AYUSHMAN BHARAT Operationalizing Health and Wellness Centres To
AYUSHMAN BHARAT Operationalizing Health and Wellness Centres To Deliver Comprehensive Primary Health Care
AYUSHMAN BHARAT – Rationale TERTIARY PMRSSM SECONDARY Referral PRIMARY Unmet need: NCDs/other Chronic Diseases Preventive, Promotive, Curative, , Rehabilitive & Palliative Care Existing services: RMNCHA CONTINUUM OF CARE – CPHC & PMRSSM 2
Rationale • Currently the Primary Health Care is selective: limited to RCH and Communicable Diseases- addresses about 20% of health care needs • Low utilization of public health facilities -NSSO data (71 st Round) : 28% in rural areas and 21% in urban areas sought care in the public sector; of which only 11% and 3% respectively sought any form of care at a level below the CHC (other than child birth related services) • Health care is fragmented –disrupts continuity of care and impacts on clinical outcomes and leads to high OOP • High Costs are incurred because of lack of gate keeping function – raises the load on secondary and tertiary facilities and compromises quality • Epidemiologic Transition: Death from the four major NCDs –Cancer, CVD, Diabetes, and Respiratory Diseases accounts for nearly 62% of all mortality among men and 52% among women –of which 56% is premature
DALYs Rate Attributable to Risk Factors in India 2016
Rationale • Unfinished Agenda of RCH and Communicable Diseases Ø Persistent challenge –high levels of maternal and child mortality with Inter and intrastate variations Ø High TFR- States of Bihar, UP, Rajasthan, MP, Jharkhand Chhattisgarh(56% of India’s population increase) Ø High Proportion of Underweight Children-38% children under five are stunted and 36% continue to have low weight for age Ø Challenge of communicable diseases –Tuberculosis including MDR TB, Hepatitis and rising burden of Dengue, Chikungunya
CPHC: Policy Articulation • Task Force Report on Primary Health Care Rollout, 2015 • National Health Policy 2017 – Two thirds to be committed to PHC • Budget Announcement, 2017: Conversion of 1. 5 lakh sub Centres into Health and Wellness Centres (HWCs) • Financial Commitment, Budget 2018,
Launch of AYUSHMAN BHARAT 14 th April 2018 -Honorable Prime Minister launched the first Health and Wellness Centre at Jangla, Bijapur, Chattissgarh
Key Elements to Roll out CPHC
Partnership for Knowledge & Implementati on Key Elements to Roll out CPHC Robust IT System Continuum of Care – Telehealth /Referral Expanded Service Delivery Expanding HR - MLHP & Multiskilling CPHC through HWC Financing/ Provider Payment Reforms Infrastructure Community Mobilisation and Health Promotion Medicines & Expanding Diagnostics point of care & new technologies
Comprehensive Primary Health Care Team • Health & Wellness Centre – SHC • Health & Wellness Centre – PHC (@30, 000) / UPHC (@50, 000) Ø Mid-level health provider 5: BSc/ GNM or Ayurveda Practitioner trained in 6 months Certificate Programme in Community Health/ Community Health Officer (BSc-CH) Ø MPW F- 2 per SHC IPHS Ø MPW M- 1 to be provided from state resource Ø 5 ASHAs as outreach team per SHC Ø PHC team – (Atleast - 1 MBBS Doctor, 1 Staff nurses, 1 Pharmacist, 1 Lab Technician and LHV) + MPW + ASHAs s Ø Services (IPHS +) - Screening of NCDs (VIA) and wellness room SHC SHC PHC SHC
CPHC - ESSENTIAL PACKAGE OF SERVICES 1. 2. 3. 4. Care in Pregnancy and Child-birth. Neonatal and Infant Health Care Services Childhood and Adolescent Health Care Services. Family Planning, Contraceptive Services and other Reproductive Health Care Services 5. Management of Communicable Diseases: National Health Programmes 6. General Out-patient Care for Acute Simple Illnesses and Minor Ailments 7. Screening, Prevention, Control and Management of Non-communicable Diseases 8. Care for Common Ophthalmic and ENT Problems 9. Basic Oral Health Care 10. Elderly and Palliative Health Care Services 11. Emergency Medical Services including Burns and Trauma 12. Screening and Basic Management of Mental Health Ailments
