HWC Assam Journey so far and lesson learnt

HWC –Assam Journey so far and lesson learnt Dr. Lakshmanan S, IAS Mission Director, NHM Govt. of Assam

Assam at a glance Population: • 3. 11 Crores (Census 2011 ) • 27 districts (6 new districts yet to be operationalized as health districts) Health Facilities: 4644 SCs 946 PHCs 54 UPHCs

Assam has been awarded the ‘most improved large State’ in the categories of Overall performance, Economy and Health by India Today at the “State of the States Conclave”

Launching of 100 new Health and Wellness Centres by Hon’ble Union Health Minister

Inauguration of Bagori Health & Wellness Centre, Nagaon by Secretary, Ministry of Health and Family Welfare, Go. I

§ Based on the conditionality performance indicators, Assam received 12% incentive for the FY 2018 -19 § Assam got 2 nd highest incentive next to Haryana (13%) only. Additional Incentive amount will be received by the state § § § Assam is the one of the 5 most improved States as per NITI Aayog report. Overall score improved from 44. 13 (2015 -16) to 48. 85 (2017 -18) In overall performance in Health, Assam rank improved from 16 to 15

HWC progress RHS 2018 Approved in 2018 -19 Operational in 2018 -19 Approved in 2019 -20 Notified in 25% of Total 2019 -20 Health Facilities SC - 4644 691 630 542 430 PHC - 946 133 254 300 210 UPHCs - 54 54 50 - - TOTAL 5644 878 934 842 640 1411 • A total of 151 CHOs (B. Sc. Community health) has been recently posted and are undergoing 5 days induction training • Shortfall in HWC-SC will be covered by converting additional PHCs into HWC in November 2019 and January 2020 after training of MO/SN and branding

Extension of Primary Health Care to Remote corners Health & Wellness Centre : Community Health Officer run Model Mobile Medical Unit (MMU) : Doctor run Model (Special focus on Tea Garden, Hard to reach areas and Boarder areas) Boat Clinic : Doctor run Model (Special focus on Char/ Riverine areas)

Health & Wellness Centre run by Community Health Officers (CHOs) Mid Level Service Provider Model – Initiative of Govt. of Assam

Rationale of Mid Level Service Provider § § More intense shortage of medics and para medics in remote areas. Mid Level Provider became the most optional mechanism for providing health services Government of Assam had taken an initiative to create a cadre named Community Health Officers (formerly known as Rural Health Practitioners) to serve the underserved. Provide Primary Healthcare at the Sub Centre level even at the remotest areas of the State.

Journey of CHO Programme in Assam legislature had enacted the Assam Rural Health Regulatory Authority (ARHRA) Act 18 th September 2004 Established Medical Institute, Jorhat (100 seat capacity) 8 th April 2005 1 st Batch of Diploma in Rural Health Care and Medicine (DMRHC) started September 2005 1 st Batch of 92 students completed DMRHC September 2008 1 st Batch of 92 appointed under NHM 1 st June 2009

Journey of CHO Programme in Assam IMA challenged Constitutional validity of the ARHRA Act, 2004 in the Hon’ble Gauhati High Court The Hon’ble Gauhati High Court struck down the ARHRA Act, 2004 30 th October 2014 Govt. of Assam notified The Assam Community Health Professionals’ (Registration and Competency) Act, 2015 29 th May 2015 Govt. Gazatte Notification redesignation as “Community Health Officer” 29 th May 2015 Mid Level Service Provider in Health & Wellness Centre for providing CPHC 7 th June 2018

Job Responsibilities of Community Health Officer § Maternal Health Services: § Ante Natal Care Services. § Delivery Services. § Post natal Care Services. § Child Health Services: § Manage cases of Asphyxia. § Prevent Hypothermia and infection after birth. § Promotion of early and exclusive breast feeding § Routine immunization and Vitamin -A supplementation. § Provide treatment of Diarrhoea and ARI cases § Family Planning Services : § Create awareness about contraceptive and advantages of small family § Male participation in family planning by adopting modern family planning methods.

