In pursuit of Universal Health Coverage, we should not lose sight of health equity, especially for people with disabilities

Manivannan G.

The basic tenet of Universal Health Coverage (UHC) is provision of “full range of quality health services” to people “when and where they need them,” without having to face financial hardship. UHC includes the entire continuum of health services, ranging from health promotion and prevention to treatment and rehabilitation. In a world that’s vulnerable to pandemics, climate extremes, and other exigencies, one cannot emphasise enough the importance of enabling people to access health services “when and where they need them.”

The timeliness and proximity of health service delivery is not just a UHC prerogative, but also aligns with the principle of health equity, especially when we consider people who are marginalised due to their disabling health conditions, poverty, geographical remoteness, and other factors. We make this argument on behalf of a certain constituency of people.

Each year, India reports over 100,000 cases of leprosy, a bacterial infection which is the leading cause of disability among communicable diseases. Individuals affected by leprosy need to visit a health facility regularly for medicines (antibiotics and steroids), ulcer dressing, physiotherapy, etc. Moreover, they often live farthest from district headquarters, where secondary and tertiary health facilities are concentrated. They often lack the resources to pay for conveyance. For some, disability has already set in, thus restricting their mobility.

When COVID-19 lent greater importance to UHC and health equity

During COVID-19, when all ‘non-urgent’ hospital consultations and admissions in health care facilities were discouraged and public transport became out of bounds, the scope of getting specialised leprosy and disability management services in health care institutions further reduced. There were concerns over conditions getting worse for people with ulcers. COVID-19 safety protocols like social distancing also made it harder for them to tap into that limited social network to seek help.

Under such circumstances, The Leprosy Mission Trust India (TLMTI), the largest leprosy-focused NGO in India, took up a two-fold challenge: a) reaching the last-mile person in far-flung areas, on time; b) ensuring early diagnosis of leprosy and holistic treatment intervention to prevent deformity and other consequences.

An intervention towards UHC and health equity

TLMTI had launched a mobile therapy clinic in May 2019, few months before COVID-19 lockdown came into effect in India. After rigorous research on disability management and other therapy needs in the three districts of Tamil Nadu—Cuddalore, Villupuram and Kallakurichi—TLMTI retrofitted a van with electrotherapy equipment, orthotic/prosthetic unit, therapy bed, telehealth facility, public address system and a LED monitor (for awareness and health education). The clinic is managed by a team of physiotherapists, occupational therapists, prosthetic and orthotic technicians, nursing staff, and community volunteers.

All the services that one expects to get in a hospital are squeezed into this mobile therapy van, which reaches the marginalised communities with the most advanced care. The telemedicine facility in the mobile clinic helps the community connect with doctors at The Leprosy Mission. People affected by leprosy undergo ulcer dressing and callus debridement in the clinic, and those with below-knee amputation undergo stump management and pre-ambulatory training. Measurements for artificial limbs are taken for those with below-knee amputation. The mobile clinic also transports patients to TLM hospital whenever they need to be admitted.

How did the community benefit?

The mobile clinic has significantly improved healthcare access for people with leprosy and other disabilities in the three districts. So far, it has served 1,754 individuals, delivering 52,104 physiotherapy and occupational therapy services. It has facilitated 8,838 orthotic and prosthetic services, distributed 1,473 aids and appliances, and fitted 286 artificial limbs. Additionally, the clinic identified 101 individuals who needed reconstructive surgeries and provided them pre-operative physiotherapy at the doorstep of the patients and transported them to TLM hospitals.

By offering doorstep services such as ulcer care, stump management, and artificial limb measurements, the clinic has reduced the need for patients to travel long distances, thus saving time, avoiding wage loss and logistical challenges. TLMTI had the privilege of presenting concept at the International Leprosy Congress and to the National Institute for Empowerment of Persons with Multiple Disabilities (NIEPMD, Chennai).

Tamil Nadu at the forefront of making care accessible to PWDs

When it comes to UHC and health equity, Cuddalore district has been ticking all the boxes. The District Differently Abled Welfare Office of Cuddalore has the distinction of having issued UDID cards to 99.97% of PWDs in the district, which is the highest in Tamil Nadu. This is apart from ensuring extensive coverage of advanced assistive aids and appliances for PWDs in the district through ADIP Scheme. In fact, Cuddalore is one of the pilot districts for India’s first one-stop rehabilitation centre—Vizhuthugal—which is an initiative of the Tamil Nadu government. The state plans to have 273 of these centres, which will offer six rehabilitation services under one roof. The state government has also flagged off the ‘Vizhuthugal’ mobile outreach and therapy vehicles, which will serve PWDs who cannot access the one-stop centres. The vehicles will focus on people residing on the farthest end of the zone that has a one-stop centre.

Conclusion

In India, when we discuss UHC, we allude to different stressors: high population density, low density of health care facilities, significant population living in hard-to-reach terrains, and poverty. Tamil Nadu is changing this status quo and inspiring other states to think of such inclusive health service delivery systems that are rooted in community and respond to layered vulnerabilities of the local population.

Manivannan G. is a Program Manager & Senior Occupational Therapist at The Leprosy Mission Trust India, Cuddalore, Tamil Nadu