AYUSHMAN BHARAT HEALTH AND WELLNESS CENTRES REGIONAL WORKSHOP
AYUSHMAN BHARAT – HEALTH AND WELLNESS CENTRES REGIONAL WORKSHOP , GOA - 19 TH – 20 TH AUGUST 2019
AYUSHAMAN BHARAT – HEALTH AND WELLNESS CENTRES – A PLATFORM TO INTEGRATE SERVICE DELIVERY – PROVIDE COMPREHENSIVE Geriatric etc Comprehensive Primary Health Care – Oral, Mental, Preventive and Promotive Non Communicable Diseases RMNCHA+N . CARE Moving towards Universal Health Coverage
CHC/ SDH/District Hospitals / PMJAY empanelled Pvt. facilities TERTIARY SECONDARY CPHC through HWCs Referral/Gatekeeping PRIMAR Y Unmet need: NCDs/other Chronic Diseases Existing services: RMNCH+A Preventive, Promotive, Curative, Rehabilitative & Palliative Care AYUSHMAN BHARAT – HEALTH AND WELLNESS CENTRES
RMNCHA+N : THE UNFINISHED AGENDA Strengthen the existing RMNCHA+N services and build on quality of services being provided Role of Primary Health Care Team led by CHO – Immunization and ANC – not just ANM and ASHA Defined role of CHOs for FP services, ANC / PNC care , immunization etc. – linking with performance linked payment of the AB-HWC team
AB-HWCS - WHAT HAS CHANGED ? Improved infrastructure Human Resources at AB-HWCs – ideally as per IPHC norms ; Community Health Officer (SHC), 1 MO, 1 LT, 1 Pharmacist (PHC/UPHC) ANM and ASHA (as per population norms) Strengthening of existing services – RMNCHA+N Availability of essential medicines Availability of essential diagnostic services Population Based Screening for 30+ (NCD , 3 Common Cancers) Emergence of IT – AB-HWC portal and NCD Application Wellness activity – YOGA and others
GOOD PRACTICES : 1 ST REGIONAL WORKSHOP - HYDERABAD Andhra Pradesh : Tele consultation at e-UPHC ; paperless e-health record accessible throughout the State Safe Delivery Calendar at the facility Level Karnataka : CHO – Streamlined recruitment process and Performance Linked Payments Kerala : PRI Involvement in Palliative Care Arogya Sena / Health Ambassadors Puducherry : Range of Wellness activities at AB-HWC
GOOD PRACTICES : 1 ST REGIONAL WORKSHOP - HYDERABAD Odisha : Population Based Screening – Campaign mode Mahila Aarogya Samitis (SHG) are actively involved for in house profiling, IEC and health promotional activities – urban areas Yoga and Mediation – for pregnants Tamil Nadu : 24*7 -AB-HWCs 3 months of buffer stock of medicines Population being served is defined with SHC – PHC linkages, Yoga and Mediation Telangana : Basti Dawa Khana in Urban Areas State run diagnostic hub ; streamlined collection of samples and reporting
2 ND REGIONAL WORKSHOP – GOA (STATE AND DISTRICT VISITED) Bihar (Patna, Jahanabad) Jharkhand (Hazaribag, Bokaro) Uttar Pradesh (Allahabad, Meerut) Maharashtra (Nagpur - Urban, Wardha and Osmanabad) Gujarat (Kheda and Patan) Goa (North Goa & South Goa) Daman and Diu Dadra and Nagar Haveli
GOOD PRACTICES : 2 ND REGIONAL WORKSHOP - GOA Maharashtra Model AB-HWCs – SHC layout-3 Designs Certificate Course in Community Health through MUHS – capacity of 6300 candidates/batch Healthcare services to the elderly in Chandrapur district (Physiotherapy) Netradan trust – NGO collaboration for diagnosis and treatment for cataract etc. Gujarat Yoga at SHC/PHCs - daily by trained CHO/MPW-M/ANM while at UPHCs it is conducted twice a week by trained ANMs. Meditation and Sapthdhara included Arogya Samanwaya – Integration of Ayurvedic and Yogic practices with Allopathy – 21 days training for CHO on ayurvedic healing practices, preparation of decoctions etc. Goa Good linkages with School Health Programs - Identified Health & Wellness Ambassadors Expanded Wellness Activities – laughter clubs etc.