Organization of Comprehensive Primary Health Care : Preventive, Promotive, Curative, Palliative, and Rehabilitative and delivered close to where people live. Family/Household and Community Level Sub centres/PHC/UPHC strengthened as HWC Health and Wellness Centres First Referral Level General medical Consultation (at PHC/UPHC); Specialist consultation and First level of hospitalization at CHC/SDH/DH
• • MLHP/CHO • • Population Enumeration Outreach Services Community Based Screening Risk Assessment Awareness Generation Follow up of confirmed cases Counselling: Lifestyle changes; treatment compliance • • Advanced diagnostics Complication assessment Telehealth Tertiary linkage/PMRSSM • • • First Level Care Screening Use of Diagnostics Drug Dispensation Record keeping Telehealth Referral to MO at PHC for confirmation/complications Diagnosis / Prescription and Treatment Plan Referral of complicated cases Telehealth Real time monitoring PHC/UPHC CHC/SDH/DH ASHA/MPW SHC Village/Urban Ward Community – Facility: Maintaining Continuum of Care 14
Mid Level Health Provider (MLHP) • Selection process of candidates for MLHP to be designed so as to attract competent and motivated candidates- Preferential Local Selection • MLHPs trained in a six month, IGNOU accredited “Certificate Programme In Community Health” to build competencies in public health and primary care- theory, Skill and experiential learning • Career progression pathways for MLHPs in public health functions to be charted at least up to district level – to synergize with Public Health Cadre
Scaling up the Certificate Course States to increase enrolment byü Increase Batch size and enrol 60 candidates/Programme Study Centres(PSC) hospitals with >150 beds (Govt/ NGO) with Counsellor: Students ratio- 1: 60 (Theory) and 1: 10 (Skill Sessions) ü Include Hospitals with 75 -100 beds (Govt/ NGO) meeting the criteria as PSC to enrol 30 candidates/batch- Counsellor: Students ratio- 1: 30 (Theory) and 1: 5 (Skill Sessions) • Explore other options through state accredited public/health universities to enable rapid and effective scaling up, but ensuring requisite skills and knowledge Immediate Requirement ü Entrance Examination and Selection of Candidates to complete by 30 th May ü Coordination with IGNOU Regional Centres for notification of required number of Programme Study Centres
Multi-Skilling of Frontline Health Workers
Addition of Skills for Frontline Health Workers Ø ASHAs-5 Days in seventh Package for NCDs in first phase + refresher and newer packages annually(15 days) Ø MPWs(Female and Males)- 3 days for seventh package to begin with and new packages(8 -12 on ENT& Opthalmology, Oral, Elderly and Palliative, Basic Emergency Services and Mental Health) to be added. Ø Joint training of MPWs with ASHAs wherever possible Ø Reporting and Recording information using digital applications. Additional 3 days
Training of PHC Team- Staff Nurses, Medical Officers Ø Seventh Package(Five days for screening and Management of NCDs) Ø 21 days for screening for Cancer-VIA for CA Cervix and further management Ø Online Training through Massive Open Online Courses (MOOC) and Extension for Community Health Outcomes (ECHO) Ø Other Distance mode certificate programmes in areas such as- NCD management/MCH Care/Elderly Care/Mental Health etc. to be planned in long term. Ø Additional Incentives/ rewards can be introduced Ø Partnerships with AIIMS/Regional Cancer Centres/Knowledge networks to act as training resource centres and provide handholding support
Medicines and diagnostics require early attention Ø Diagnostics – § Establishment of effective Hub and Spoke models for diagnostic services at different levels § Point of care diagnostics will be expanded based on recommendations of Task Force. Ø Medicines – § Essential List of Medicines to be expanded and in place across all states § MLHP to be able to dispense medicines for chronic diseases on the prescription of the Medical Officer § Uninterrupted Availability of medicines to ensure adherence and continuation of care (Eg: HT/DM/ Epilepsy/COPD) § DVDMS implemented in 28 states to streamline logistics- implementation in remaining states to be completed over a period of six months - Expansion to the level of HWC- PHCs/UPHC and HWC-SHC § Robust Implementation of Free drugs and Diagnostics schemes in all states to eliminate OOPE Ø Requirement of Medicines and Diagnostics updated based on recommendations of task forces
