SEVAK Project
Improving Access to Care in Villages ofGujarat,India: a Pilot Study
Investigative Team:
(1) Thakor G. Patel, MD
Chair, Public Health Committee
American Association of Physicians of Indian Origin (AAPI)
10980 Rice Field Place
Fairfax Station, VA 22039
(2) Ranjita Misra, PhD, CHES, FMALRC
Professor & Director, Online MPH Program
3830A, Robert C Byrd Health Science Center
Department of Social & Behavioral Sciences
School of Public Health
West Virginia University
Morgantown, WV 26506-9190
Tel: 304-293-4168; Fax: 304-293-6685
Email:
(3) Hemant Patel, MD
Past President, American Association of Physicians of Indian Origin (AAPI)
(4) Padmini Balagopal, PhD
Public Health Committee, AAPI
(5) Kamal Pathak, MD
Dean, Baroda Medical College(Retired)
Baroda, Gujarat
Background and Significance:
Non-communicable and chronicdiseasesare the leadingcauses of death as observed ina study in rural India. It was also observed that this patternof death is unlikely to be unique to these villages and provided a new insight into the rapid progression of epidemiological transitioninrural India (1).Four studies in rural Alamarathupatti, Samiyarpatti and Pillayar Natham in the state of Tamilnadu and another in the village of Karakhadi, in the state of Gujarat showed marginalized access to health care and besides there were no primary health care centers that could manage chronic diseases. This lacuna made them even more vulnerable to chronic diseases and their complications. Seventy per cent of India lives in the villages(700 million people) and the importance of educatingand delivery of healthcare to this large base of India in its resource-poor settings becomes an urgent and viable issue.Large-scale efforts to improve generalawareness about diabetes, hypertension, cardiovascular disease, its risk factors, and to promote healthylifestyles, should be undertaken.
According to Srinath Reddy et al (2) at the present stage of India's health transition, chronic diseases contribute to an estimated 53% of deaths and 44% of disability-adjusted life-years lost and cardiovascular diseases and diabetes are highly prevalent in urban areas. Further, according to the authors, hypertension and dyslipidaemia, although common, are inadequately detected and treated. Demographic and socioeconomic factors are hastening the health transition, with sharp escalation of chronic disease burdens expected over the next 20 years.
In view of the conclusion of the studies done, this is a proposal for a prototype program to address the shortfalls in the healthcare needs of the villages. One village per district (27) in Gujarat will be chosen to screen the residents for diabetes, hypertension, obesity, and monitor those with chronic diseases. The project will involve coordinating with the villages and identifying bright individuals with, medical and or non-medical backgrounds who are interested in the project (one per a village of 1000-1500 population), and then train to be SEVAKs. Such a program will become self-sustaining as the SEVAKs who live in the village will be able to continue the screening, delivery of care and health education.
Specific Aim of SEVAK Project
The specific aim of this project is to create standardized delivery of diabetes and hypertension screening and care in the villages by trained health educators who live in the village. The program is based on the peer educator’s model and the trained health educators will be called the “SEVAKs.” Twenty two SEVAKswill be identified and trained in Baroda in the diagnosis and treatment of diabetes, hypertension, and knowledge of symptoms of heart attack, stroke etc. (A curriculum has been developed for the same by the investigative team). They also will be trained on how to network with other health care providers, to act as facilitators when individuals need information on treatment and services (i.e., beyond knowledge level), and how to refer cases to Taluka Clinic and District Hospital. Other training will include prevention, sanitation, safe drinking water, smoking cessation, and malaria prevention. SEVAKs will maintain a database on the medical problems of the villagers and target the high risk groups for health education and monitoring. They also will act as liaison between the patient and his/her physician, whether government or private. They will help ensure that patients on TB, HIV, and Malaria treatment take their medicines and that patients with diabetes and hypertension come for regular checkups and attend health classes. Pregnant women will be screened for diabetes and they will be encouraged to deliver in a hospital or safe environment to decrease maternal mortality. SEVAKs can have the clinic open in the mornings and evenings to facilitate farmer’s compliance.
This project is modeled on the Independent Duty Corpsman (IDC) in the US Navy. IDC’s are high school graduates interested in health care. They are given 12 months of training and then assigned to Marine Corps units or Navy Ships. On ships, they are fondly referred to as the “doc”. They provide primary care, look at injuries, manage disasters and also check on the preventive care of sailors along with conducting environmental checks such as humidity, temperature and sanitation. We have adopted this to help provide health care access in rural India in our Mini-Doc program.
