Ayushman Bharat Arogya Karnataka Health and Wellness Centres

Ayushman Bharat- Arogya Karnataka. Health and Wellness Centres – Road map Department of Health and Family Welfare, Government of Karnataka

Evolution of CPHC-HWCs in Karnataka • Started after a district health assessment in 2015 -16 for Universal Health Coverage pilot districts in § Mysore a Non High Priority District § Raichur a High Priority District • Rationale – to start § Low utilization of PHCs and SCs (33% in Mysore; 25% in Raichur) § High OOPE (Average annual OOPE Rs 16, 189) § Low access of Junior Health Assistants to marginalized poor households (75% in rural Raichur) Karnataka Raichur Mysore

Scale up of Comprehensive Primary Health Care Pilot phase FY 2016 -17 105 HWCs functionalized Scale up FY 2017 -18 460 HWCs functionalized (Aug 2018) FY 2018 -19 Operationalization in process for 505 HWCs 132 PHCs, 71 UPHCs to converted as HWCs FY 2019 -20 Approvals accorded in PIP for 766 HWCs 402 PHCs, 293 UPHCs will be converted as – HWCs under CPHC

Institutionalization of CPHC –HWC in State § Technical Committee and State Working Teams constituted for strategic § inputs and programme planning. § Development of operational guidelines for Dist/Taluk/PHC § Planning supplemented with Systematic Gap Analysis with Mapping of § infrastructure, equipment and supplies done using standard checklist – need based resource allocation was done. § THOs/KHSDRP Engineers inspected and provided inputs § Phase wise coverage in entire state and better performing districts/ blocks to be covered by 2025 (9000 HWCs covered) § Centralized planning, procurement through KDLWS for HWCs § with decentralizing supplies, AMC adoption , RACI matrix for quality logistic management § Involvement of PRI for § Identification of Govt buildings for HWC, NCD camps conduction, ARS fund & health promotion activities, Branding designs.

Branding of HWC after Institutionalization

Input- Local Selection and appointment of MLHPs § Prioritized BSc Nursing/Post Basic Nursing Personnel with two years of work experience as Mid Level Health Providers § De-centralized Selection process for candidates - based on written exam/interview and willingness to serve in rural and remotest areas to ensure minimum attrition and drop outs § Complete transparency of exam conduction by use of CCTV under supervision of CEO ZP and DHS § Strict adherence to timelines of one month from advertisement to filling of admission forms § Preferred Nomenclature- MLHPs (Middle Level Health care Provider)

Processes: Training of MLHPs and Multiskilling of Frontline Functionaries § Six month residential Certificate Programme in Public Health Nursing § accreditation by IGNOU -rolled out in Medical Colleges & State of art District Hospitals of Karnataka ( 8 PSCs) § Karnataka identified Medical Colleges as Centre of Excellence in capacity building for academic Certificate Programme § Monitoring visits were made to PSCs using a standardized checklist prepared by State Team in collaboration with NHSRC § State NHM and PHFI hand held the PSCs throughout the period of training, completed orientation of Programme in Charges and academic counsellors § IGNOU provide study materials, give assignments/ log books & conduct term end exams

Training under the Certificate Course in Community Health

Processes - Multiskilling of Primary Health Care Team • Multiskilling of ASHA, ANMs, MPW (M), Staff Nurse and PHC MOs on population based screening on NCDs NCD Training ASHA ANM MPW (M) Staff Nurse PHC MO Mysore 248 60 15 25 16 Raichur 228 34 13 32 13 • Yoga- Identification of AYUSH YOGA trainers at the District level. • Training of Trainers for Yoga lessons conducted every month at DTCs

Processes -Medicines and supplies § Drug MIS Indenting Application rolled out to PHCs § Medicines listed in sub-centre essential list plus as per expanded package of service have been supplied (164 listed items) § To begin with, 10% of listed Essential Drugs from PHCs were made available to HWCs § Medicines now being indented through PHC based on requirement projected by MLHPs § Medicines for DM and HTN being indented based on refills by MLHPs from PHC medicine list § District warehouses supply to PHCs within a period of 3 -4 days after the requirement is placed. § Untied funds are utilized for drug procurement from local market in case of irregular drug supply