Robust IT System – to meet diverse needs of different stake holders q Patient centric – • Unique Individual ID • Individual health record • Family health folder-SECC data/mapping PMRSSM • Facilitates continuum of care through alerts • Facilitates access to patient care information q Service Providers • Enables continuity of care across levels • Generates workplans/serves as job aids • Facilitates use of platforms like MOOC and ECHO • Facilitates follow up and compliance to treatment • Decision Support System for service providers at various levels q Programme Managers • Dashboard for monitoring at different levels • Provide monitoring reports to assess performance for payments Overarching system – integration of all existing IT systems Eg. RCH portal/ NIKSHAY/ IDSP/ HMIS/ PMRSSPM
Health promotion Community mobilization and Intersectoral Convergence “Health in All” Approaches – NHP 2017 Recommendations • Swachh Bharat Abhiyan • Balanced, healthy diets and regular exercises • Addressing tobacco, alcohol and substance abuse • Yatri Suraksha – preventing deaths due to rail and road traffic accidents • Nirbhaya Nari –action against gender violence • Reduced stress and improved safety in the work place • Reducing indoor and outdoor air pollution States to develop strategies and institutional mechanisms in each of the seven areas, to create “Swasth Nagrik Abhiyan” –a social movement for health.
Promoting Wellness through Yoga • Yoga to be mainstreamed into the health care delivery system, • Close coordination with Ministry of AYUSH/Department of AYUSH at the state and district level. • Pool of Local Yoga Instructors at the HWC level to be identified • Training and certification of local Yoga Teachers to be steered by Department of Ayush • Weekly/monthly schedule of classes for Community Yoga Training at the HWCs • Provision for additional remuneration to in house yoga teacher or in sourced yoga instructor
Health Promotion by Ayushman Ambassadors Age appropriate, skill-oriented, theme based, graded curriculum for the teachers (primary, middle and high school) 2 teachers in every school as “Health and Wellness Ambassadors”, trained to transact health promotion/disease prevention through interesting activities for one hour every week 20 hour sessions delivered through weekly interactive classroom-based activities All Tuesday -Health and Wellness Day in the schools Students will act as Health and Wellness Messengers in the society. Regular reinforcement of messages/themes through IEC/BCC activities such as interactive activities/posters/class room/Assembly discussion
Innovation Learning Centres for CPHC • Support centres for testing innovations and learning for scale up, where CPHC will be provided to the population of one block. Key roles • To generate knowledge and evidence • Building capacity of primary health care team and at district level to organize effective interventions for CPHC • To deploy a team for required change management for CPHC Selected ILCs • Jan Swasthya Sahayog-Chhatisgarh • TISS- Mumbai • Charutar Arogya Mandal, Gujarat • AIIMS-New Delhi • Catholic Health Association of India-Telangana
Flexible financing - Performance linked compensation to service providers Aligning payment to performance (Suggestive) • For MLHPØ Contractual - About 37. 5% (up to Rs. 15, 000) of total salary (Rs. 40, 000) of MLHP to be linked with performance Ø Regular- Difference between Rs. 40, 000 and existing salary to be linked with performance • Team Based incentives as per existing guidelines Facility budgets – • Increase in untied funds for HWC –SHC to Rs. 50, 000 • Incentives after getting NQAS certification – guidelines under preparation • Capitation based payments to health facilities to be explored
