Arogyabanks 2012


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This is an idea I tested in 2010 in some vilages with help of NGOs. It is workable, but we need a more serious trial and analysis. I am proposing that village & community based health centers is a key to many of our health system problems. This will provide a wide network of services at the base of the health care pyramid, generate local employment and spread health information in the last mile. I am appealing for help. Pl call me on 09422271544 or email on

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Arogyabanks 2012

  1. 1. • An initiative for village/community based self-reliant health facilities• Will provide primary Info, disease detection, care and linkages
  2. 2. Arogya BanksA business or CSR plan PROPOSED BYDr Shyam Ashtekar, MD (PSM)Consultant Community Health Nashik 422013
  3. 3. Need and feasibility
  4. 4. In 1940!
  5. 5. Need• 70% villages have no local health facility• Villages have to purchase inferior health care, travel a distance, pay stiff costs (Rs 50- per episode) and access costs• Loss of daily income for two (sick+attendant)• Major drain on rural family incomes, 2nd important cause of indebtedness
  6. 6. 16% villages and docs: 2000 study in Nasik villages w ithout doctors villages w ith docs 84%
  7. 7. A health system pyramid without much foundation!!No docs for villages, not even good health workers
  8. 8. Many efforts on rural health: A draw? O X X X O O O O X
  9. 9. Concept-Arogyabank• We want to provide a comprehensive and winning formula• A health facility for serving comprehensive first level care-curative, preventive, health-promotive, information needs and referral• A PPP model at grassroots
  10. 10. We take our Mandate from • Health for all by 2000 • National Health Policy 2002 • National Rural Health Mission • 72-73rd constitutional amendments • Policy on PPP (public-private partnerships)
  11. 11. Integrated model-PPP • Several old and new experiments/schemes are integrated in this • Provides a broad-frame for innovation and experiments • We will technically support the network
  12. 12. Ownership- model• Shared between village panchayats, public health dept, people, private sector and provider (health worker)• Corporate ownership possible• Each AB Unit–ownership with local bodies/SHGs
  13. 13. Objectives-to provide• Primary medical aid for 50+ health problems• Health information through print and e- medium• Preventive care for important health problems• Referral to proper institutions and follow up• Save some health expenditure and some access costs
  14. 14. Feasibility• Crying public need felt-expressed felt need!• Many villages are deprived of health care• 73rd amendment to constitution empowers villages• People already spend resources• Govt schemes exist-PHW/ASHA etc-but defunct• We need to explain the options and tie up loose ends
  15. 15. Location and Hardware
  16. 16. Locating• 1000-2000 pop cluster and within 2 km• Rural location (can be urban also)• based on expressed need by Panchayat/a valid village body or group• Generally we will omit village with health sub/center• Selection on basis of participation by village panchayat/ SHGs and fulfilling conditions
  17. 17. Space and shelter• The facility should have a visible shelter-room• Standard color code• A small room/dome can do
  18. 18. Hardware• Furniture-cupboard. table, chairs/seats• Clinical set-wt machine, BP, thermometer etc• Computer for health demos, with 2 hr back up.• Connectivity welcome –will start E health• Mobile phone mandatory
  19. 19. Legalities
  20. 20. Legal support• Mandate from 73rd amendment to constitution• Use of MMP act section2/iv- exempting health volunteers from MMP (no sales, no profits)• Use of FDA schedule K, 13-use of medicines by CHWs etc• Use of FDA schedule 23-village shop remedies
  21. 21. Human Resources
  22. 22. Better trained HealthWorker• A trained professional health care worker (we will train)• Man or woman, or both for a bigger population• Retired soldier, disabled persons can also participate• Part time work and compensation to start with.
  23. 23. Use of ASHA-PHW• Both ASHA & Pada Health Worker are existing health workers with some financial and system support• PHW (Pada Health Worker) gets 400 Rs per month, little work, looking for worthwhile work and role inn the health system
  24. 24. ANM or MPW?• Both Auxiliary Nurse and Male health worker are existing health workers with good financial and system support• MPW/ANM can fit the bill if Govt system wants an experiment with Arogyabank.
