1. AYUSHMAN BHARAT Operationalizing Health and Wellness Centres
To Deliver
Comprehensive Primary Health Care

2. AYUSHMAN BHARAT – Rationale CONTINUUM OF CARE – CPHC & PMRSSM
TERTIARY
PMRSSM
SECONDARY
Referral
Preventive, Promotive, Curative,, Rehabilitive & Palliative Care
PRIMARY
Unmet need: NCDs/other Chronic Diseases
NCDs account for 62% mortality; 55% Premature, 62% OOPE of Total Health Expenditure
NSSO data (71st Round. 2014) shows 11.5% and about 4% in rural and urban areas respectively sought any form of Outpatient care - at or below the CHC (secondary health centres) (except for Childbirth).
Presently the Sub centre and Primary Health centre- currently provide preventive care mostly related to maternal and child health,
The need for primary health care is met by unqualified practitioners. particularly in the high focus states,
There is a huge unmet need for early detection and management of Non-communicable diseases and other chronic conditions. NCDs currently account for 62% mortality of which 55% is premature mortality.
Studies show that losses associated with physical NCDs is expected to be about $3.55 trillion by 2030
Existing services: RMNCHA
CONTINUUM OF CARE – CPHC & PMRSSM

3. 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

5. DALYs Rate Attributable to Risk Factors in India 2016

6. 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

7. 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,

8. Launch of AYUSHMAN BHARAT
14th April 2018-Honorable Prime Minister launched the first Health and Wellness Centre at Jangla, Bijapur, Chattissgarh

9. Key Elements to Roll out CPHC

10. Key Elements to Roll out CPHC
through
HWC
Continuum of Care – Telehealth /Referral
Expanded Service Delivery
Expanding HR - MLHP & Multiskilling
Medicines & Expanding Diagnostics - point of care & new technologies
Community Mobilisation and Health Promotion
Infrastructure
Financing/
Provider Payment Reforms
Robust IT System
Partnership for Knowledge & Implementation

11. Comprehensive Primary Health Care Team
Health & Wellness Centre – PHC / UPHC
PHC team – (Atleast - 1 MBBS Doctor, 1 Staff nurses, 1 Pharmacist, 1 Lab Technician and LHV) + MPW + ASHAs s
Services (IPHS +) - Screening of NCDs (VIA) and wellness room
Health & Wellness Centre – SHC
Mid-level health provider 5: BSc/ GNM or Ayurveda Practitioner trained in 6 months Certificate Programme in Community Health/ Community Health Officer (BSc-CH)
MPW F- 2 per SHC IPHS
MPW M- 1 to be provided from state resource
5 ASHAs as outreach team per SHC
PHC
SHC

12. CPHC - ESSENTIAL PACKAGE OF SERVICES
Care in Pregnancy and Child-birth.
Neonatal and Infant Health Care Services
Childhood and Adolescent Health Care Services.
Family Planning, Contraceptive Services and other Reproductive Health Care Services
Management of Communicable Diseases: National Health Programmes
General Out-patient Care for Acute Simple Illnesses and Minor Ailments
Screening, Prevention, Control and Management of Non-communicable Diseases
Care for Common Ophthalmic and ENT Problems
Basic Oral Health Care
Elderly and Palliative Health Care Services
Emergency Medical Services including Burns and Trauma
Screening and Basic Management of Mental Health Ailments

13. Organization of Comprehensive Primary Health Care
Family/Household and Community Level
Health and Wellness Centres
First Referral Level
Comprehensive Primary Health Care : Preventive, Promotive, Curative, Palliative, and Rehabilitative and delivered close to where people live.
Sub centres/PHC/UPHC strengthened as HWC
Take fromog
General medical Consultation (at PHC/UPHC);
Specialist consultation and First level of hospitalization at CHC/SDH/DH

14. Community – Facility: Maintaining Continuum of Care
ASHA/MPW
MLHP/CHO
Village/Urban Ward
SHC
First Level Care
Screening
Use of Diagnostics
Drug Dispensation
Record keeping
Telehealth
Referral to MO at PHC for confirmation/complications
Population Enumeration
Outreach Services
Community Based Screening
Risk Assessment
Awareness Generation
Follow up of confirmed cases
Counselling: Lifestyle changes; treatment compliance
CHC/SDH/DH
PHC/UPHC
Advanced diagnostics
Complication assessment
Telehealth
Tertiary linkage/PMRSSM
Diagnosis /
Prescription and Treatment Plan
Referral of complicated cases
Telehealth
Real time monitoring

15. 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

16. 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 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
Add in group

17. Multi-Skilling of Frontline Health Workers

18. 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

19. 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

20. Medicines and diagnostics require early attention
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

21. 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

22. 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.

23. 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

24. 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

25. 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

26. 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

27. Infrastructure Branding / Colour code Citizen Charter Space for –
Examination room with adequate privacy and Telehealth
Diagnostics and medicine dispensation
Wellness room
Waiting area
IEC
Labour room at delivery points
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

28. 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

29. 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
In order to assist the roll out of the 12 packages, Task Forces (7) have been constituted to develop operational guidelines for newer packages, training material, identification of training hubs and creation of online content for MOOC, The Task Forces have held several meetings and are in the process of drafting OGs and material.
In addition, a Task Force has been set up to explore payment reforms (addressed in a later slide)
To ensure that interventions are cost effective and enable addressing DALYs, another Task Force has been set up.

30. 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

31. 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

32. 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

33. 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, and (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
Officer-Assistant Mission Director/ Joint / Deputy Director with minimum 15 years of experience who can coordinate with SNOs of other programmes

34. Thank You