A total of
422 respondents were surveyed. The questionnaire was structured in three parts
socioeconomic factors, reasons for patient satisfaction, and reasons for patient
dissatisfaction. The tests involved unpaired t-test and one way ANOVA. The study showed
that higher satisfaction was observed among the people of the group 18-20 years. Males were
more satisfied than females in quality care, and literate people showed higher satisfaction
than illiterate people. The major reasons for the dissatisfaction were longer waiting queues,
the inadequacy of seating arrangement, lack of cleanliness, non-availability of toilet facilities,
and behaviour of doctor.

Objectives:

1. To assess the role of Aardram Mission in delivering public health care in the state

Methodology

The research is based on secondary data. Various analytical and descriptive techniques have
been used to analyse the role of Mission Aardram, an initiative of the Government of Kerala
as a part of Nava Kerala Karma Padhathi. Several research papers, articles and several reports
published by the journal, the World Health Organization (WHO) and the Institute of Medicines
were cited.

Results

Kerala has already organized healthcare before the advent of the European medical system.
Before the formation of the state, accessible healthcare facilities were available in the
principalities of Thiruvananthapuram and Cochin. Primary and secondary health centres, two
malaria control units and 138 maternal and child care units were developed during the first
period of the five-year plan. The second five-year plan focused on improving health facilities
for communicable disease control. The third five-year plan included 39 new pharmacies, 80
nursery and child centres and then the fifth plan focused on communicable disease
prevention at the school level. Since 1996, the control and management of PHC was entitled
to the Gram Panchayath and they were empowered to allocate the funds for PHC. However,
a path breaking development in the rejuvenation of the rural health system was brought by
the introduction of the National Rural Heath Mission. The NRHM2005 aimed at improving the
health status of the rural population through health centres. Later, during the 12th plan
period at the institutional level, CHC was equipped with palliative care services.

Our health policy adopts a three-tier structure, including primary, secondary and tertiary levels of
health care, to deepen people's access to health care. The primary level is designed to have three
types of health facilities, namely a sub-centre (SC) for a population of 3000-5000, a primary health
center (PHC) for 20000-30000 people and a health center community (CHC) as a referral center for
the four PHCs covering a population of 80,000 to 1.2 lakh. District hospitals should serve as the second
level for rural health care and the primary level for the urban population. Tertiary health care should
be provided by health facilities in urban areas that are well equipped with sophisticated diagnostic
and examination facilities.

Table 1.1: Number of Health Centres during Plan Period

Community health centres Primary Health Centres Sub-centres

Plan India Kerala India Kerala India Kerala
6th 761 4 9115 199 84376 2270
7th 1910 54 18671 908 130165 5094
8th 2633 80 22149 938 136258 5094
9th 3054 105 22875 944 137311 5094
10th 4045 107 22370 909 145272 5094
11th 4833 217 24049 809 148366 4575
12th 5396 222 25308 852 1523655 4575
Source: Rural Health Statistics 2015

From the table the growth rate of CHC from 1st to 12th plan is 6.90%.In case of Kerala the growth rate
from 1st to 12th is 54.5%. The growth rate of PHC in India is 1.77% while in Kerala it is 3.28%. Sub
centres grow by 17.05% in India and there is a negative growth of sub centres in case of Kerala 1.015%.
This was due to the standardization of health care institution. The Community Health Centres during
the 6th five-year plan (1981-1985) were 761 and 4 in number in India and Kerala respectively. The
number of institutions had increased to 5,396 in India and 222 in Kerala, later on. In the case of primary
health centres, the numbers were 9,115 and 199 for India and Kerala respectively. After the 12th five-
year plan, it was increased to 25,875 in India and 944 in Kerala. The story was different in the case of
sub centres due to the standardization of health institutions in 2009 lead to a decline in the number
of sub centres and PHCs.

Aardram Mission

Instead of setting in past lures, the state of Kerala decided to gear up with a revolutionary programme
called Aardram Mission. The mission was launched in 2016 November. Throughout the state, we have
an excellent network of hospitals, including sub-centres, PHC’s, CHC’s, Medical College Hospital’s
(MCH), and Regional Cancer Centres (RCC). However, MCH’s are not able to deliver their services
properly since they are unable to manage the enormous quantity of patients. This will affect the
quality delivery services of these institutions. This is mainly due to the absence of a proper gatekeeping
system. Many people approach Medical College hospitals for the ailments, which could have been
treated at the lower-level hospitals. This is primarily due to reasons such as lack of proper treatment
or cares at lower-level hospitals, lack of confidence from the side of beneficiaries to approach the
lower-level institutions, and increased number of casualty cases. All these factors force people to
approach the higher level institutions like medical college directly.