  25. 25. Eligibility and Entry Test• Eligibility: 10th is fine• We may conduct an entry test, hence village panchayat can recommend 3-4 candidates
  26. 26. Training and accreditation
  27. 27. Training• Level 1-Arogyamitra course -spread on 5 months, ODL, total 5 wks• Level 2-palliative care, clinic assistant, emergency aid,• Level 3 additional modules: select diseases, scientific massage, data-management,• Level 4: child care, geriatric care, care for disable, even Skilled Birth Attendant
  28. 28. Accreditation• Health worker: We will conduct examinations for every level annually, This will be an ODL programme with continuous assessment and credits• Procedures: SOPs are ready• Center: standard norms
  29. 29. Tasks & activities
  30. 30. Free/public paid Tasks1. First aid for emergency (free)2. Nutrition education3. Detection of important illnesses-anemia, HBP,DM,TB,cancers4. Water test, water-disinfection5. School Health6. Assisting in RCH & NHPs (VBD, Nirmalgram)7. AYUSH promotion8. Referral and follow up9. Health data
  31. 31. User paid Tasks• Part-time primary care• Detection of important illnesses- anemia, HBP,DM,TB,cancers• Home care• Simple lab tests, water test• Assisting in RCH & NHPs (VBD, Nirmalgram)
  32. 32. Time-sharing• 1 hour in morning and evening -for medical care to start with.• The health worker will do his/her livelihood activities in the daytime• Public interest activities to be timed as per inputs/supports
  33. 33. Drug kit and supplies
  34. 34. Consumables• 20 primary care medicines each from allopathy, Ayurveda, Homeo• National Health program supplies like DOTS, malaria remedies, condoms, pills etc• Herbal remedies• Wound care material
  35. 35. Fever Aspirin/Pamol Tribhuavnkirti, Guduchighanvati Belladona Tulsi kadha, w arm w ater, tepid sponging old injury pain/muka mar Aspirin/Pamol Arnica 30 Toothpain AspirinRS Common cold paracetomol* tribhuvankirti allium sepa ST3/ST3/LI19/LI4 Lemon grass tea URTI Aspirin/Pamol Sitophaladi, tribhuvan***, Ginger+honey or jaggery URTI-productive Cozal+pamol Sitophaladi, Milk+haldi, Jeshthimadh, adulsa childhood LRTI Cozal+pamol Milk+garlic LRTI adults Cozal+pamol Steam inhalalation Tonsillitis Cozal+aspirin/pamol Mirc IR Asthma attack# Salbutomol-inhale/tab Sitophaladi Rein17/LU7 Breathing exercises,GIS Acidity Gellucil** Sootshekhar*** Hiccoughs Jaggery child dirrhea ORS Jaiphal (balghuti) Diarrhea-adult Furazolid+ORS Kutajghanvati Arsenic alba Cof ee, Constipation triphala churna, Arogyavardhini LI4/ST36/ST6 Aamla, Rajgira bhaji, Constipation-child Gheee/oil by mouth at night w orms albendazole dysentery-amebic metronidazole Kutajghanvati Merc Cor Cof ee, dysentery-w ith blood Cozal+dicylomine Kutajghanvati Ghee Nausea/motion sickness Ipicac Moravala vomiting/ motion sickness domperidone sootshekhar Arsenic alba Pain-abdomen-adult Dicyclomine#& para Mag phos Indigestion, gases Hinguastak churna ST36/P6 for appetite Pain-abd-baby (criyng)# Hing appl/murudshengskin Boil Arogyavardhini Hepar sulf Inf w ounds Cozal+dressing triphala w ash+neem oil calendula papaya, aloe Itch/alleregy/insect bite CPM Fungal inf ection w hitfield /miconazole Scabies-dry GammsacbUrinary Burning urine sodamint dhaniya paani, kulatha kadhaHem opoietic Anemia FersolateOther infect dis Malaria chloroquin China 30 chirait-kadha Jaundice & fever Pamol Arogyavardhini Bhi-amalki kalk conjunctivitis Tetra eye drops ear inf ection Cozal+Para+CPM Wax in ear Hydrogen peroxideFem Repr sys Vaginitis GV+Metro pessary# Triphala w ash Crushed garlic petal dysmenorrhea Paracetomol Lactation(to boost lactation) Shatavari kalpEm ergencies dog-bite soap w ash snake bite Elastic bandage Chest pain (acute)# IsobarbideT+aspirinUshnatavikar Burning, piles, nosebleed Chandrakala Barf f or nosebleed
  36. 36. Supplies• Standard purchase from listed store for allopathy and Ayurveda & Homeopathy• Home /local remedies• NHP (programs) supplies from primary health center /subcenter• Explore periodic Network supply
  37. 37. Panchayat links• Mandated by 73rd amendment• Contractual worker for specified period and tasks• Panchayat shares owenership• Space is owned by panchayat
  38. 38. Info bank and software
  39. 39. Software• Common clinical protocols• CDs for health information-e book• E-learning modules for HW and people• Slideshows and Videos on health• Info on health facilities with contacts