CHOs: Our Warriors in the farthest Corridors CHOs providing service in HWCs and community outreach area

CHOs in Assam has been given administrative power by a Govt. order and have been designated as Member Secretary of HWC Management Committee

Expansion of services through training on NCD of HWC Staff Health Cadre Trained Medical Officers Community Health Officers (CHO) Staff Nurses MPW(F & M) ASHA Training duration 3 days 5 days Total trained 3 days 4 days 5 days 348 1, 812 7, 012 313 740

Service Delivery CBAC Filled 10, 23, 413 Individuals Empanelled 35, 57, 740 New Cases Total(OPD) 31, 17, 226 Old Cases Total(OPD) 3, 79, 414 Total OPD Total (Hypertension- screening) 34, 96, 640 4, 54, 160 Total (Hypertension -Newly diagnosed) 57, 737 Total (Hypertension -On Treatment) 61, 816 Total (Diabetes- screening) 3, 90, 732 Total (Diabetes-Newly diagnosed) 30, 439 Total (Diabetes- On Treatment) 28, 479 * As on 26/09/2019

Service Delivery Total (Oral Cancer- screening) 3, 94, 454 Total (Oral Cancer-Newly diagnosed) 764 Total (Oral Cancer- On Treatment) 200 Total (Breast Cancer- screening) 1, 96, 771 Total (Breast Cancer- Newly diagnosed) 338 Total (Breast Cancer- On treatment) 168 Total (Cervical Cancer- screening) Total (Cervical Cancer- Newly diagnosed) Total (Cervical Cancer- On treatment) 2, 566 12 0 As on 26/09/2019

Mobile Medical Unit (MMU) – Mobile Health & Wellness Centre Doctor run Model - Special focus on Tea Garden, Hard to reach areas and Boarder areas

Healthcare Issues in Tea Garden areas ▪ ▪ Around 20% of State population Poor health outcomes High MMR- Low health seeking behaviours TG population has health issues of Tea Garden ▪ High Risk Pregnant Women (HRPW) Char Area ▪ Anemia ▪ Hypertension ▪ Poor nutritional status- High Alcoholism ▪ Low Birth Weight Babies (LBW) ▪ High prevalence of TB ▪ High Prevalence of Leprosy

Healthcare Issues in Tea Garden areas ▪ Comprehensive survey of all Tea gardens with support from RRC-NE ▪ Survey Findings: ▪ 428 (57%) Tea gardens have functional hospital Tea Garden out of total 758 Tea gardens surveyed Char Area ▪ out of total 649 Tea garden Area hospitals: ▪ Only 324 (49. 9%) have Medical Officer (Allopathic) ▪ Only 258 (40%) have Staff Nurse ▪ Only 301 (46%) have Functional Labour Room ▪ Only 118 (18%) have Functional NBCC ▪ Only 146 (22. 5%) have Functional laboratory Coffee Table Book on Tea Garden

Mobile Medical Units (MMUs) – To reach the unreached § To provide primary health care services along with diagnostics facilities § Tea Garden areas = 80 MMUs § Non tea garden areas = 50 MMUs § Each MMU equipped with lab diagnostics and consumables. § Each MMU: § One doctor § Two GNMs/ANMs § One Pharmacist § One Lab Tech § Two Drivers § Each MMU will have two vehicle one fitted with lab and diagnostics and next one for staff mobility § Comprehensive primary healthcare services at the doorstep § Free drugs and free Lab diagnostics in the labour lines at the door step § Early identification and treatment of communicable and non communicable diseases § At present 414 Tea gardens are covered by MMU services

Expanding MMU services to provide CPHC § § § State has 171 HWCs manned by CHOs in Tea garden districts Existing MMU services expanded to cover Comprehensive Primary Health Care with posting of MO MBBS Comprehensive Service Package and Training plan prepared covering all Communicable and Non Communicable disease control programmes Comprehensive Family Health Card prepared to cover all programmes Digitization of Family Health Card under process

Expanding MMU services to provide CPHC § § § § Primary health services-Basic OPD care- (acute simple illness) Maternal Health Services Neonatal and Infant Health ( 0 to 1 year old) Child Health Services including Immunization services (for dropout and fresh) Nutritional services. Adolescent Health Services Reproductive health and Contraceptive Services (Family Planning) Management of chronic communicable Diseases Eye/ENT care BCC services Diagnostic Services Higher facility referral for management of complicated cases. Screening and Basic management of Mental health ailments. Care for Common Ophthalmic and ENT problems. Basic Dental health care. Geriatric and palliative health care services.