GOOD PRACTICES : 2 ND REGIONAL WORKSHOP - GOA Jharkhand ATAL Clinic (Community Clinic) started on 16 th August, 2019 to cater health care needs of urban marginalised population by Nagar Nigam. Uttar Pradesh Community Health Officer – Virtual Classrooms Curriculum for CHOs has been improvised Dadra Nagar Haveli & Daman Diu Upgradation of Infrastructure using MP-LAD / CSR funds e-Arogya (Cloud based health ecosystem) at all public health facilities in Daman and Diu
AB-HWC CONDITIONALITY 2019 -2020 State/UT Total Facilities in the State/ UT ROP approvals for FY 2017 -20 Target for 25% Functional HWCs Total Functional as on 19. 08. 2019 Dadra and Nagar Haveli 73 58 18 31 Daman and Diu 27 28 6 23 Bihar 10048 2205 2512 610 Goa 218 58 54 28 Gujarat 9471 3480 2367 1602 Jharkhand 3907 1797 977 363 Maharashtra 11151 9035 2787 2669 Uttar Pradesh 21113 7570 5278 2119
FIELD FINDINGS : INFRASTRUCTURE 1. Upgraded centres have been adequately branded in most of the facilities visited except Goa. But, infrastructure upgradation and branding is yet to be completed in Jharkhand, Bihar, Maharashtra. 2. Planning for HWCs - identification and prioritization of facilities for transformation not done in all states. 3. Space constraints especially in the Urban - PHCs (Uttar Pradesh, Maharashtra)
FIELD FINDINGS : EXPANDING HR AND MULTISKILLING Adequate HR was observed in almost all the facilities visited. But, shortage of staff at AB-HWC-PHC (APHC – Bihar) CHOs are well-versed with the concept of primary Health care and are committed to Primary Health Care (Uttar Pradesh, Maharashtra) CHOs are being delegated additional duties – Bihar and Maharashtra (Osmanabad) MPW - Male cadre (Gujarat) NCD training of MO, ANM, SN has not yet started at district level (Bihar) Trainings on screening for 3 common cancers – yet to be
FIELD FINDINGS : EXPANDING MEDICINES • All medicines as per STP were available in Wardha, Maharashtra • However, facility based medicines available were not displayed at the HWC – SHC in the Maharashtra, Bihar. • Gujarat, UP it was printed and displayed on A 4 paper. • Implementation of DVDMS till AB-HWC-SHC level is an area of concern in all the State. • Drugs being indented manually at all AB-HWC-SHCs & PHCs (Bihar, Jharkhand, UP) and in UPHCs (Gujarat, UP). • On an average 40 - 50 % of the medicines were available as
FIELD FINDINGS : EXPANDING DIAGNOSTICS SERVICES • Only one test is being done at the HWC – SHC level in Bihar. • 4 -5 tests at HSC-HWC and 10 -12 tests at the level of PHC / UPHC Jharkhand. • Uttar Pradesh - 5 tests are being conducted at PHC, 10 at UPHC level and 4 tests at SHC • 17 tests are being conducted at PHC/UPHC level and 7 tests are done at SHC level in Gujarat • Maharashtra - Records are not maintained - for tests conducted inhouse (11) and through HLL (25) at PHC. Glucometer strips shortage reported at PHC-HWC in Wardha. • No action plan for expansion from 19 to 63 at PHC/UPHC level.
FIELD FINDINGS : COMMUNITY MOBILISATION AND HEALTH PROMOTION • No NCD register (Bihar), NCD roll out is slow in the urban areas (Uttar Pradesh) • CBAC forms have been printed as registers (Gujarat, Maharashtra). Separate registers in Maharashtra – difficult to locate corresponding family members in the two registers. • Plan for Door to Door screening (Maharashtra) vs camp based screening (Gujarat) , special outreach camps • AAA meetings being conducted at SHCs with involvement of CHO in Osmanabad, Maharashtra • Community Based Platforms i. e. VHSNC/MAS were not being effectively used in rural and urban areas. (Uttar Pradesh)
FIELD FINDINGS : IT SYSTEM • Daily reporting not started on AB-HWC portal at many facilities. • Adequate number of tablets have not been procured in most of the States , Smart phones for ASHAs are yet to be provided (Gujarat, Uttar Pradesh) • MPW M&F are not well versed with NCD application. Both MPWs and CHOs shared that there are issues with the tablet, mostly with the i. Ball tablet. (Uttar Pradesh) • Medical Officer is in-charge of data entry operations at AB-HWCs-PHCs (Gujarat) • All UPHCs have been designated as Microscopy Centers. Data entry in NIKSHAY portal is done either by TB-HV or Pharmacists. (Gujarat) • EHR application developed by Tata Trust used at UPHCs is a facility based model, however not linked to higher facilities (Maharashtra).
