Human Resources and Capacity Building

1. Human Resources and Capacity Building Group 2-Ayushman Bharat Operationalizing HWCs to deliver CPHC National Consultation-1st-2nd May 2018

2. Group Constitution • Group Chair-Shri Pradeep Vyas • Members- • Mr Keshavendra- MD-NHM Kerala • Mr Naveen Jain-MD-NHM Rajasthan • Dr Satish Pawar Additional MD-NUHM Maharashtra • Dr Shirodkar-State Nodal Officer CPHC Maharashtra • Dr Adkekar-Assistant Director Health Services-Pune • Dr RathiBalchandran-ADG-Nursing Council • Ms Reeta Devi-Programme Coordinator –IGNOU Certificate Programme in Community Health • Dr. ManjuMalik Director Health Services-Uttar Pradesh • Dr. Suresh Chandra Director MCH • Dr Rajesh Jha, Nodal Officer CPHC-Uttar Pradesh • Dr Pranjal Nodal Officer CPHC Assam • Mr Samir Garg- Nodal Officer-Chhattisgarh • Dr Dileep Singh-WHO • Ms Ritu Moni Das-HR Consultant NERRC • Dr Shalini Singh- Senior Consultant NHSRC • Dr Balu Mote-State Programme Manager NCD-Maharashtra • Dr Gopal Chauhan-State Nodal Officer NCD/CPHC Himachal Pradesh • Dr Arti • Dr. Bharat • Dr. Tapaswi

3. Ensuring Quality in Selection • Designing of Curriculum to be left to States Approved by GOI • Ensuring quality and transparency in selection will largely be the responsibility of the State government/NHM • Numbers of Screening Exam Based should be based on the number of candidates to be recruited. • Large number of candidates could have a two step recruitment/screening exams • Frist screening could be the existing screening process as currently underway in NHM • Second could screening exam being undertaken for the Certificate Course • States may also plan for adequate weightage could also be given for the Basic Qualifying Exam of the Candidates (40% to Qualifying Exam: 60% to Screening Exam) • However, only last two-three years period should be considered for validity of scores for Qualifying Exam • Flexibility of single screening exam should be there when target number of candidates are less. • Exams Multiple times in a Year –scores to be valid for certain period

4. Issues regarding selection • There are three Channels for entry as Mid Level Health Providers- • In-service regular candidates • In service NHM Contractual • Fresh Candidates through open selection • Initial thought was that this process requires a standard criteria to be made uniform across the country • Large scale selection of in service nurses may lead to significant gaps in facility based position of staff nurses and adversely affect service delivery • Commensurate addition of new posts will be a challenge in many states as approvals from State Finance will be a challenge for many • Example of West Bengal was given which prioritizes selection of only in-service candidates and has also institutionalized approvals from State Finance for undertaking new regular recruitments in positions where Staff Nurses have opted for becoming Mid Level Health Providers • However, this may not be easily possible for many states • Nevertheless, similar policy action and approvals will be required if in-service regular candidates are to be prioritized for selection as MLHP • Dentists to be selected as MLHPs

5. Key Inputs for selection • The process should be seen as “Recruitment” rather than selection • Once recruited, candidates should first be appointed to their respective HWCs and then deputed for attending the Certificate Programme rather than vice versa which is the present mechanism being followed in all states except Karnataka • There are challenges in making it a district cadre as not all districts will have adequate availability of candidates meeting the eligible criteria • State level advertisement would be necessary indicating district wise positions. However, preference/priority for local candidates may be specified • Process of recruitment should be made state specific • Mid Level Health Providers to be envisioned as a separate New Cadre • However, these providers should be taken on contract wherever possible and planning and framework for there eventual absorption as regular employees should be initiated • For this, the Cadre Management and Promotion Rules will be state specific

6. In view of the services to be delivered, priority or preference should be given to selection of women candidates. • As of now wherever large scale selection is being undertaken majority male candidates are joining the pool and may affect delivery of care for the first five package of services and also for screening of Cancer Breast/VIA if planned under HWCs at the HSCs level • Reservation of seats for women candidates may be explored wherever possible • However, one also needs to be cognizant to issue of less women candidates ready to join in HWCs of rural remote areas. • Extra weightage in scoring to women and local selection