Significance of the Project
There is no organized delivery of health care in rural India. Preventive health care is unavailable in the villages. Clean drinking water is not available to all and the sanitation is not adequate. Immunization though available, does not cover all who need it. In some cases in villages there might be circuit riders, who provide only acute care on the days they come. The second level of care is at the rural health clinic where there are no medicines or the care is at best rudimentary. The third level of care is at the district level where there is the availability of more care but still without the necessary means to provide full basic care. The fourth level of care is in the hospitals located in the cities, which are crowded and provide only acute care. Most of these facilities are financed by the government, which are not well staffed or adequately financed. They do not have any provision for screening or preventive care. Compliance with chronic treatment needs improvement. Life style modification education is not available. Indian villagers work hard in the farms and lose wages when they travel to another town for care. They need local preventive health care and screening for common diseases such as diabetes and hypertension.
Improving Access to Care in Rural India
We need to look beyond doctors for rural access to care by creating a cadre of “SEVAKs”. There will be a standardized curriculum to diagnose hypertension, diabetes and even treat early stages of these two conditions. They will be monitored by the coordinators. The SEVAKs will be trained at locations where there is a medical school or where medical teachers are available. The Mini-Doc has to be from the village that needs his/her services. Medicines, glucometers, BP machines for the pilot project will be provided by AAPI. Continuous monitoring of this project will be carried out by the monitors selected by the coordinators of the project.
Responsibilities of SEVAKS
As part of the larger study, this project will only train SEVAKs for developing their content and skills. The next stage of the project will involve SEVAKsto be placed in villages and work with the community to improve health outcomes. SEVAKswill compliment health care providers and make referrals to the health care providers for dealing with diseases that require their expertise. This project will be conducted as a pilot in Gujarat before widespread implementation. The training of the SEVAKs will be for a period of three months.
SEVAK Curriculum
The curriculum was developed from three prior intervention programs in North and South India. It is evidence-based and consisted of: 1. Introduction: Basic terminology. 2. Concept of SEVAKs. 3. Hypertension. 4. Diabetes. 5. Cardiovascular System including Basic Life Support. 6. Musculoskeletal System. 7. Pulmonary System. 8. Gastroenterology. 9. Endocrinology. 10. Infectious Diseases. 11. Trauma including transportation of patients and liaison with EMS. 12. Pediatrics. 13. Obstetrics: pregnancy and gestational age, hypertension, eclempsia, diabetes & referral. 14. Gynecology: Bleeding and referral. 15. Nutrition Concepts: requirements, CHO, Fats, Protein & Calories. 16. Exercise; Importance and various concepts. 17. Life Style Modification Education. 18. Immunization: Adult & Child schedules and importance in prevention. 19. Preventive Strategies: Breast, Cervix, Prostate, Lung, Mouth & Stomach Cancers. 20. Preventive Strategies: diabetes, hypertension, CVD and other infectious diseases. 21. Water purification. 22. Sanitation including mosquito prevention, toilets etc. 23. Telemedicine - including the use of laptops. 24. Coordination of care and liaison with different levels of care givers. 25. Data collection and analysis. 26. Clinical rotations only outpatient: A. Cardiovascular diseases. B. Hypertension clinic. C. Infectious diseases. D. Laboratory. E. Radiology. F. Surgery including orthopedics. G. Obstetrics. H. Emergency medicine. 27. Life style modification education demonstration by the students. 28. Theoretical and Practical examination. 29. Conclusion: Graduation and Certificates. The curriculum will be tailored to Gujarat and modified as per the needs of the village although the foundation is based on the needs assessment and priorities identified in the studies done in Karakadi, and the villages in Tamil Nadu.
Evaluation of Training:
Pre and post- evaluation of the training will be done by the investigative team. The project personnel include one Project Coordinator, four regional coordinators, instructors, twenty six SEVAKs, and support staff. SEVAKs are identified and one per village per district is selected. An individual (SEVAK) is required to be a resident of the village with contact information so that people have access to them. The pilot program will be for three years.
References
1)Rohina Joshi1,*, Magnolia Cardona1, Srinivas Iyengar2, A Sukumar2, C Ravi Raju2, K Rama Raju2, Krishnam Raju3, K Srinath Reddy4, Alan Lopez5 and Bruce Neal1 Chronic diseases now a leading cause of death in rural India—mortality data from the Andhra Pradesh Rural Health Initiative. 2006International Journal of Epidemiology 2006 35(6):1522-1529
2)KSrinath ReddyBelaShah MD, CherianVarghese, AnbumaniRamadoss MBBS2005 Responding to the threat of chronic diseases in India. 2005.The Lancet;366:1744-1749.
3)Misra, Ranjita, Balagopal, Padmini, Patel, TG et al. A community based Diabetes Prevention Program in a Rural Indian Village. Diabetes Care. 2008; 31(6): 1097-1104.
4)Misra, Ranjita, Patel, TG, Kotha, P, et al. Prevalence of diabetes, metabolic syndrome, and cardiovascular risk factors in US Asian Indians: results from a national study. Jn of Diabetes & itsComplications. (in print)