The only way to resolve this problem is through strengthening the lower level hospitals, making it
capable of addressing the majority of the health issues effectively with MCH's and specialist hospitals
acting only as referral hospitals. The Kerala government has set up the Aardram mission to renew and
revitalize public health facilities. Aardram Mission's goal is to provide people-friendly medical services
at state hospitals and add specialized and ultra-specialized services at district and taluk hospitals. It
aims to transform primary care centers into family care centers. This is another initiative that
addresses the health needs of the whole family. Goals include web-based appointment systems,
registration, patient reception, electronic medical records, writing rooms, improved hygiene, drinking
water, and signage. This enables web-based referrals to top hospitals. This mission ensures health care
for all families and deals with preventive, supportive and rehabilitative interventions in the
community.

In addition to regular outpatient clinics, FHCs will focus on primary prevention of communicable and
non-communicable diseases. Maternal and child care, prevention of infectious diseases and proper
control of lifestyle diseases are the responsibility of FHCs. Support structures for adolescents, couples,
the elderly and drug addicts will also be available in the FHCs. The CHFS outpatient clinics are open
Monday through Saturday (9:00 a.m. to 6:00 p.m.) and Sunday from 9:00 a.m. to 1:00 p.m.; Laboratory
facilities are available from 8:00 a.m. to 4:00 p.m.
The Mission gives importance to PHC’s, taluks, and district hospitals at its organizational levels. The
LSG has a vital role in ensuring the effective functioning of the mission. Health Services Department,
medical education, hospital management committee and so forth have a crucial role to play in this
mission. It is also expected that the malady of health hazards will appropriately be addressed and
confronted by these institutions. However, interestingly most of the aims formulated by Aardram
Mission coincide with the objectives of the Astana Conference held in 2018. All primary health centers
in the state are being transformed into Family Health Centers by 2020. The mission took 170
institutions in the first phase (2017-2018). In the second phase, 504 institutions were selected (2018-
2019). Sixteen PHCs where selected from Thiruvananthapuram district in the 1 st phase and
successfully transformed into FHCs. In the second phase total of 42 were sanctioned, out of this, 20
had been converted to FHC. So, in total, we have 36 FHCs in Trivandrum district. Since the second
phase is only heading with its progress, the study focuses on 16 completed FHC of phase 1 in
Thiruvananthapuram district.

Since the World Health Organization's Alma Ata declaration on primary health care, there has been a
debate about whether it would be better to introduce selective or comprehensive primary health care.
Proponents of selective PHC said a selective approach would provide intermediate gains, while
proponents of comprehensive PHC said it is essential to address the underlying causes of disease and
improve disease outcomes. sustainable health. Within the overall model, activities are promotional,
preventive, curative and rehabilitative. In the curative model, all attention has been focused on
curative and rehabilitative measures with very little activity. The Indian government orders
comprehensive health care to be provided in health centers.

Nava Kerala Mission is an initiative of Government of Kerala in 2016 November. This was an initiative
to address the major problems faced by the four key sectors they are agriculture, education, health
and housing. The four schemes based on each sectors are:

Haritha Keralam Mission:

The Haritha Keralam mission is an umbrella mission that integrates waste management, water
resource management and organic farming components. It is one of four mega-missions launched by
the government that focus on an alternative path of development for the people. The mission aims to

• Revitalization of water sources • Unpolluted water sources • Conservation of water with the help of
man • Environmentally friendly and sustainable waste management • Improvement of organic
farming
Comprehensive Educational Rejuvenation Programme:

Through this scheme many public schools will be made available to the citizens. These schools will
have international standard of noble teaching. Education sector will witness a huge reforms including
upgrading 1000 Government schools. There will be not only infrastructure reforms, but also modern
education and learning. Introduction of smart classrooms using ICT. There will be a new educational
program for students with disabilities.

LIFE

Livelihood Inclusion and Financial Empowerment is a comprehensive housing program for all land and
homeless people in the state. The mission aims to provide shelter for her 430,000 homeless people in
the state within five years.

