AYUSHMAN BHARAT HEALTH AND WELLNESS CENTRES REGIONAL WORKSHOP

AYUSHMAN BHARAT – HEALTH AND WELLNESS CENTRES REGIONAL WORKSHOP , AMRITSAR, PUNJAB - 5 TH – 6 TH SEPTEMBER 2019

AYUSHMAN 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 / Medical Colleges, PMJAY empanelled Pvt. facilities TERTIARY SECONDARY CPHC through HWCs Referral/Return 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

AB-HWCS - WHAT HAS CHANGED ? Improved infrastructure including branding Human Resources at AB-HWCs – ideally as per IPHC norms ; Community Health Officer (SHC), One MO, LT and Pharmacist (PHC/UPHC) MPW – M&F 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 – diabetes/hypertension, 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 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 – laughter clubs etc.

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 pregnant women Tamil Nadu : 3 months of buffer stock of medicines at SHC, PHC Population being served is defined with SHC – PHC linkages, Yoga and Meditation Telangana : Basti Dawa Khana in Urban Areas State run diagnostic hub ; streamlined collection of samples and reporting

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

3 RD REGIONAL WORKSHOP – AMRITSAR, PUNJAB (STATE AND DISTRICT VISITED) Jammu and Kashmir (Samba and Jammu) Punjab (Amritsar, Jalandhar) Haryana (Mewat, Yamunanagar) Himachal Pradesh (Mandi, Solan) Uttarakhand (Dehradun, Haridwar) Rajasthan (Jaipur, Jaisalmer) Madhya Pradesh (Ujjain, Indore) Chhattisgarh (Bemetara, Durg) Chandigarh

AB-HWC CONDITIONALITY 2019 -2020 STATE/UT Total Approval facilities s (NUHM + Accorded RHS 2018) Till date FUNCTIONAL HWC as on 04. 09. 19 SHC PHC UPHC 25% of Total facilities TOTAL AB-HWC FUNCTIONAL as on 04. 09. 19 20 34 1 0 8 5 9 Chhattisgarh 5236 1900 594 195 21 1309 810 Haryana 2685 1504 169 209 86 671 464 Himachal Pradesh 2092 785 0 37 2 523 39 Jammu & Kashmir 3016 1185 113 115 4 754 232 Madhya Pradesh 11333 2871 0 666 97 2833 763 Punjab 3043 1833 423 348 91 761 862 Rajasthan 14650 4806 130 423 57 3663 610 Uttarakhand 1847 996 85 82 34 462 201 Chandigarh

FIELD FINDINGS : INFRASTRUCTURE 1. Upgraded centres have been adequately branded in most of the facilities visited except Punjab, Madhya Pradesh. 2. In Rajasthan and Haryana - quality of branding was poor in the facilities visited. 3. Separate building / structures were noted for AB-HWCs in Uttarakhand. 4. Adequate Planning for HWCs - identification and prioritization of facilities for transformation was not observed in Rajasthan. 5. The infrastructure of the Programme Study Center (Jaipur) needs immediate attention as some parts of the skill lab are already damaged and not functional at present.

FINDINGS AND MULTISKILLING 1. FIELD Adequate HR was: EXPANDING not available -HR shortage of MO, staff nurse and labtechnician in Rajasthan, Chandigarh, Uttarakhand, Madhya Pradesh. Full time MO is not available / attachment is done from other hospitals. (MP) 2. However, MBBS and CHO posted together in RMD (HWC-SHC), Amritsar 3. Trainings have been completed in most of the states except Rajasthan, HP NCD training of MO, ANM, SN not yet started at district level (HP) 4. Training on VIA has not been initiated in most of the States. (except Haryana)

FIELD FINDINGS : EXPANDING HR AND MULTISKILLING 5. Oral Cancer Screening being done is not as per protocol – use of ice-cream sticks (use and throw) can be propagated. 6. Performance linked payments were not being disbursed (except Chhattisgarh & UK, Punjab – only for CHOs). § CHOs/ Primary healthcare team have not received PLP for past 3 -4 months (Rajasthan). § Huge disparity between remuneration of CHOs and MPW (F), thus leading to dissatisfaction amongst CHOs. (Rs 9500 pm to Rs 60000 pm)

FIELD FINDINGS : EXPANDING MEDICINES 1. NCD Drugs were available in most of the facilities except 2. 3. 4. 5. 6. 7. sporadically in Punjab. Prescription by MO, PHC and dispensation was being done at SHC. However, medicine prescription for only 10 -15 days in most SHC for chronic diseases. (except prescription by CHO in Haryana) Prescription audit in Rajasthan Focus on AMR , irrational prescription is not being monitored No IT enabled supply chain system (Chandigarh) Block CHC supplies drugs to HWC-SHCs. (Chhattisgarh) Drug stock register not maintained properly in any of the HWCs visited in district Amritsar

