Ayushman bharat – health and wellness centres

1. Ayushman bharat – health and wellness centres Regional Workshop , goa - 19th – 20th August 2019

2. Ayushaman Bharat – Health and Wellness Centres – aPlatform to integrate service delivery – provide comprehensive care

3. CHC/ SDH/District Hospitals / PMJAY empanelled Pvt. facilities TERTIARY SECONDARY CPHC through HWCs Referral/Gatekeeping Preventive, Promotive, Curative, Rehabilitative & Palliative Care PRIMARY Existing services: RMNCH+A Unmet need: NCDs/other Chronic Diseases AYUSHMAN BHARAT – HEALTH AND WELLNESS CENTRES

4. 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

5. 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

6. Good practices : 1st 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

7. Good practices : 1st regional workshop - Hyderabad Odisha : • Population Based Screening – Campaign mode • MahilaAarogya 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 DawaKhana in Urban Areas • State run diagnostic hub ; streamlined collection of samples and reporting

8. 2nd 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

9. Good practices : 2nd 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.

10. Good practices : 2nd Regional workshop - goa Jharkhand • ATAL Clinic (Community Clinic) started on 16th 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

11. AB-HWC Conditionality 2019-2020

12. 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)

13. 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 initiated in Gujarat

14. 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 A4 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 compared to the State EML.

15. 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 in-house (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.

16. 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)

17. 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 iBall 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).

18. Expanded Service Delivery 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). Bike Ambulance at Urban HWCs – Equipped with O2 cylinder (Goa) Geriatric and Adolescent OPD on designated days at AB-HWC-UPHCs (Maharashtra)

19. wellness • Nutrition counselling has been initiated in Maharashtra , Gujarat • 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

20. others OPDextended timings for UPHCs with provision for specialist services (Gujarat – Gynae and Pediatrician). States to develop reporting formats for rolling out PLP. (Maharashtra, Jharkhand, Bihar) Uniform IEC developed by the State as per CPHC guidelines and also provided to the frontline workers in Gujarat. Performance linked payments have been initiated in Uttar Pradesh 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.

21. 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 (2/3rd 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

22. 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

23. Data Source: RHS 2018 INFRASTRUCTURE : WHAT NEEDS TO BE PLANNED ?

24. 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.

25. 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.

26. EXPANDED RANGE OF POC DIAGNOSTICS • 14 at AB-HWC-SHC and 63 AB-HWC-PHC

27. IT Systems • Daily reporting and Monthly reporting at AB-HWC portal needs to be ensured • IT Systems – standardized and integrated with GoI applications • In the mean-time, manual records – should be allowed for PLPs , due lists etc.

28. bI-DiRECTIONAL REFERRAL AND RETURN linkages • Facility mapping with specialty mapping – CHC/SDH/DH/PMJAY • 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)

29. Community Health Officers : Retention and Motivation • Defined career pathways • Streamlined recruitment procedures – preference postings • Performance linked payments • Training at District level – National Health Programmes • Constant Supportive Monitoring and Mentoring • GNM – SN ; 6 month training would be required

30. 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

31. 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 • SahiBhojan, 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

32. Monitoring at AB-HWC • Facility based Monitoring: Drugs, Diagnostics, Swachhata related activities, Counselling, Wellness, Patient records, Tele-consultation Utilization of untied funds • Social Audits : • PBS, CBAC, • Immunization, ANC, Other outreach activities, Health Promotion and Wellness Activities

33. 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 DawaKhana , Telangana – thinking for performance linked payments for outreach activities ? • Linkages for secondary and tertiary care • Wellness – Open spaces or gyms

34. ESSENTIAL MEDICINES Thank-you! DIAGNOSTICS RMNCHA+N HUMAN RESOURCE TRAINING WELLNESS INFRASTRUCTURE

35. AB-HWC Conditionality 2018-2019 Incentives