Tag Archives: MYCHI

The Art and Science of Diagnosis

A professor from Ohio State e-mailed me the article with the deceivingly understated subject line of all-lower case “fyi.” The Hindu write-up’s headline, though, didn’t mask the shocking contents: “Appalling condition of primary healthcare services” it read. (1) Short and potent, it described the lurid details of a study carried out across the health sector in India, rural and urban, private and public. The details showed a fundamental lack of ability by medical professionals to diagnose even the most common conditions (asthma and dysentery, for example) or ask the most basic questions (whether there was “pain radiation” for an unstable angina). The result was a low rate of diagnosis, whether it was in rural Madhya Pradesh or Delhi.

Overall, healthcare providers provided the correct treatment only 30.4% of the time. (2) Even worse, 41.7% of the time the clinics provided unnecessary or even harmful treatments for “patients” that the research study trained (“from the local community”, the article notes). Many providers, even in public clinics, were unqualified. Medical guidelines and treatment protocols were followed at low rates; providers only asked 33.7% of the recommendations. In Madhya Pradesh, doctors spent 3.6 minutes with patients, while Delhi medical professionals spent a marginally better but still terrible 5.4 minutes. For reference, the Medical Council of India recommends doctors spend at least 10 minutes with each patient. (3)

The article highlighted tough facts that Calcutta Kids has been tackling for years. Through our experiences with the health clinic, we’ve worked to combat the norm of primary health in India: brief, non-comprehensive visits and a disregard for protocols and checklists. We’ve uploaded to the resources section of our website our child health World Health Organization’s IMCI and IMPAC-based Child Health and Pregnancy and Maternal Health protocols and checklists which our doctors are trained and demanded to use. Our two health clinic physicians, Drs. Pal and Sen, work with our management staff to ensure that the protocols we have provided them matches their process for diagnosing patients. See the above-mentioned resources below:

Child Health Protocol (0-2 months)
Child Health Checklist (0-2 months)
Child Health Protocol (2 months to 5 years)
Child Health Checklist (2 months to 5 years)

Pregnancy and Maternal Health Checklist and Protocol

It’s an important process that Calcutta Kids has to do to ensure our beneficiaries get not just quantity but truly quality care. It hasn’t been an easy process to bring in this cultural change into our clinic over the years, but it’s a necessary one. In addition, the creation of standardized protocols ensures a consistent level of care that our beneficiaries can expect, regardless of personnel changes. As Atul Gawande noted in his Harvard Medical School commencement, it’ll require an understanding of a team of healthcare providers- a “pit crew” that includes our health workers- not just the lone cowboy physician:

“The work is rooted in different values than the ones we’ve had. They include humility, an understanding that no matter who you are, how experienced or smart, you will fail. They include discipline, the belief that standardization, doing certain things the same way every time, can reduce your failures. And they include teamwork, the recognition that others can save you from failure, no matter who they are in the hierarchy.” (4)

Many rightly criticize the low rates of spending on health per GDP in India, ranking 171st out of 175 countries according to a WHO study. (5) But the situation is even grimmer: it is not enough to just increase spending, build more primary health centers or even to write diagnostic protocols at a national level. The groundwork of implementation at a doctor to patient level must be accomplished. At our health clinic, we work on this ground level to make sure that provision of the highest level of primary healthcare is a reality for the mothers and children of Fakir Bagan.–Pranav Reddy

Citations:

  1. Appalling condition of primary healthcare services. The Hindu. R Prasad. December 6, 2012. Retrieved from http://www.thehindu.com/health/medicine-and-research/appalling-condition-of-primary-healthcare-services/article4167677.ece on Jan 1, 2013.
  2. In urban and rural India, a standardized patient study showed low levels of provider training and huge quality gaps. J Das, A Holla, V Das, M Mohanan, D Tabak, B Chan. Health Affairs. December 2012. 31(12):2774-84
  3. MCI wants docs to spend at least 10 mins with each patient. The Times of India. K Sinha. September 1, 2011. Retrieved from http://articles.timesofindia.indiatimes.com/2011-09-01/india/29953546_1_opd-patients-doctors on Jan 1, 2013.
  4. Cowboys and Pit Crews. The New Yorker. Atul Gawande. May 26, 2011. Retrieved from http://www.newyorker.com/online/blogs/newsdesk/2011/05/atul-gawande-harvard-medical-school-commencement-address.html#ixzz2H02jhJMO on Jan 1, 2013.
  5. World Health Statistics 2011 Report. World Health Organization (WHO). 2011; 127-139. Retrieved from http://www.who.int/whosis/whostat/2011/en/index.html on Jan 1 2013.

Beating the Heat with Mangoes

It’s hot here in Kolkata—incredibly hot. Humidity levels are hovering around 95%, and the mid-day temperatures are reaching as high as 112 degrees Fahrenheit. With such weather, one would expect productivity to reduce, but with so much going at Calcutta Kids these days, productivity remains high and much is being accomplished. I’d like to use this blog post to catch you up on our news and give you snapshots of what is keeping us so busy.