Infrastructure 1. 2. 3. Ø Branding / Colour code Citizen Charter Space for – Examination room with adequate privacy and Telehealth Ø Diagnostics and medicine dispensation Ø Wellness room Ø Waiting area Ø IEC Ø Labour room at delivery points 4. 3 -4 Alternate prototype designs will be provided 5. Display boards – Ø Contact Details of Primary Care Team and referral centres Ø Jurisdiction of Gram Panchayat/ Urban Local body representatives
Quality of Care Key principles Provision of Patient Centred Care Enable Patient Amenities at HWC Adhere to standard treatment guidelines and clinical protocols for care provision Ø Achieve Indian Public Health Standards with regards to HR, infrastructure, equipment, service delivery and supplies • National Quality Assurance Standards for HWCs will be developed • Patient satisfaction to be captured through IT systems • Ø Ø Ø
Task Forces First draft of operational guidelines developed by Task forces for the following packages • Care for Common Ophthalmic and ENT Problems • Basic Oral Health Care • Elderly and Palliative Health Care Services • Screening and Basic Management of Mental Health Ailments • Emergency Medical Services including Burns and Trauma – under process Operational Guidelines/Training Manuals for Primary Health Care Team – being developed 29
Task Forces • • Review existing packages for care at community, HWC and secondary levels Define specific interventions and organization of services at each level of care Delineate referral pathways from primary to secondary care levels Review existing STGs for each disease condition -recommend updation or new development Highlight key areas that require preventive and promotive action, Recommend areas for research to enable the delivery and effective coverage of primary health care Identify institutions at state and national level to support states in enabling effective integration, research and service delivery for Comprehensive Primary Health Care
HWCs in Urban Areas • • Current norm is one UPHC per 50, 000 population All existing Urban Primary Health Centers (roughly 4000) to be strengthened as HWCs by March 2020 Where dispensaries exist, they could be upgraded to serve as H&WC, based on the HR available and geographical context Frontline workers- 4 -5 ASHAs and 1 MPW(F) for 10, 000 population - trained to deliver preventive and promotive services through outreach, including monitoring drug compliance for chronic diseases. MLHP would not be required, as MO MBBS is already approved for UPHCs Explore partnerships with not for profit and private sector to provide primary health care, where UPHCs do not exist, as a gap filling measure Financing – to be worked out with state consultation in the workshop
Immediate Next Steps Ø Strengthen Programme Management (2 consultants in small states and 3 -5 in big states as per requirement) Ø Leverage technical support from Training institutions/ Research Organizations / SHSRC/ Medical Colleges Ø District level – District Coordinator in selected districts as per requirement (with atleast one block saturation with HWC) Ø Based on annual Targets of HWCs- commensurate selection/ enrolment in IGNOU Certificate Programme in Community Health Ø Completion of training of ASHAs, MPWs, PHC Staff-Medical Officers and Staff Nurses in NCD Ø Undertake gap analysis against the requirement of equipment/medicines/ consumables Ø Prioritize Implementation of Seventh Package-NCD Care Ø Roll out of IT Systems and Training of Providers in NCD App/MO Portal
Key Areas for Priority Action Ø Appoint Senior State Nodal Officer : Director/Additional Director/Joint Director level officer Ø Periodic reviews by Principal Secretary at all levels Ø Road Map for converting all SHCs to HWCs by Dec, 2022 Ø Annual Plans for financial year 19 -20, 20 -21, 21 -22 and 2022 -23 (up to December, 2022) Ø Prioritizing Aspirational Districts/ NPCDCS Districts Ø Block Saturation with HWC and linkage to appropriate referrals Ø Create HR policy for MLHPs Ø Resources Mobilization from non –Health sources Sources-MP-LAD/MLA-LAD/MNREGA/Urban Local Bodies/PRI/ State Development Programmes/District Mineral Funds/District Innovation Funds/CSR etc. Ø NHM funds could be used to leverage some of these sources
Thank You
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