EXPANDED SERVICE DELIVERY 1. In Goa all facilities are delivering RMNCH+A services along with designated days (weekly ENT, Dental, Psychiatry, Ophthalmic, Elderly and Palliative care services (CPHC package). 2. Bike Ambulance at Urban HWCs – Equipped with O 2 cylinder (Goa) 3. Geriatric and Adolescent OPD on designated days at AB-HWCUPHCs (Maharashtra)
WELLNESS 1. Nutrition counselling has been initiated in Maharashtra , Gujarat 2. Other wellness/ health promotion activities include Meditation, and Saptdhara are being conducted in some facilities. Kitchen garden, Herbal garden, Moong dal distribution to all pregnant women. (Gujarat) 3. Laughter challenge at Old age Home, Tree plantation competition, Cricket competition for senior citizens, Special camps for school kids etc. (Goa) 4. No wellness activities initiated in Bihar 5. Uttar Pradesh – no regular Yoga sessions being organized due to lack of Yoga trainers and space constraints. 6. Activities pertaining to Health Calendar are yet to be initiated at the district level – Gujarat, Maharashtra, Uttar Pradesh
OTHERS 1. OPD extended timings for UPHCs with provision for specialist services (Gujarat – Gynae and Pediatrician). 2. States to develop reporting formats for rolling out PLP. (Maharashtra, Jharkhand, Bihar) 3. Uniform IEC developed by the State as per CPHC guidelines and also provided to the frontline workers in Gujarat. 4. Performance linked payments have been initiated in Uttar Pradesh 5. Tele Consultation facility operational at PHC-HWC as Hub Spoke Model in PPP Mode in collaboration with Apollo, Hyderabad. (Jharkhand) Yet to be initiated in other States.
VISION DOCUMENT FOR AB-HWCS !! An ad-hoc mechanism or it needs comprehensive thinking & planning for a bigger structural reform - Overarching objective of CPHC ? Financial planning – NHP 2017 (2/3 rd allocation to Primary Care) Infrastructure strengthening Strengthening of Drug Distribution and Management Systems and Expansion of essential Diagnostic services Expanded package of services , Capacity building of the existing staff Bidirectional referral and return CHOs retention and motivation
FINANCIAL PLANNING – OPTIMAL RESOURCES Gap analysis and planning – Infrastructure & HR Recurrent expenditure - Human Resource and Training Additional resources – Medicines (0. 5% of the GDP) and Diagnostics, IT – tablets / laptops, telemedicine etc. Untied funds Telemedicine Hubs and Spokes
Data Source: RHS 2018 INFRASTRUCTURE : WHAT NEEDS TO BE PLANNED ? Number of SHCs Without Water supply Number of PHCs State /UT Total Facilities Without electricity Total Facilitie s Without Water supply Without electricity Dadra and Nagar Haveli 71 16. 9 % 0 9 0 0 Daman and Diu 26 0 0 4 0 0 Bihar 9949 49 % 64 % 1899 0 0 Goa 214 0 0 25 0 60 % Gujarat 9153 10. 2% 4. 7 % 1474 0 0 Jharkhand 3848 53. 2 % 66. 5 % 298 45. 3 % 43. 3 % Maharashtra 10638 5. 9 % 11. 7% 1823 1. 3 % 1. 9 % Uttar Pradesh 20521 0 35. 9 % 3621 7. 5 % 5. 9 %
PLANNING FOR INFRASTRUCTURE AT AB-HWCS Additional space for lab services, drug dispensation & drugs storage cabinets, patient waiting area, etc. Space for YOGA / other wellness activities Rooms for ANM / CHO etc. Draft layout plan for AB-HWCs – shared with the States.