Boat Clinic – Floating Health & Wellness Centre Doctor run Model - Special focus on Char/ Riverine areas

Healthcare Issues in Char/ Riverine areas Around 10% of Flooding/erosion population facing Annual 1. Inadequate Health Infrastructure – permanent health infrastructure is a challenge Tea Garden Char Area 2. Accessibility issues resulting in. Area home deliveries 3. High teenage pregnancy 4. Poor nutritional status 5. Anemia 6. Diarrhea 7. Poor health seeking behaviours

Boat Clinic - To provide healthcare services in Riverine areas § To provide health services to the communities residing in the remote river islands (Char/Saporis) Boat Clinic Services started. § At present 15 Boat Clinics functioning in 13 Districts. § It is in PPP mode § Assam has 127 HWCs manned by CHOs in riverine districts

Expansion of services for Boat Clinic § § Services provided by boat clinic: § Curative care, referral of complicated cases, early detection of TB, Malaria, Leprosy, Kala-Azar and other locally endemic communicable diseases and non – communicable diseases such as diabetes and cataract cases etc § Minor surgical procedure and suturing § Reproductive and Child health care including ante-natal check up and related services e. g. injection – tetanus toxoid, iron and folic acid tablets, referral for complicated pregnancies, Promotion of institutional deliveries and post – natal check up § Immunization clinics § Family Planning Services All the services under H&WC being included in the Boat Clinic Trainings for the staff of Boat clinics Underway to bring continuum of care Linked to the Boat Ambulances of Mritunjoy 108

IT and Tele - Consultation • • State has provided IT infrastructure to 16 number of SC-HWCs and 13 PHC- HWC before 15 th of August, 2018 with training support from Tata Trust In-house model of Tele-consultation with support from specialist from GMCH is going on 1585 Tablets received from GAVI for aspirational district and distributed. Training is planned on October 2019 In order to implement the IT services across all HWCs, proposal has been submitted to Mo. HFW, Go. I for approval in Supplementary PIP 2019 -20 as in the main Ro. P it was approved in principle

Certificate Course in Community Health • • Six District Hospitals in six (6) districts (Cachar, Karimganj, Darrang, Nalbari, Bongaigaon, Goalpara) accredited across state as Program Study Centre (PSC) under IGNOU In July 2019 batch, 211 candidates enrolled for the course in 5 PSCs 5 more program study centres (Lakhimpur, Tinsukia, Sivasagar, Golaghat and Nagaon) under IGNOU (Jorhat Regional Office) have been selected and assessment has been completed with support from Jhpiego In next January 2020 batch, 11 PSC with 660 seats will be functional

Wellness activity in HWC • • • State has drafted “Wellness guideline” and shared with districts for starting wellness activities in all HWCs of the state State has also started working closely with Directorate of AYUSH Mission, Go. A under which yoga trainers identified in 100 identified Yoga blocks of AYUSH Mission in 1 st phase Yoga sessions in identified HWCs are planned twice a week

Key priority areas for 2019 -20 • • Training of Medical Officer, Staff Nurses, ANM & CHOs in the notified HWCs Training of Medical Officer and Staff Nurses on Cervical cancer screening (VIA) with Dr. B. Borooah Cancer Institute (RCC) Ensuring regular uninterrupted availability of drugs (as per EDL) Expanding diagnostic services in HWC – SCs (from 7 to 14) and in PHCs (from 19 to 24 and rest in DH) Ensure referral and follow up to appropriate Health facility for continuum of care Increasing the number of Program Study Centre from 6 to 11 thereby increasing the seats to 660 Establishment of IT system in notified HWCs

