HWC –Assam

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

2. 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

3. 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”

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

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

7. Based on the conditionality performance indicators, Assam received 12% incentive for the FY 2018-19 • Assam got 2nd 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

8. HWC progress • 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

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

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

11. 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.

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

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

14. 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.

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

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

17. Expansion of services through training on NCD of HWC Staff

18. Service Delivery * As on 26/09/2019

19. Service Delivery As on 26/09/2019

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

21. 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 • High Risk Pregnant Women (HRPW) • Anemia • Hypertension • Poor nutritional status- High Alcoholism • Low Birth Weight Babies (LBW) • High prevalence of TB • High Prevalence of Leprosy Tea Garden Area Char Area

22. 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 out of total 758 Tea gardens surveyed • out of total 649 Tea garden 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 Tea Garden Area Char Area Coffee Table Book on Tea Garden

23. 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

24. 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

25. 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.

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

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

28. 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

29. 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

30. IT and Tele - Consultation • State has provided IT infrastructure to 16 number of SC-HWCs and 13 PHC- HWC before 15th 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 MoHFW, GoI for approval in Supplementary PIP 2019-20 as in the main RoP it was approved in principle

31. 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

32. 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, GoA under which yoga trainers identified in 100 identified Yoga blocks of AYUSH Mission in 1st phase • Yoga sessions in identified HWCs are planned twice a week

33. 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

34. Guide To Good Practices

35. 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

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

38. 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

39. Components of the Assam CHO portal

40. HWC-NCD tracking Bag and HWC-NCD card

41. 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: • 100 % tracking and follow up of NCD patients • 100% continuum of care will be ensured through this process • The process will be easy and simple for health workers to track the NCD patients • Reducing drop outs (NCD patients) Currently it is being developed and piloted in selected HWC of Nagaon district with support from Jhpiego and WHO

42. 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

43. 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 HWC-NCD card is to track the treatment of the patient Sample NCD Card

44. 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

45. 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

46. 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

47. Technical Support – Our Partners

48. THANK YOU