IT innovations Building Digital Platforms Ø ANMOL and NCD app institutionalized Ø Tablets and internet connectivity made available at HWCs. Ø Two representatives from each district given hands-on training by Dell Team – Ø who in turn have trained MOs/MLHPS/MPWs in their respective districts. Ø State adopted process of Integrating all Ø service delivery softwares Ø Implementation of Comprehensive software to record MLHPs activities through digital platform Ø NIC Bangalore is under process

Service delivery work flow

Organization of Work Processes/Service Delivery Flow for RMNCH+A Activity Details Primary Care Team Member responsible 1. MCH Care Conducting Annual Survey now integrated with Population Mobilization of identified cases to Jr HA in outreach / HWC-ANC, Immunization, Uptake of FP services ASHA in coordination with Jr H A and ASHA Facilitators ASHA Community based Screening for ANC, ANM and MLHPs during field activity Counselling for contraceptive use, identification of high- risk cases, breastfeeding, complementary feeding, WASH Centre based ANC and examination of High- Risk First Trimester, Third Trimester and Cases and counselling monthly for high risk cases by MLHP and PHC MO as part of PMSMA Normal Institutional Delivery and referral for high risk cases PHC Staff Nurse/ Referral MLHP/MO *Concurrent monitoring of HWCs by PHFI

Organization of Work Processes/Service Delivery Flow for RMNCH+A--- cont’d Immunization/VHND Jr H A(ANM) and ASHA Monitoring by MLHP Post Natal Care HNBC visits MLHP/Jr H A (ANM) ASHA/AF Management and referral of high risk newborns and sick children MLHP/PHC MO Referral for screening for 4 Ds RBSK Teams Provision of contraceptives -IUCD insertion Jr H A , ASHA as 60% MLHPs are males PHC Staff Adolescent meetings, distribution of SNs, Conducting SNEHA Clinics Jr H A , ASHA as 60% MLHPs are males PHC Staff

Communicable Diseases- Service Delivery workflow Activity 1 Screening Details of activity • Identification and treatment of common communicable diseases • Conducting surveys for larva, TB, malaria • Sputum collection from suspected cases • Chlorination of well • Along with above- Providing optimal treatment (drugs) as per guidelines • Minor wound dressings (first aid) 2 Community • Health education on causes and prevention of mobilization and Health common communicable diseases Promotion • Identifying double burden of diseases, treating minor ailments Primary Health Care team Jr. HA (ANM) and ASHA MLHP Jr. HA, ASHA MLHP

Communicable Diseases- Service Delivery workflow – cont’d 3. Appropriate referral 4. Follow up (at HWC and community) • Referral of suspected cases to appropriate facility- CHC, THs DH, Medical College for diagnosis • Follow up of suspected cases for diagnosis • Follow up of confirmed cases for treatment compliance MLHP/ MO MO and MLHP, Jr. HA, ASHA

Non-Communicable Disease- Service Delivery workflow Activity 1 Planning for screening Details of activity Primary Health Care team involved • Estimating the population to be screened Medical Officer, MLHP, • Planning of approach- fixed day at SHC, PHC/ and Jr. HA AWC/ panchayat bhavan for distant villages • Preparation to ensure adherence to principles of screening at selected places 2 Population enumeration • Family folder and CBAC form filling ASHAs, Jr. HA 3 Community Mobilization • Coordinating with PRI for implementingcamps, BCC & and Health Promotion activities MO, ASHAs with MLHPs • IEC activities during VHSNC/MAS meetings MO, MLHP and Jr. HA, ASHAs • Ensuring IEC material availability at PHC and MO, MLHP and Jr. HA SHCs

Non-Communicable Disease- Service Delivery workflow Activity Details of activity Primary Health Care team 5 Screening at HWCs • Screening at HWCs/ identified places in the community • Opportunistic screening of individuals above 30 visiting the PHC • Examination of suspected cases of breast cancer and oral cancer referred by Jr. HA • Referral of suspected cases to appropriate facility- THs, DH, Medical College for diagnosis & Management • Follow up of suspected cases for diagnosis MLHP and Jr. HA 6 Appropriate referral 7 Follow up (at HWC and community) • Follow up of confirmed cases for treatment compliance MO and staff nurse MLHPs/MO MO and MLHP, Jr. HA, ASHA