• A new MCPC—Since 2005, we have used the same Mother and Child Protection Card (MCPC) to keep track of the growth of pregnant woman and children; remind families of best healthcare practices; and track their immunization status. Over the past several months we have revised and improved upon these MCPC cards. The changes include updating the growth chart to be consistent with that of the government of India and WHO; sections added for monitoring deworming, home visits, breastfeeding/complementary feeding; and additional space allocated for measles vaccine and for non-CK immunization information. Our Community Health Workers have collected the old MCPC cards from our beneficiaries and are tirelessly transferring information from the old cards to the new cards. 

• Medicine database overhaul—Evan Mullen, our summer intern through the Skolnik Internship Program arrived in Kolkata last week after completing his sophomore year at Yale University. Along with overhauling our medicine database to ensure the most efficient use of medicines, Evan is also working with our doctor, Dr. Mukherjee, on learning and then implementing the WHO/UNICEF-created Integrated Management of Neonatal and Childhood Illnesses (IMNCI ) protocol so that all of Calcutta Kids’ curative care is done following this established protocol.

• Music for our beneficiaries—as part of the launch of their second album, the well-known Bangalore-based band Swarathma will be performing a free concert for the beneficiaries of Calcutta Kids. (This is a real honor for Calcutta Kids and our beneficiaries—the night before, the band will be playing at the most prestigious music club in Kolkata, Tantra, at the Park Hotel.) Especially for the women and children of Fakir Bagan who rarely venture outside the slum, this concert will be a special treat. Our blog next week will be a review of this concert.

• A new HR manual—Having years of HR management experience at the Akanksha Foundation in Pune, the Child In Need Institute in Ranchi, and ITC in Kolkata, Evangeline Ambat has joined Calcutta Kids as a consultant to design a new Calcutta Kids human resources manual. The Calcutta Kids staff has asked for a comprehensive HR manual and we are confident that Mrs. Ambat will be able to deliver this much-needed document.

World Bank Development Marketplace Nutrition Award wrap-up—MYCHI Project Coordinator Sumana Ghosh and CK Director Noah Levinson, are planning their presentation to share in Kathmandu about CK’s experience with the World Bank funded Diarrhea Treatment Center . The conference takes place on June 11th and 12th and is titled “Sharing Lessons from Community Experiences: Improving Infant and Young Child Nutrition”.

• AIF Fellowship transition—this is Margy Elliott’s last week at Calcutta Kids concluding her ten month William J. Clinton Fellowship through the American India Foundation.  Along with building the new Calcutta Kids website, Margy has created a field-level manual for illness assessment and treatment guidance for use by our community health workers, she has been an essential part of designing and implementing our new community mobilization program, she has helped to raise funds for Calcutta Kids, and she is now wrapping up an intensive SWOT (strengths, weaknesses, opportunities, threats) analysis among key CK stakeholders. Margy has become a member of the Calcutta Kids family and we will sorely miss her. That being said, however, thanks to Margy’s marvelous experience at CK, AIF’s Clinton Fellowship Program is providing us with two fellows for the 2012-2013 year. We are excited about welcoming Pranav Reddy, and Sriya Srikrishnan who will begin working with us in September.

So while we are drenched in sweat and continuously drinking plain and coconut water to keep ourselves hydrated, there is one saving grace to this weather— mangoes. For those of you who have experienced the intoxicating flavors of the wide variety of mangoes in India available at this time of year, you’ll understand that the mangoes are almost worth our suffering from this heat. For those of you who have not…you may enjoy reading this New York Times article which nicely explains how fantastic these mangoes really are. -Noah Levinson

Programs to Address Malnutrition

Despite the progress that has been made on other fronts, including infant and child mortality, in India over the last decade, nutrition remains a major public health challenge and nutrition indicators for young children have barely changed. There are many factors that complicate ongoing efforts to implement successful community nutrition programs–including inadequate access to food, unhealthy environment and exposure to infectious diseases, and inappropriate care and feeding practices. Since its inception, MYCHI has targeted the nutritional status of young children in Fakir Bagan during the first 1,000 days of their lives, primarily through preventive care and counseling along with curative care as needed.

The earliest data on nutritional status of children based on weight for age was collected in October 2009. It showed that 33.3% of children 0-3 years old were normal weight, while 32.7% were mildly, 21.6% were moderately, and 12.3% were severely underweight. Two and a half years later, in May 2012, the percentage of severe underweight children has dropped by more than half—from 12.3% to 5.5%, a remarkable success. Data is currently being analyzed to explore the specific factors that have had contributed to the reduction of the severe underweight in our catchment area, but it is clear that the MYCHI approach to deliver key health interventions during pregnancy and young childhood coupled with close counseling, education, and preventive health have made a significant impact in our community.