Guide To Good Practices

GOOD PROCESS INITIATIVE • Formation of State Steering committee with major stake holders and development partners to review the progress of HWC under the Chairmanship of MD, NHM • Monthly review of the progress of HWCs in District Health Society meeting Fixed screening services in HWCs (Tuesday and Friday) Preparation of micro-plan for screening • •

CHO-HWC PERFORMANCE MONITORING SYSTEM http: //nhmssd. assam. gov. in/ 39

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CHO (HWC) REPORTING PORTAL § Assam had in-house online system for tracking monthly performance of CHOs § The portal has been re-designed with Jhpiego support to track the performance based incentives of CHOs of the HWCs on all indicators through a single platform instead of multiple data sources § Performance of each and every CHO will be analyzed at State HQ and monthly feedback will be provided § State has also developed an excel based log sheet with calculation based on the PBI indicators for easy payments 41

Components of the Assam CHO portal • Name of district and block SC/HWC • No. Basic of villages and information with HR total population status • Manpower status of SC and training • • Infrastructure and equipment status Status of building and quarter availability Labour room Water supply and electricity Equipment status with functionality(Delivery equipment, autoclave, digital haemoglobinometer, glucometer etc) Community outreach and social mobilization • VHND session planned and held • Total population enumeration • Total CBAC filled Service delivery data • Reproductive services including FP performance • Maternal health services • Child health services with immunization, diarrhea, pneumonia, SAM data • NCD services with screened, suspected, referred data • Availability of drugs and diagnostics • OPD services and status of TB

HWC-NCD tracking Bag and HWC-NCD card

HWC-NCD tracking Bag and HWC-NCD card Challenges which lead to the innovation: • Continuum of care is still a hurdle • Patients were lost in follow up CONCEPT: It’s a HWC-NCD Tracking bag with NCD card in it, for follow up Expected outcome: I. 100 % tracking and follow up of NCD patients II. 100% continuum of care will be ensured through this process III. The process will be easy and simple for health workers to track the NCD patients IV. Reducing drop outs (NCD patients) Currently it is being developed and piloted in selected HWC of Nagaon district with support from Jhpiego and WHO

HWC-NCD tracking Bag and HWC-NCD card What is HWC-NCD tracking Bag? § HWC-NCD tracking bag is a clothed tracking bag (Tickler bag) with 14 pockets with HWC-NCD card in it. This is a simple tool for follow up of beneficiaries (patients) through filling up of HWC-NCD card § Twelve pockets in the bag indicates months of a year § The thirteenth pocket will be used for NCD card who has completed the treatment or already deceased § The fourteenth pocket will be for those who are dropped from the treatment § Each ANM/ ASHA in every month will prepare who are due in receiving treatment based on the HWC-NCD card similar to immunization MCP card

What is HWC-NCD card ? • HWC-Non communicable disease card (HWC-NCD) is a card which will be provided to patients with any kind of disease i. e. Diabetes, Hypertension, Oral Cancer, Breast cancer and Cervical cancer at SC-HWC • The main objective of the HWCNCD card is to track the treatment of the patient Sample NCD Card

STREAMLINING CBAC USE § CBAC is critical of PBS-NCD, identifying person with high risk, bringing them for screening and getting them screened at HWC and finally starting treatment (if necessary) and proper follow up § Hence, it is introduced – to keep CBAC ……ASHA wise (separate folder) and ASHA will keep CBACs , Family wise § During screening, CHO refer the CBAC of the person, who attend screening and check CBAC to know the quality of filling up

§ Peer learning among ASHAs on filing up of CBAC with quality § Signature by CHO on screened CBAC form with annual NPCDCS No § ASHA mobilizes beneficiaries for next screening, whose CBAC Forms are not signed by CHO § Incentive of ASHA on CBAC is calculated based on signed CBAC forms

Challenges § Selection of GNM for the Certificate Course in Community Health (CCCH) course from other districts and their dislodgement § Training on IT (NCD portal) – support from Tata Trust § Stressing on quality of services in the HWCs § Sustainability of service delivery and regular updating in AB portal the performance data

Technical Support – Our Partners

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