MLHP- Weekly Schedule DAY 09: 00 AM TO 01: 00 PM 02: 00 PM TO 05: 00 PM MONDAY Regular OPD Clinic NCD Clinic at HWC -9 -12 pm HOME VISIT-12 -1 pm OPD Clinic 2 -5 pm TUESDAY WEDNESDAY Out reach NCD CAMP at planned villages THURSDAY IMMUNIZATION CAMP in coordination with ANM & ASHA OPD Clinic in afternoon special emphasis to high risk ANC care/ PNC follow-up visit FRIDAY SATURDAY ANGANWADI/ SCHOOL VISIT/ VHSNC/ VHND Review & co-ordination meeting- MO Yoga day monitoring/ supervision-9 -10 am OPD Clinic 10 am-1: 00 pm OPD Clinic and special health promotion session to community -5 pm 1

Jr. Health Assistant (ANM)/ ASHA- Weekly schedule. DAYS MONDAY ASHA Jr. HA (ANM) Home visit- ANC and PNC visit along ANC or PNC Visit with ANM TUESDAY Home visit- ANC and PNC visit along ANC or PNC Visit with ANM WEDNESDAY Anganwadi and HWC visit/ NCD camp THURSDAY HWC/NCD camp coordination activity Identify the children for immunization Immunization day along with MLHPs and bring them to the centre FRIDAY Anganwadi visit followed by meeting Anganwadi visit followed by with PHC MO meeting with PHC MO – MLHPs. SATURDAY Yoga followed by Conduct larva survey Yoga activity Followed by Health and educate people. promotion/Home visit to ANC, PNC

NCD Screening by Nurse Mid Level Healthcare Providers

Programme Outcomes: Pilot blocks -Progress at the HWCs: (12 Essential Service Packages (February 2018 - Jan 2019)) No Service Delivery of Essential Packages Name of the blocks T. Narsipura 1 Total OPD footfalls in the HWCs 2 Lingasagur 4, 10, 239 2, 01, 021 Reproductive and Child Health (1 st to 4 th packages) 26, 794 19, 070 3 Common Communicable Diseases (including National Programme) [5 th& 6 th packages) 87, 893 43, 069 4 Non- Communicable Diseases (7 thpackage) 1, 30, 519 51, 709 5 Mental, Oral, Elderly, ENT& Ophthalmic, Basic Trauma care and Additional Services (Cases) (8 th – 12 th package) 1, 65, 033 87, 173

Programme Outcomes- Pilot blocks Month-wise total OPD attendance at HWCs in T. Narsipura and Lingasagur

Programme Outcomes- Pilot blocks average daily footfalls (each month) at HWCs in T. Narsipura and Lingasagur

NCD screening, treatment and follow-up

Accomplishments phase-1(2018 -19) Service Delivery of Packages in Blocks Essential Sedam & Kustagi Yalaburga Devadurga Chincholi & Yadgir Shahapur & Bidar & Basavakalyan Total OPD footfalls in the HWCs 59620 85595 54360 62846 37012 Reproductive and Child Health (1 st to 4 th packages) 13610 13430 15022 9961 7630 Common Communicable Diseases (including National Programme) [5 th& 6 th packages) 14240 19473 12337 12668 8636 Non- Communicable Diseases (7 thpackage) screened 17723 22754 5569 16019 11929 Mental, Oral, Elderly, ENT& Ophthalmic, Basic Trauma care and Additional Services (Cases) (8 th – 12 th package) 14047 29938 21432 24198 8817

Top 10 Causes (diseases) of out-patient attendees in HWCs

Perspective from the field- ASHA The concept of CPHC as perceived by ASHA • “people get health facilities closer to their homes”. • HWC serve as a facility where people can avail treatment for acute simple illnesses. • MLHP commonly referred to as “UHC Doctor” and are responsible for the overall functioning of HWC • ASHAs mentioned that “in case if a patient does not come for followup visit to HWC”, then we make home visits and counsel patients to visit HWC *Concurrent field visits by PHFI

