Lasiyo is two years old and lives in Khajuri- a remote, sparsely populated and poorly connected tribal hamlet in Rajasthan.
Last year in September, his mother noticed that Lasiyo had high fever. The closest functional health facility was in a nearby town, but she had never been there alone. The only bus that would take here there had left. Her husband, who works in Ahmedabad as a labourer, was also away. She decided to take him to a newly-opened clinic close to her village where young nurses are always available, she was told.
Ramila, the nurse on duty, quickly assessed the child for a danger sign, conducted the Rapid Diagnostic Kit test for malaria and detected the child was suffering from a severe form of malaria caused by Plasmodium Falciparum. She comforted the mother, sponged the child to bring down the temperature, and in tele-consultation with the physician, gave the first dose of artesunate-combination treatment and Primaquin. She then kept the child in observation for about an hour, and counseled the mother on how to give the medicines at home. Since the mother was pregnant, Ramila also gave her an insecticide treated bed-net and advised her to sleep under the net. She followed up with the child the next day and two days later the child was well and symptom free.
Nearly three-fourth of India’s population lives in rural areas. For a large segment of this population, especially those living in far-flung areas, consulting a qualified physician is a remote possibility.
Nurses can help meet this commitment if they are skilled, supported and mandated. While it is extremely important to improve living and working conditions of the doctors and re-look at their training, skills and remuneration, there is an urgent need to identify and engage alternate care providers to meet this huge responsibility.
In underserved tribal communities in southern Rajasthan, not-for-profit AMRIT Clinics are providing high quality evidence based and low cost primary health care. Based on our experience of working closely with primary health care nurses in these clinics, we believe that this cadre can substantially and rapidly fill the gap of providing high quality primary healthcare to all age groups in remote, rural areas.
This is how nurses can contribute in underserved tribal areas:
1. By skilling the nurses for assessment and management of common illnesses like malaria, and typhoid or conditions like diabetes or hypertension and use of standard protocols helps significantly in ensuring quality of care and minimizing chances of error. In addition, the primary healthcare nurse needs to be well-versed in communication techniques and effective social interactions, so as to instill the necessary behaviour change and ensure greater community participation.
In our experience, nurses with skills in obstetric and newborn care have enabled them to prevent and manage complications such as post-partum haemorrhage and neonatal asphyxia, conditions which could have been fatal.
In Udaipur, Bedawal is a sparsely populated tribal panchayat, about 20 kilometers from the nearest functional health facility. Till few years ago, most women delivered at home, often at a high risk of death to themselves and their children. Bedawal AMRIT Clinic was set up four years ago and since then, skilled nurses have so far conducted more than 300 safe deliveries, significantly reducing the risk of complications and death among mothers and newborns.
As a result of their training in child health and nutrition, the nurses can also identify childhood pneumonia, diarrhoea with dehydration, and manage children with Severe Acute Malnutrition.
2. By supporting the nurses to provide primary healthcare though use of technology for point-of-care diagnostics and tele-consultation can enable them provide high quality healthcare. Availability of smartphone helps them transmit pictures or videos to the physicians for advice on patients’ diagnosis or treatment.
Having a physician for tele-consultation and regular training helps the nurses discuss the cases as well as maintain a professional affiliation. Responsive and alert referral systems can help transfer sick patients to higher facilities without wasting time.
3. By mandating the nurses to provide primary curative care. At present, there are restrictions on a registered nurse to prescribe drugs. Though they can manage a patient under supervision, a clear mandate to PHC nurses that enables them to assess and manage patients can go a long way in ensuing high quality primary health care closer home.
Nurses are our best bet to provide healthcare for all those who live in remote rural areas and whose voices are drowned in the distance and din of development.
Dr Pavitra Mohan (Secretary, Basic Health Care Services, and Dr Sanjana Brahmawar Mohan, Director, Basic Health Care Services) work closely with Nurses and believe in their power to transform primary healthcare systems
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