STRENGTHENING OF DRUGS AND VACCINE MANAGEMENT SYSTEM Strengthen the current system for Drugs and Vaccine management – till AB- HWC-SHC – for management of drug stock outs, stock availability and consumption patterns. Name of State/ UT HWC- PHC HWC - SC EML as per guideline State EML Available EML as per CPHC guideline State EML Available Uttar Pradesh 285 98 40 to 50 91 43 30 to 35 Maharashtra 285 443 158 91 108 54 Jharkhand 285 130 42 91 100 15 to 20 Bihar 285 50 30 91 18 10 Goa 285 75 85 91 - 30 Daman & Diu 285 244 - 91 33 - D&N Haveli 285 244 - 91 33 - Gujarat 285 249 221 91 92 69
EXPANDED RANGE OF POC DIAGNOSTICS 14 at AB-HWC-SHC and 63 AB-HWC-PHC S. No State/UT HWC_SC HWC_PHC 1 Uttar Pradesh 7 12 2 Maharashtra 8 11+25 3 Jharkhand 7 19 4 Bihar 2 24 5 Goa - 18 6 Daman & Diu 7 15 7 D&N Haveli 7 15 8 Gujarat 7 19
IT SYSTEMS Daily reporting and Monthly reporting at AB-HWC portal needs to be ensured IT Systems – standardized and integrated with Go. I applications In the mean-time, manual records – should be allowed for PLPs , due lists etc.
BI-DIRECTIONAL REFERRAL AND RETURN LINKAGES Facility mapping with CHC/SDH/DH/PMJAY specialty mapping – Referral to be prioritized treatment – referral slips / cards / point person at the referred facility Return linkages – information to be provided to the linked AB-HWC-SHC (CHO and ASHA)
COMMUNITY HEALTH OFFICERS : RETENTION AND MOTIVATION üDefined career pathways üStreamlined recruitment procedures – preference postings üPerformance linked payments üTraining at District level – National Health Programmes üConstant Supportive Monitoring and Mentoring üGNM – SN ; 6 month training would be required
IEC Logo for AB-HWCs ? Uniform IEC display at facilities – local language State / District specific media plan / IEC strategy Wider dissemination of services available – use of Social Media IEC on prevention, promotion (Eat Right), early diagnosis and improved treatment outcomes (with regular treatment) – need to be emphasized
BASKET OF WELLNESS ACTIVITIES YOGA – the only activity being focused on – can CHOs be trained as Yoga instructors? Different options : Open Gyms – in collaboration with the local panchayats Sahi Bhojan, Behtar Jeevan – Eat Right Campaign Nutrition Counselling – expanded to adolescents, patients suffering with chronic conditions, awareness building (BMI), lifestyle modifications – less salt, less sugar Food adulteration kits Medicinal Plants and their use Health Talks / Discussions / Counselling / Laughter Clubs Health Calendar / Planning of Events Cycling / Zumba Activities
MONITORING AT AB-HWC Facility based Monitoring: Drugs, Diagnostics, Swachhata related activities, Counselling, Wellness, Patient records, Teleconsultation Utilization of untied funds Constitution of RKS (facility level) VHSNCs / SHGs (community based) Social. Audits : PBS, CBAC, Immunization, ANC, Other outreach activities, Health Promotion and Wellness Activities
AB-HWCS IN URBAN AREAS Criteria for establishing AB-HWCs ? Population based / Ward based / Restricted to slum population Infrastructure (Buildings) - Community Halls of Urban Local Bodies / Corporation can be utilized Facility based services - Specialty Services- Model ? (Facility based / Tele- consultation) Outreach – Can we have a different Model ? Role of Self Help Groups , RWAs Basti Dawa Khana , Telangana – thinking for performance linked payments for outreach activities ? Linkages for secondary and tertiary care Wellness – Open spaces or gyms
THANK-YOU! IC T S DI S HU M AN RE RM O N G A SO NC HA UR CE +N ESS EN L TIA ME DIC S INE TRAI IN E FRA ST RU C TU R NING WE LL N ES S
AB-HWC CONDITIONALITY 2018 -2019 INCENTIVES State / UT Dadra & Nagar Haveli Daman & Diu Jharkhand Maharashtra Gujarat Bihar Goa Uttar Pradesh Full Immunization Coverage Incentive / Penalty 77 66 81 95 89 77 90 82 14 7 5 5 5 -12 -3 -1
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