AARDRAM MISSION

The Aardram mission will target the same core delivery capabilities launched with the goal of
completely transforming the public health sector amidst the changing United Nations 2020
development focus towards sustainable development. is one of four missions in the Nava Keralam

Mission.

Logo of Aardram Mission

The primary focus of the Aardram missions is SDG3 'Good health and well-being'. The mission has
short-term goals to be achieved by 2020 and long-term goals to be achieved by 2030. These goals are
formulated by expert committees on prevailing health issues in Kerala. Aardram's mission is an
ambitious government project to make dramatic changes in the state's healthcare system. The main
objectives of the Aardram mission are;

• Friendly outpatient services

• Conversion of primary health centers into family health centers.

• Access to comprehensive health services for marginalized and vulnerable groups in society.
• Standardization of services from primary to tertiary care.

• Added specializations and super specializations to district and Taluk hospitals.

It focuses on developing primary care centers into family health centers that can meet all the
medical needs of family members. Promote preventive, rehabilitative and curative health care
interventions in the community. It includes a web-based appointment system, patient reception
and registration, and a well-equipped waiting room. Medical colleges and regional hospitals are
being upgraded and transformed into more patient-friendly facilities.

In addition to regular Out patient’s consultancy, FHCs will focus on primary prevention of non-
communicable and communicable diseases. Appropriate lifestyle disease control, maternal and
child care services and infectious disease prevention. There are also counselling centres for the
elderly, drug addicts and young people.

The clinic is open from Monday to Saturday from 9:00 to 18:00. On Sundays, OP time is 9:00am to
1:30pm earlier. The laboratories are available from 8:00am to 4:00 pm. State- and centrally-
implemented health care is delivered in FHCs. At the district and panchayath level, different
committees have been formed to manage the health centres.

The transition from PHC to FHC is a gradual series of administrative and infrastructural changes.
For a long time, the popularity of private hospitals in our state was higher, so people began to lose
faith in public hospitals. A stronger healing force is giving private hospitals the upper hand, forcing
PHCs across the state to head in the same direction just to stay afloat. A general shift in curative
healthcare services and a drastic increase in patient healthcare expenditure, coupled with
demographic and epidemiological shifts at this time, ultimately necessitate the intervention of
Aardram Mission. Strengthening primary health care and improving the quality-of-service delivery
largely focuses on improving infrastructure, training staff, managing records through electronic
health systems, improving laboratory facilities and a preventive rather than curative attitude
towards health care.

The 1994 Panchayath Raj, which transferred institutions such as PHCs to local self-government
bodies, proved particularly beneficial during the transformation, as it paved the way for greater
convergence with other departments such as national, state or Panchayath level programmes,
making the FHC transformed into a better position to address the social determinants of health.
Community participation is an important feature of a FHC, especially in the more rural FHCs, as
they lead the community to improve the quality of life in the area through the various forums, for
which 'Arogyasena' would be a noteworthy mention in this context. There is a predetermined
chronological sequence of checkpoints through which patients are guided, allowing for a
systematic flow of patients. Not only does this have a positive impact on the operation of FHC,
enabling it to deliver better service every step of the way, but it also enables the center to treat
more patients.

Co-ordination and Community Involvement

LSG is best positioned to act as a coordinator and involve other departments, organizations and
panchayats, so the involvement and autonomy of local government activities in the functioning of
the FHC is beneficial and is proven. Engagement of such organizations is fundamental as it helps
address the social determinants of health in a healthier way. The lack of health in the community
does not mean that the health sector and panchayat are not doing their job. This is because there
are several social determinants of health other than health that are related to other sectors. LSG's
involvement provides the perfect platform for this kind of cross-sectoral coordination. Mission
Aardram also ensures community involvement in the services available through ASHA, WHNSC,
Kudumbashree Volunteer Health Workers and their much-lauded initiative 'Arogyasena'Since
FHCs are geographically linked to a particular Panchayath, quantitative indicators on the scope or
impact of particular outreach programs can be intuitively derived. For example, based on the
population of a Panchayath, which is widely known by all FHC employees, and taking into account
the statistic that 20% of the population is prone to developing diabetes, an approximation can be
made from the recorded cases of diabetes in the area to compare the use of e-Health with the
expected number of diabetic patients. While this requires no official documentation and can be
done at very little cost, it's not the best or most accurate measurement out there. It does not
account for residents who may choose to visit private hospitals instead, and the eHealth case
count premise may itself be incorrect due to its limited scope. Flooding in Kerala in 2018-2019
severely hampered the progress of Phase 2 of the Aardram mission. The Ministry of Health and
the LSG had to shift their funding and focus on relief and rehabilitation operations. Many of the
newly established centers and ongoing construction sites have been severely damaged. With this
in mind, it is important to set aside emergency reserves to reduce the blow that unforeseen events
such as the implementation of a particular project have. Other than completing the health report,
other methods of documenting, measuring, and evaluating outcomes are not uniform across all
FHCs in the state. All centers must be subjected to the same treatment in order to make a fair
comparison between them.