Perspective from the field- ANM • The concept of CPHC as perceived by ANM is healthcare services which are easily accessible to people so they don’t have to spend money. • On being probed about how MLHPs has reduced your work they reported that earlier due to workload stipulated number of ANC and PNC visits could not be completed. With MLHPs in place, ANMs can complete these activities § Follow-up medicines for HT, Diabetes were issued by MLHPs at SHC in ANMs absence including IFA – reduced the burden on ANM

Perspective from the field- MLHP • MLHPs have Adequate knowledge about own roles and responsibilities as well the other members of HWC team • Quality of training received by ASHA and ANMs was satisfactory as the were able to effectively do risk assessment for NCDs • Strengths§ “We get good support from ASHA and ANM” § “They motivate people to attend NCD camps, to go to HWCs” § “Monthly meeting with MO” § “people from State and district visit our center and see the service delivery and enquire people if we are taking money from the public” Challenges“Sometime we will not have few drugs except for BP monitoring and blood sugar measurement other services are recently provided”

Findings from the field- PHC MO • Satisfactory knowledge about the programme and expected roles and responsibilities of HWC team and their work distribution • PHC MO encouraged patients to visit HWC first (before approaching PHC) • Coordination mechanism followed- Weekly meetings at PHCs have been able to address issues of confront. Many instances demanded Direct intervention by MO • Team Management- 70% of the teams reported cordial working *Concurrent field visits by PHFI

Fund allocation and Expenditure done by State (in lakh Rs) Phase Fund allocated (in Lakh Rs) Pilot phase - FY 2015 -16 881. 87 Phase 1: FY 2016 -17 995. 95 Phase 2: FY 2017 -18 7415. 12 Phase 3: FY 2019 -20 19701. 62 Expenditure (in Lakh Rs) Remarks 528. 6 60% of funds spent with committed for remaining amount. (Got approved in Supplementary Ro. P -2015 -16) 619. 09 2183. 13 Committed for Civil works and logistic procurements. 90% work already completed

Challenges • Rationalization of human resource deployment and Pay structure § Need to consider additional MPW (M) each for 1 SHC § State has 1 MPW(M) /10000 population. • Additional structure for HWC clinic for MLHPs- storage facilities for logistics. • Role conflict management at SHC level • Compulsory Placement of Medical officers and specialists § at aspirational C PHCs/CHCs – for continuum of care • IT based innovation-integration § Also for rationalization of drugs

Way Forward • • • Recruitment policy Role conflict management policy – C& R formation. Grievance management under district nodal officers Capacity building cell at each district to have regular induction training to new MLHPs (including replaced MLHPs of drop outs) Regular orientation and re-orientation of District Health team and MLHPs. Standard Operating Procedures for management at HWCs pertaining to packages Ensuring adequacy of regular supply by integrating with KDLWS software. Strengthening IEC activities- flip/ flash charts, signage's, AV aids, announcements for campaign modes IT based management with integration of all health care functionalities

Arogya Karnataka- Ayushman Bharat: Universal Health Coverage for APL and BPL families (CPHC, Secondary & Tertiary Care Services) HWC MLHPs - Treatment/ Referral/ Follow up Community PHC MO – Primary Care/ Treatment/ referral ASHA/ ANMsreferral/ follow up CHC/ GH Specialist – Primary & Secondary Care Treatment/ referral Medical College/ Tertiary Hospital Specialist treatment District Hospital Specialist –Secondary & Tertiary Care Treatment/ referral

Projected future outcome • NCD screening of all the individuals above 30 years § especially belonging to the vulnerable sections of the society. • Increase in daily OPD footfall at each HWCs and population coverage § to address Communicable diseases with passive stimulated surveillance • Reduce OOPE burden for families on the secondary and tertiary healthcare facilities § through early intervention and prompt referrals • Provision of basic health services at patient’s doorstep § follow-up drug services to chronic illness, continuum of care • Strengthen follow-up and referral mechanism § with adoption of IT innovation and software integration.

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