Although we have made progress, there are still improvements to be made to our child health initiative in order to fully integrate nutrition and growth. This year, we began efforts to systematically address malnutrition and move away from short-term trials, which consumed disproportionate resources and time at the expense of our regular programs. We have made several recent changes to make it easier to monitor and track malnourished children, which we hope will help us reach every child at risk of improper nutrition and growth:

– Early this year, we began generating our lists for monthly home visits by health workers on the basis of the nutritional status of children. Children having a z-score of -3 and below in weight for age (severely underweight) are referred to Swastha Kendra for clinical examination. This also ensures that our health workers have nutrition and growth on their minds as they enter the home of each child and can provide appropriate and intensive counseling to the family.

– At Swastha Kendra the referred child is provided care to resolve any associated medical problems and given supplements for micronutrient deficiencies. Follow up homes visits are carried out by our health workers two days after the doctor’s visit to check up on the child.

– Last month, we designated a space in Swastha Kendra as a nutrition corner, where mothers can freely breastfeed younger children and feed older children when they come for a doctor’s visit. We offer a meal of kichuri and egg in this corner to malnourished children who have been referred by the health workers. The privacy of the corner also enables close counseling with the family.

– Child health community meetings have been re-started in our new community center for mothers of children 0-12 months with an increased focus on complimentary feeding, as we recognize that children begin growth faltering at the time of weaning and introduction of semi-solid foods.

We are optimistic that these changes will enhance MYCHI’s efforts to improve child nutrition in Fakir Bagan. – Danya Sarkar

Swastha Kendra is Open and Fully Functional

The Swastha Kendra (Health Center) is now open to see patients five days a week. Over the last few months, we have been transitioning the space that was formerly the diarrhea treatment center into a health center that can treat all manner of minor illnesses. While before we had a ‘health camp’ once a week, we now have a fully staffed clinic in order to better serve the needs of Fakir Bagan. The patients are seen by a nurse for basic vitals, then see the female doctor for a full examination and finally receive any necessary medications along with counseling on proper administration and possible side effects of medications as well as beneficial behaviors in the home in relation to the specific illness or complaint.

This transition is an effort both to make the clinic space more cost-effective per patient treated, but is also an answer to the needs of the community. In the month of February, 226 clinical visits took place in comparison with an average of 126 visits from July to December. These 100 visits were made possible by the additional hours.

Transitioning to this health center approach has also allowed us to start implementing a clinical protocol based on the Integrated Management of Neonatal and Childhood Illness (IMNCI) guidelines. These guidelines are used worldwide for the simple diagnosis and treatment of childhood illnesses with minimal and inexpensive, but effective, medications. Having a full time doctor also allows us to treat more conditions than would be possible simply following IMNCI. It also helps to increase the level of confidence that the patients have in these relatively simple treatments.

The diarrhea treatment center is still fully functioning and will be an increasing part of clinical care as diarrhea season approaches. The only change is that diarrhea treatment is now a part of a larger clinic rather than sharing a space with the health camp once per week.

We have also incorporated a new nutrition corner where mothers can be counseled on a regular basis including observed breastfeeding and observed feeding of complementary foods. Look out for a post in the next few weeks about Ajay and Promila who have been taking advantage of this nutrition corner. – Dora Levinson

Note: We are looking for a sponsor to endow the Swastha Kendra and ensure that these services can continue. For more information about this endowment please write to Noah@calcuttakids.org.

Flip-Charts, Training and a Community Center – Oh MY(CHI)!

Originally posted in the Fall 2011 Newsletter

The Maternal and Young Child Health Initiative (MYCHI) staff has been working diligently over the past nine months to make our programs even more effective. Danya and Sumana have been revising the pregnancy care program to reflect changes in international maternal and neonatal health guidelines and to utilize the lessons we have learned over the past 6 years. We now have two excellent flip charts that are culturally appropriate to help counsel families about best practices and the early detection of problems.

In May, we had an in-depth training on the new pregnancy care program with all of our community health workers and other MYCHI staff. In this training, we were able to explain exactly why each type of data is collected; to provide refresher information on the complications that can occur during pregnancy, delivery and the first few months of life; and to talk through specific problems that have arisen in our area. In the course of the training, we also were able to strengthen the bonds that have enabled us to work as a team and to have fun together!

We are also working to revise the child health program to better tackle the non-food related causes of malnutrition as well as to update the program more generally. During the past six months, we worked with a small sample of severely malnourished children to find out with precision the causes of their malnutrition. We found that many of these children were suffering from anemia, a high worm load, several micronutrient deficiencies and stress in the home, all of which hinder the absorption of nutrients and, in turn, impede affect mental and physical development. We now can use this information to inform our protocols as we redesign the child health program. We are very excited about the new community center, located in Fakir Bagan itself, which will be opening in December – a safe, clean and attractive site where we can hold our regular community meetings and gatherings of small support groups – a space for women and children to come together comfortably for support and information.