Analyzing and understanding the gap and what caused it and how many of them were filled in
another center is the first step towards its resolution and for that very reason a unified
measurement that identifies the specific KPIs listed in the policy national health. Only top
performing FHCs are identified for NQAS (National Quality Assurance Standards), grouped broadly
under areas of concern – service delivery, patient rights, inputs, support services, clinical care,
infection control, management quality and results. These standards are accredited by ISQUA
(International Society for Quality in Health Care) and meet global standards for completeness,
objectivity, evidence and development rigor.

The state of Kerala is planning a Peoples Campaign with motto “OUR HEALTH OUR
RESPONSIBILITY”

TRANSFORMATION OF PRIMARY HEALTH CENTERS TO FAMILY HEALTH CENTERS:

It was aimed to transform all the primary health centres into Family Health Centres by 2020. The
programme plans to cover 894 Primary health centres of the state. In the financial year of 2017-
2018; 170 institutions were selected for this transformation in the first phase and for the financial
year 2018-2019 aimed at transformation of 504 institutions. The remaining 220 institutions were
considered in the third phase.

Table: Fund details of infrastructure development

Activity 2017-2018 2018-2019 2018-2019 2019-20

170 centres plan 204 centres plan 300 centres 220 Centres
fund. fund NHM fund NHM fund
Infrastructure 23cr 28.55cr 46.50cr 34.10cr
Lab equipment 7cr 8cr 13.5cr 9.9cr
Total 30cr 36.55cr 60.00cr 44cr
Source: Aardram Mission Report 2019.

In the first phase 170 institutions were allocated with a total of 30 cr. The fund allocation has
raised successively to the next two phases. Phase four that was comparatively allocated with
lower fund. The contribution for infrastructure requirements stands high for the all four phases.
Apart from this fund such as MLA, MP funds, CSR and donations from individuals are also
considered for FHC transformation.
 District Total Number Completed Work in Progress Yet to start
(Selected)
Trivandrum 42 2 10 30
Kollam 38 11 27
Pattanmtitta 26 4 15
Alappuzha 40 3 9 24
Kottayam 34 3 12 12
Idukki 25 4 4 13
Ernakulum 40 7 32
Trissur 48 17 29
Palakkad 45 1 3 37
Malappuram 42 1 12 23
Kozhikode 37 14 17
Wayanad 15 2 8 1
Kannur 50 10 31
Kasaragod 22 1 20
Source: Aardram Report 2019

The highest number of institutions selected for transformation was from Kannur followed by Trissur
and Palakkad. The least number of institutions were from Wayanad, Kasaragod and Idukki. The total
number of institutions in the phase 2 were 504.Out of which only 16 institutions are completely
transformed FHC. Work of 122 institutions is in progress. Three hundred and two institutions are yet
to start.

Comprehensive and ongoing training for all FHC employees is essential to ensure quality service
delivery. To achieve this, the State Health System Resource Center (SHSRC) has been tasked with
providing various types of training. There are three training programs: team-building training,
concept-based training, and competency-based training. This government's Aardram mission has
improved the functioning of public hospitals, from primary care centers to government medical
colleges. Primary care centers are transforming into friendly family care centres. For the third phase
of the Aardram mission, 212 of its PHCs were selected to be transformed into FHCs. In addition, 76
Community Health Centers (CHCs) will be converted into Block Family Health Centers. An improved
health insurance system will allow more low-income patients to receive free treatment.

Looking at government literature and reports, the government has taken initiatives to provide
adequate health care for all through a program called Mission Aardram. It has emphasized quality
health care for all. To date, examining the evidence from the formulation of the Aardram mission as
part of the Nava Kerala Karma Padhathi shows that the Aardram mission includes: It can be said that
it has its own role or domain in improving public health.
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