FIELD FINDINGS : EXPANDING DIAGNOSTICS SERVICES 1. States are yet to plan for expanding the list of diagnostics to be provided at the AB-HWCs. 2. No structured policy existed for procurement of reagents for diagnostics in the state – Uttarakhand 3. No screening is being done for any cancers (logistics not available with MPWs) (J & K) 4. State has established Hub and spoke model for PHC-HWCs, samples are collected from SHCs/PHCs and sent to Hub CHC/PHC (Madhya Pradesh) 5. Limited diagnostic tests(Hb, sugar, rapid malaria test, sputum collection) were being conducted at SC-HWCs of District Amritsar and

FIELD FINDINGS : COMMUNITY MOBILISATION 1. Organization of need based camps at village level, participation in VHNDs (Uttarakhand) 2. CBAC formats are not been adequately and appropriately filled by ASHAs (Uttarakhand, Rajasthan) 3. NCD registers were not found at HWCs (Himachal Pradesh) 4. Good linkages with School Health Program. RBSK doctors are conducting 2 hrs OPD at identified schools. (Chandigarh) 5. Family folders and CBAC forms are filled by ASHAs, however lack of clarity was observed in ASHAs with regards to scoring in the CBAC form – Old forms were being used. (Haryana, J & K)

FIELD FINDINGS : COMMUNITY MOBILISATION 6. Special outreach camps are being conducted twice a month per UPHCs with the involvement of Specialists (Rajasthan, Haryana). Eye Camps in Urban Areas of Yamunagar for Drivers to reduce accident cases (Haryana). 7. Community level NCD screening not happening across facilities visited. (J & K)

FIELD FINDINGS : IT SYSTEM 1. NCD application, NCD MO Portal and HWC portal are in use at HWCs. HWC portal is updated daily at visited HWCs. (Chhattisgarh) 2. Tablets not provided to CHOs and ANMs and no smart phones provided to ASHAs. Data entry in HWC portal are done at block level – internet connectivity is an issue at SHC. (Uttarakhand, Amritsar – Punjab, No training in Rajasthan) 3. Laptops procured , but yet to be provided at the AB-HWCs. Daily reporting was being done at HWC portal through centralized mechanism (MOs from HWC send the data to DEO at head quarter and DEO enters the data into HWC portal). (Chandigarh) Entry into NCD application software was limited (software related

FIELD FINDINGS : IT SYSTEM 4. Battery related issue in the tablets at the facilities (Mewat) – no data entry. 5. No tablets were functioning- either not available at most of the facilities or login credentials not provided to end user (J & K). 6. MO Portal is not made available at PHCs and PHC staff is not aware about daily reporting (Madhya Pradesh) NCD registers are filled up by the MOs, and data of hypertension and Diabetes Mellitus was available at the facility level. 7. e-Aushadhi system is functioning well in Madhya Pradesh and Rajasthan Portals like PCTS/HMIS/HWC/NCD/Nikshay/E-Aushadhi/OJAS/E-

SERVICE DELIVERY(INCLUDING EXPANDED PACKAGES) 1. Engaging PGI Specialists for OPD services at HWCs. (Chandigarh) 2. Lack of coordination among CHO and ANM were observed at SC level during field visit (RCH register are with ANM and not accessible to CHOs) 3. Sanitary Napkins vending machines along with disposal machine were installed at SC-HWCs in district Mewat leveraged through District Collector office. Staff Nurse utilized as Adolescent Heath counselor in UPHC, Yamunanagar. (Haryana) 4. All RMNCHA+N services were not being provided in Himachal Pradesh. 5. Dental Officers were posted at PHCs where no dental chairs were available. Fixed day facility based RI sessions

SERVICE DELIVERY(INCLUDING EXPANDED PACKAGES) 6. RDT kits with ASHA were not available during the visit. (Madhya Pradesh) 7. CHO updates the data base of Identified NCD cases to follow up regular with them to ensure treatment compliance and life style modification. (Rajasthan) 8. OPD register for HWCs and Health card for NCD patients. (Chhattisgarh) 9. Work plans were displayed at the SHCs for CHO in Haryana, Uttarakhand. No work-plan in Rajasthan, Punjab.

