Summary of NICE International visit to Kerala, October 2009

In October 2009, and following a series of interactions with the Ministry of Health of Kerala, NICE International organised a two-day visit to the State of Kerala with the support of DH International. The visit followed previous ‘missions' to AO and New Delhi and Bombay, and its objective was to understand the current development in clinical guideline development (GL) in Kerala and to help inform the thinking of policy makers, especially in the context of the Rural Health Mission Reforms.

Kerala is a relatively small state with 30m inhabitants and remarkably good health performance indications such as infant mortality and maternal death. It boasts high literacy rates and small gender gap -markers comparable to those of rich western countries. However, these indicators are in decline and the government is keen to ensure the quality, accessibility and efficiency of the system are maintained or improved. In this context, the government, in collaboration with the Medical Colleges (which, recently, have been directed by the Ministry to focus solely on public practice), professional associations and the Clinical Epidemiology Resource & Training Centre (CERTC) of Kerala, are committed to formalising the development, dissemination and implementation of best practice guidelines for the high priority diseases and conditions affecting the population of the state.

Given the level of technical expertise amongst clinicians of Kerala, many of whom have been trained in the UK's NHS and maintain strong links with the UK, CERTC's potential for building more technical capacity in systematic reviewing and economics, the commitment of the State medical colleges, the nationwide PHFI/IIPH initiative, and the Rural Health Mission activities, an initiative to streamline GL development is highly timely. Starting with ‘low hanging fruit' where the burden of disease is high and treatment well know and relatively simple, such as leptospirosis, decision makers can bring onboard key stakeholders, build confidence in their process and improve it through field testing and feedback from front line users.

During our visit, we had the chance to meet with the Secretary of State for Health and her team, as well as many academics, professionals practicing in rural and urban, private and public settings, and representatives of physician associations. While there are concerns as to the legal status of the guidelines and the degree of flexibility they will allow practicing clinicians, the great variation between primary and secondary care and rural and urban settings which would require setting-specific guidelines and procedural and stakeholder involvement issues, there is general commitment to proceed and a relevant committee has been established to pursue the development of guidelines in the state. The introduction of health insurance (currently in the form of a fixed copay) makes the need for establishing a basic level of minimum quality standards more pressing.

Decision makers in Kerala are not starting from scratch; professional associations have made a lot of progress in developing evidence-based GLs adapted to the local setting, with Palliative Care being a great example of locally driven, responsive best practice algorithms relevant to the local setting (e.g. home tapping of malignant ascites; pain management/morphine administration by carers at home. Furthermore, with a number of States having similar discussions, this is a good opportunity to build on economies of scale: IIPH and State policy makers in Andhra Pradesh; NHSRC in New Delhi; OHSP in Orissa and IIPH and State policy makers in Tamil Nadu, are in the process of having similar discussions/launching similar initiatives and have been in touch with NICE for technical support and operational advice.

NICE is committed to supporting these activities in Kerala and other parts of India. Its involvement, at least initially, could be marginal -through offering some technical advice, access to and support in adapting its products and strategic and process input, as well as its ‘brand name' to try and bring more clinicians and policy makers on-board as the process develops. Subject to funding support from local and international sources, including DFID India, NICE would be keen to continue its involvement and possibly to help catalyse synergies between Indian States and across neighbouring countries working towards setting up the processes and methods for using evidence to inform health policy and practice.

• Press coverage from this visit.