Assessment of implementation of the Pradhan Mantri national dialysis Programme in Hospitals in Delhi

Background: Annual-demand for haemodialysis-sessions in India is 3.4 Crores. To make Renal-care-services affordable to APL and free to BPL, Ministry of Health and Family Welfare launched Pradhan-Mantri National Dialysis-Programme (PMNDP). Objective: Aim of Study is to assess Implementation of PMNDP and suggest Recommendations for improvement. Methods: Out of 7 functional Dialysis Centres where PMNDP is operational in Delhi, 4 centres were randomly selected. In total, 170 respondents (enrolled in Dialysis-Units) were interviewed. In-depth-Interviews of healthcare-providers and secondary data-collection was also done. Results: The 4 dialysis-centres became functional during 2018-21. These 4 centres had 35 Haemodialysis-machines providing services to 200 patients on an average. One of the four centers visited for assessment conducted up to maximum 40 haemodialysis-sessions daily. Only two dialysis shifts were operational at the other three centers. On an average waiting-time is less than one hour at all the 4 centres visited. Two-thirds beneficiaries came to know about this programme from relatives, neighbours and after visiting various hospitals. No healthcare-worker Accredited Social Health Activist (ASHA) or Auxiliary Nurse Midwife (ANM) visited to counsel them in community to generate awareness. 43 % patients availed dialysis-services from private-centres initially, due-to lack-of awareness of-PMNDP. Dialysis-centres are not being fully utilized due to the lack of staff and patients. Only 1 Centre displayed The PMNDP FREE Dialysis Logo Signboard, the other three centres lacked PMNDP FREE Dialysis Logo displayed with the relevant details. Spread-of-awareness through IEC-BCC is required in community. PMNDP Portal and PMNDP Mobile app needs to be improved, to make them more user-friendly and useful for the patients seeking renal-care services. Service provider has Standard Operating Procedure Protocols (SOPs) for Dialysis Procedures. As per the SOP for Maintenance of Hemodialysis Machine Equipment, solution is prepared, and water rinse is given to all HD machines. Also, as per Standard Operating Procedure Protocols, filters and equipment are cleaned and maintained. Patients and families told that beneficiaries utilizing Dialysis services from PMNDP centres are satisfied and stated that they did not have to pay any cost for the Dialysis service under PMNDP. As per this study it was found that Three Hospitals didn't have blood-transfusion facilities for patients enrolled in PMNDP. Patients before undergoing haemodialysis, have to get arterio-venous-grafting placement with fistula from any outside-facility. This procedure is not covered under PMNDP. (Although as per Qualitative Studies, Arterio-Venous Fistula Insertion has been included). Also, no shoe-covers were observed at the entrance of Dialysis-area, depicting deficiency in effective Infection Prevention Control Practices in the Dialysis-Area. It was observed that, basic-amenities like number of seats, toilet-facilities, pest-control, fans, drinking-water, hygiene-practices for attendant-waiting-rooms were not adequate. Majority patients utilizing dialysis services from PMNDP centres, and their families were dissatisfied with doctor-patient interaction at the centres, and that no trained doctor was available for monitoring of the dialysis-sessions and examination of patients during dialysis sessions. Only one dialysis-unit had a nephrologist for effective monitoring during dialysis and to deal-with exigencies (which is not as per the Operational Guidelines of National Dialysis Programme, NHM). In case of emergencies, patients are referred to any tertiary care hospital, but without any referral-linkage helpful for these PMNDP beneficiaries. Patients are thus left to suffer the fate on their own, which leads to lack in building of trust among the patients and healthcare providers. Recruitment of nurses/doctors, standards as-per guidelines should be maintained. Some of the patients utilizing dialysis services from PMNDP centres died and few stopped coming. Details of these were not provided by the centre. Further studies must be done to find out the causes of deaths of these patients and those who discontinued. Internal Quality Improvement and Quality Assurance Program are required to be conducted regularly. Supervisory visit by third party will also be beneficial in providing insights regarding how to improve the Programme further. Conclusion: Patients and their families were asked what media source they preferred for building awareness and sharing information regarding this program. Patients and their attendantstold that they lacked prior knowledge of PMNDP from any media focus (e.g., on radio, television, or newspapers) on kidney disorders and treatment services (free Dialysis for the BPL and discounted rates of Dialysis for APL patients) being provided by Government. “Free Dialysis” at PMNDP-centres, did not appear in, Google-Search through digital-media. Thus, effective advertisement (Marketing of this Programme) on the Internet is required, so that, if patients/attendants are searching for “free dialysis centres”, they can easily locate programme facilities (and guidance regarding “enlisted-facilities” where dialysis-programme is available, “what-to-do”, “where to get fistula inserted” etc). PMNDP Portal and PMNDP Mobile app needs to be improved, to make them more user-friendly and useful for the patients seeking renal-care services. Audio-based Mobile-applications should be developed for educating patients in community which guide patients regarding availability of “Free Dialysis” services at enlisted-centres and related information. Dialysis-Programme Hand-outs should be shared with patients at help-desk (Reception itself). These Hand-outs should contain key information about Empanelled-centres, documentation-protocol explanations. Based on the Study, it was envisaged that it is essential to increase the number of Dialysis-centres and “Tie-up” with nearest Government health-facilities well-equipped with free-medicines, vascular-access-placement, availability of teleconsultation services, sample-collection, blood-transfusion facilities, reducing travel-cost and hassle for patients who live far-away from district-hospitals; especially as dialysis-sessions are required 3-times-a-week. Resuscitation medical-equipment, RO-water treatment-plant with output water-as per standards for haemodialysis, 24-hour back-up power-supply and quick referral in case of emergencies with 24x7 ambulance-connectivity is essential. Procurement can also be done through The Free Drugs Initiative under The National Health Mission (NHM). For maintaining quality standards of Clinical care, an effective Internal Quality Improvement Program and Quality Assurance must be conducted regularly, that documents, measures, analyses, and follows-up quality-indicators for providing Quality Dialysis-Treatments. Clinical outcomes should be measured and analysed. Supervisory-visits by Government-Officials may be conducted annually. Only 2 dialysis-units had a nephrologist for effectively monitoring patients during dialysis and to deal with exigencies (which is not as per the Operational Guidelines of National Dialysis Programme, NHM). Recruitment of nurses/doctors, standards as-per guidelines should be maintained. Specialised-Dialysis-Training Courses for MBBS-doctors posted at Dialysis-Centres should be formulated for holistic medical skill-based-training of healthcare-professionals. After successful completion of trainings, medical-staff should be certified. These specifically designed-courses (along-with Newly-Designed Training Modules) for Doctors and staff of Dialysis-centres should ensure availability of adequate manpower to provide healthcare services to CKD patients. Service-providers should also take initiative to train identified-staff for management during emergency, using ECG, resuscitation-kits etc. On-The-Job Trainings for Dialysis-Technicians. Short-Term-Trainings for nurses on HD and PD. To address requirement of specific-infrastructure, PPP-model may be used for conducting trainings.