WELLNESS § Tug of war in schools, awareness in dance performance in schools, community dances (Haryana) § Various health days (Suraksha Sutra Divas, Pyari Bitiya Divas, Nirogi Divyang Divas) are celebrated in HWCs. Other wellness activities such as Jalebi race, NCD snake & ladder game, Chair race etc. were conducted in some HWCs during NCD Suraksha Maah in 900 HWCs across 27 districts. (Chhattisgarh) § Collaboration with Government Yoga College for recruitment of Yoga Instructors. Monthly sessions on oral hygiene awareness at the facility, camps for elderly at old age homes(in partnership with an NGO). Integration of Mobile Food Testing Laboratory at designated HWCs to

WELLNESS § Wellness activities including exercise for joint pain , laughing club and dancing and folk activities conducted. Mobile Mitra for community awareness. (Haryana) § No wellness activities are being conducted at UPHC visited – space constraints. (Uttarakhand) § Activities yet to be initiated in HP, Madhya Pradesh, Rajasthan. § CHO has planted medicinal plants within the HWC premises and also encourages the community to make use of herbs and medicinal plants in their lifestyle. (Rajasthan)

OTHERS 1. Good CSR leverage – TATA Steel and Indian Oil, Mewat. (Haryana) MO at PHC level can indent drugs of district level - Mukhya Mantri Muft Illaj Yojana to reduce OOPE. 2. Uttarakhand has identified Himalayan Medical university for designing and conduction of certificate course (3 months) in the state. Himachal Pradesh is yet to start the Certificate Course in Community Health. 3. Trainings were not being given as per the recommended protocol. Training is yet to be completed for Medical Officers, ANMs and ASHAs on NCD screening in both rural and urban areas. (Haryana) 4. Display of citizens charter (except Haryana), list of essential medicines and diagnostic tests was not done at the facilities. 5. Definite referral pathways and mechanisms were not established for continuum of care. Except Madhya Pradesh, (urban) where at the tertiary care centre, a separate queue of referred clients is made so that waiting time is reduced

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 State/UT Chandigarh Total Facilities Number of PHCs % Without % Water Without supply electricity Total Facilities % Without % Water Without supply electricity 17 0 0. 0 Chhattisgarh 5200 26. 6 14. 9 793 9. 6 5. 0 Haryana 2589 11 10. 2 368 0. 8 Himachal Pradesh 2084 17 0 576 5. 0 0. 0 Jammu & Kashmir 2967 51. 1 41. 2 637 20. 7 16. 8 Madhya Pradesh 11192 27 35. 7 1171 9. 6 0. 0 Punjab 2950 3. 4 6. 1 432 0. 0 Rajasthan 14405 34 32. 5 2078 7. 7 2. 8 Uttarakhand 1847 33. 1 27. 4 257 11. 7 12. 8

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 MPW / 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- SHC HWC - PHC EML as per guideline State EML Available EML as per CPHC guideline State EML Available Madhya Pradesh 91 30 30 285 171 74 Chhattisgarh 91 46 31 285 90 40 -50 Himachal Pradesh 91 43 35 285 106 80 -85 Punjab 91 91 30 -35 285 90 75 Chandigarh 91 - - 285 44 25 -30 Haryana 91 91 79 285 94 90 Uttarakhand 91 32 15 285 65 40 J&K 91 23 15 285 71 50 Rajasthan 91 91 32 -35 285 244 140 -150

EXPANDED RANGE OF POC DIAGNOSTICS 14 at AB-HWC-SHC and 63 AB-HWC-PHC S. No State/UT HWC_SC HWC_PHC HWC_UPHC 1 Madhya Pradesh 7 19 17 -18 2 Chhattisgarh 6 10 12 3 Himachal Pradesh 3 16 16 4 Punjab 4 12 12 5 Chandigarh - 8 2 6 Haryana 6 19 15 -21 7 Uttarakhand 4 19 2 -7 8 J&K 4 12 12 9 Rajasthan 7 12 12

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 – allowed for PLPs till December 2019.

BI-DIRECTIONAL REFERRAL AND RETURN LINKAGES Facility mapping with CHC/SDH/DH/MC/ PMJAY speciality 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 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: Medicines, 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 / existing health facilities 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 ? In areas where there are no ASHAs, existing community volunteers, SHGs, NGOs, Nursing students etc may be identified to undertake population enumeration and risk assessment (using CBAC) under Universal Screening of

AB-HWCS IN URBAN AREAS Outreach services for the marginalized/vulnerable can be planned in a camp mode, to insure Universal Coverage. Nutrition related services to be strengthened in slum areas and identified pockets with vulnerable population sub group Linkages for secondary and tertiary care Community based platforms to be involved actively in Health Promotion and preventive care activities. 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