AYUSHMAN BHARAT

Operationalizing Health and Wellness Centres

To Deliver
Comprehensive Primary Health Care
AYUSHMAN BHARAT – Rationale

TERTIARY PMRSSM

SECONDARY

Referral

Preventive, Promotive, Curative,,

Unmet need: Rehabilitive & Palliative Care
PRIMARY
NCDs/other
Chronic Diseases Existing
services:
RMNCHA

CONTINUUM OF CARE – CPHC & PMRSSM

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 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 (71st 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 -

 Persistent challenge –high levels of maternal and child mortality with Inter
and intrastate variations
 High TFR- States of Bihar, UP, Rajasthan, MP, Jharkhand and
Chhattisgarh(56% of India’s population increase)
 High Proportion of Underweight Children-38% children under five are
stunted and 36% continue to have low weight for age
 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
14th April 2018-Honorable Prime Minister launched the first Health
and Wellness Centre at Jangla, Bijapur, Chattissgarh
Key Elements to Roll out CPHC
 Continuum of
Care –
Partnership Telehealth
/Referral Expanded
for Service
Knowledge & Delivery
Implementati
on

Key Expanding
HR - MLHP &
Elements Robust IT CPHC Multiskilling
to Roll System through
out HWC
CPHC Medicines &
Expanding
Financing/ Diagnostics -
point of care
Provider
& new
Payment
technologies
Reforms Community
Mobilisation
Infrastructure and Health
Promotion
 Comprehensive Primary Health Care Team
• Health & Wellness Centre – SHC • Health & Wellness Centre – PHC
(@30,000) / UPHC (@50,000)
 Mid-level health provider 5: BSc/ GNM
or Ayurveda Practitioner trained in 6  PHC team – (Atleast - 1 MBBS
months Certificate Programme in Doctor, 1 Staff nurses, 1 Pharmacist,
Community Health/ Community Health 1 Lab Technician and LHV) + MPW +
Officer (BSc-CH)
ASHAs s
 MPW F- 2 per SHC IPHS
 Services (IPHS +) - Screening of NCDs
 MPW M- 1 to be provided from state
(VIA) and wellness room
resource
 5 ASHAs as outreach team per SHC
SHC

SHC SHC
PHC

SHC SHC
 CPHC - ESSENTIAL PACKAGE OF SERVICES

1. Care in Pregnancy and Child-birth.

2. Neonatal and Infant Health Care Services
3. Childhood and Adolescent Health Care Services.
4. 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
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

General medical Consultation (at

PHC/UPHC);
First Referral Level Specialist consultation and First level of
hospitalization at CHC/SDH/DH
Community – Facility: Maintaining Continuum of Care

Village/Urban Ward

ASHA/MPW MLHP/CHO

SHC
• Population Enumeration • First Level Care
• Outreach Services • Screening
• Community Based Screening • Use of Diagnostics
• Risk Assessment • Drug Dispensation
• Awareness Generation • Record keeping
• Follow up of confirmed cases • Telehealth
• Counselling: Lifestyle changes; • Referral to MO at PHC for
treatment compliance confirmation/complications
CHC/SDH/DH

PHC/UPHC
• Diagnosis /
• Advanced diagnostics • Prescription and Treatment
• Complication assessment Plan
• Telehealth • Referral of complicated
• Tertiary linkage/PMRSSM cases
• Telehealth
• Real time monitoring
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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 by-
 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)
 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
 Entrance Examination and Selection of Candidates to complete by 30th May
 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

 ASHAs-5 Days in seventh Package for NCDs in first phase +

refresher and newer packages annually(15 days)
 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.
 Joint training of MPWs with ASHAs wherever possible
 Reporting and Recording information using digital applications-
Additional 3 days
Training of PHC Team- Staff Nurses, Medical Officers

 Seventh Package(Five days for screening and Management of NCDs)

 21 days for screening for Cancer-VIA for CA Cervix and further
management
 Online Training through Massive Open Online Courses (MOOC) and
Extension for Community Health Outcomes (ECHO)
 Other Distance mode certificate programmes in areas such as- NCD
management/MCH Care/Elderly Care/Mental Health etc. to be
planned in long term.
 Additional Incentives/ rewards can be introduced
 Partnerships with AIIMS/Regional Cancer Centres/Knowledge
networks to act as training resource centres and provide
handholding support
Medicines and diagnostics require early attention
 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.
 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
 Requirement of Medicines and Diagnostics updated based on
recommendations of task forces
Robust IT System – to meet diverse needs of different stake holders

 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
 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
 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 MLHP-
 Contractual - About 37.5% (up to Rs. 15,000) of total salary (Rs. 40,000) of
MLHP to be linked with performance
 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. Branding / Colour code
2. Citizen Charter
3. Space for –
 Examination room with adequate privacy and
Telehealth
 Diagnostics and medicine dispensation
 Wellness room
 Waiting area
 IEC
 Labour room at delivery points
4. 3-4 Alternate prototype designs will be provided
5. Display boards –
 Contact Details of Primary Care Team and
referral centres
 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
 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
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

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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

 Strengthen Programme Management (2 consultants in small states and 3-

5 in big states as per requirement)
 Leverage technical support from Training institutions/ Research
Organizations / SHSRC/ Medical Colleges
 District level – District Coordinator in selected districts as per requirement
(with atleast one block saturation with HWC)
 Based on annual Targets of HWCs- commensurate selection/ enrolment in
IGNOU Certificate Programme in Community Health
 Completion of training of ASHAs, MPWs, PHC Staff-Medical Officers and
Staff Nurses in NCD
 Undertake gap analysis against the requirement of equipment/medicines/
consumables
 Prioritize Implementation of Seventh Package-NCD Care
 Roll out of IT Systems and Training of Providers in NCD App/MO Portal
Key Areas for Priority Action

 Appoint Senior State Nodal Officer : Director/Additional Director/Joint

Director level officer
 Periodic reviews by Principal Secretary at all levels
 Road Map for converting all SHCs to HWCs by Dec,2022
 Annual Plans for financial year 19-20, 20-21, 21-22 and 2022-23 (up to
December,2022)
 Prioritizing Aspirational Districts/ NPCDCS Districts
 Block Saturation with HWC and linkage to appropriate referrals
 Create HR policy for MLHPs
 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.
 NHM funds could be used to leverage some of these sources
Thank You