7. Ensuring Training Quality • Rather than six months-can be broken to modular structure without compromising on the curriculum content • Skill and Written Examination at the end of training of each module • At the completion of training content content-Certification Exam by IGNOU or any other Public University should be planned and is mandatory • Idea of IGNOU licensing SIHFWs to undertake the certification process on its behalf can also be explored • SIHFW/NIHFW are already certifying/accreditation agencies for critical LSAS/BEmONC/EmONC Trainings and should be seriously explored • District Level Committee of Observers to monitor the process should be constituted and a pool of individuals from-NGOs/Nursing Training Colleges/ANM TCs/Medical Colleges/DH-Counsellors should be created to monitor the training process and submit feedback to State NHM/District Health Officers/CMHOs • Certification Exam multiple times in a Year

8. Options for Rapid Scale Up • 1. Leverage the decision to use 75-bedded and above sub divisional hospitals to start a batch of 30 • 2. Plan for a batch of 60 in hospitals 150 bedded and above maintaining the specified Counsellor: Student Ratio • 3. Engage NGO/Charitable Hospitals from early on but not for profit private hospitals. • 4. IGNOU should License accreditation process of hospitals/Counsellors to SIHFW • 5. All District Hospitals 100 bedded and above and all Sub-Divisional Hospitals75 bedded and above with specified Counsellors pool should be deemed accredited by IGNOU as Programme Study Centres and permission may be granted to commence training without a formal notification. Certification by MD-NHM should suffice for any further payment. • 6. Multiple term end exams/Multiple cycles of admission could be possible when other public universities are being engaged • 7. Additional Six months to be integrated with the BSc/GNM Curriculum as an “Honours Course” so that candidates graduating can be directly absorbed on campus selection- 1.25 Lakh GNMs graduate every year and should be harnessed for developing this cadre

9. On-Site Mentoring • PHC Medical Officer to be the main Technical Mentor • District Mentoring Team for the HWCs Team could be planned comprising of-Counsellors from District Hospitals, Co-opt Expertise from NGOs/Chartiable Hospitals. Dakshta and Laqshaya Monitiring Committees/

10. Career Progression • Not a uniform consensus in making the MLHPs regular after a period of six years as indicated in the present guidelines in view of multiple challeneges • Permission of Rural Development/Approvals from State Finance/Varying Capacity in the states to make it possible • Limited agreement on imparting additional trainings and using these CHOs as Hospital Managers or Block Level Public Health Officers at the block serving assisting the BMO. • Option of exit is not viable because that would also require commensurate addition of position in respective clinical cadre by the states. • They at any given point will not be called Assistant Medical Officers • Should be continued as CHOs with periodic promotions as PHC Level CHOs, Block Level CHOs and District Level CHOs and discretion should be left at the states to engage them in different areas.

11. Retention Mechanisms for MLHPs • Long term Career Progression one way but complex at the moment • Short Term-Residential Facilities at the HWCs could be used but limited takers • Instead-Block Level Residential facilities/Good Hostels should be created for CHOs • Loan Advance for purchase of the Two Wheelers • Preference and reservation of seats in other job opportunities at the district level/Continuing Medical Education-MSc courses/PGDPHM or any others • Compulsory Provision of Hardship Area Allowance to be made for MLHPs serving in such areas as is applicable for other service providers from State/NHM

12. Online Models ECHO for scaling up regular capacity building Programs • Platforms like ECHO can be adopted and adapted for capacity building of CHOs. • Existing online courses contents from Tata Memorial can be integrated. • There should be provisions individual certification for individual CHOs who have completed online modules • Certain other online courses available on WHO , ICMR can be integrated . • The states can purchase online courses available that can enhance capacities of the cadre at Health and Wellness Center. • State can utilise webinars available online for the CHOs • For states with districts and facilities with very less internet connectivity can opt for offline modules.

13. Mechanisms for multi-skilling for Primary Health Care Team • The service orientation on Health and wellness centers for ASHAs and other health care teams is essential • There is no requirement for any additional role allocation for ASHAs at H&WC. • Immersion programs for the entire team is necessary for clarity of roles. • Special attention should be paid to skill building of ANMs and MPWs deployed at Health and Wellness Center.

14. Involving ASHA in Complex Role • Consensus that planning newer roles of ASHA will be a challenge and not desirable • ASHAs should continue with the existing roles of being a community level facilitator, service provider and activist for reach to the marginalized • Increase in the number of ASHAs not required and ASHAs should continue to support the care delivery for expanded package of services within the framework of exsting roles. • Career Progression for ASHA as envisaged for ANM Trainings etc should be continued