  40. 40. Mobile connectivity• Use of mobile mandatory• For information exchange and network• Broadband connectivity will offer extra advantage.• Back up by experts• Referral links
  41. 41. Continuous health education through• Arogyavidya: CD• Print-outs, printed pamphlets• Meetings• Refresher training• Posters• SMS /voice narratives on cellphone.• House-journal
  42. 42. Academic• The flexi-learning model (ODL) with accreditation,• use of IT based learning• low-cost adult learning –lifelong learning• Deconstruct and ring type model with increasing complexity level• Epidemiologically fitted for needs
  43. 43. Economics of Arogyabanks
  44. 44. A) Development funds-• Human Resource development/ unit costs Selection Training & accredit 5000 Level2 training 5000 10000
  45. 45. B) Capital-fundsfurniture Netw ork 5000equipment Netw ork 5000starting kit Netw ork 1000Computer Netw ork 30000cellphone& cdNetw ork 4000Corpus Netw ork 5000 60000
  46. 46. C) Operational Costs Operationl exp annualisedHonorarium PHW/ASHA payment 24000Drug refills revolving fund 1000HEd material 1000maintenance 1000travel 1000 28000
  47. 47. Costs and returns: Some Guestimates•10 illness services daily- at Rs average 10s, brings2500 per month. (drug costs are extra)•Tests and other services: 1000 per month•Out of 3500, 2000 will go to paramedic•1500 will go to overheads and network profit permonth. Rs 500 for monitoring•Rs 12000 annual profit, on a capital of 60000.•We plan to start 100 centers, hence about 12 lakhproceed per cluster of 100 (say half a district)
  48. 48. Additional Pay for the health worker (3h/day/6day per week) • Village retainership through panchayat funds/untied funds (300 pm) for 1 hr daily • Task payment from Public Health dept for national programs (about 300 pm) for 1 hr daily • User fees for other personal health needs (about 1400 pm) for 1 hr daily
  49. 49. Overheads• This factor will depend upon the network size and spread• A 100 unit network should require two full timers to look after and coordinate
  50. 50. Outcome and cost- efficiency• Primary care for 70% needs at 30% costs (less than access costs),• Will reduce irrational care by unqualified persons• Preventive care of enormous value to people and nation• Will reduce hospital loads, hence improve efficiency• Early care will reduce morbidity• Follow up tasks will improve outcome• Public health system gets a foothold in community
  51. 51. Monitoring and quality• Code of conduct for care providers• Technical work monitoring by network agency• Social and cost monitoring with village body
  52. 52. Network and management
  53. 53. Network• A close network of 100 centers will maximize use, impact, visibility and viability• Professional and info-management, supplies
  54. 54. Management- Various models• Stand-alone units• Small area networks• Large are networks
  55. 55. Corporate Social Responsibility• CSR can add value and management inputs• CSR can create this unique contribution to health system
  56. 56. Linkages with Public health system• Links with MPW, ANM, Health visitor and PHC doctors• Links with Anganwadi• Village sanitation and water supply committee
  57. 57. Stakeholder priorities
  58. 58. Peoples’ priorities• People need to get good quality care• At low cost• Timely• Humanitarian• Accountable services• Referral and follow up support
  59. 59. Health Worker priorities• Should get quality training, some life saving skills• Reasonable earning for part time work-about 1000-2000 at least• Respectable role, popular utility• Hold interest of community• Safety from hassles
  60. 60. Public health system should• Appreciate the complimentary role of this network• Be ready to contract out work and provide support and supplies• Deliver timely payments for program tasks
  61. 61. Steps and phases GramP passes resolution for the AB & gives undertaking Village has ASHA/PHW & enroles in AM-YCMOU 6m prog OR or the ASHA/PHW passes in Entry test equal to L1Preparation Selects-prepares one room/shelter/hut Logo painting Team visits and Okays Undertaking of the HCProvider Computer system donated-trial run Network provides basic kit and equipment (15000) Candidate gets mobile if connectivity is availablePhase1 (1yr) AB starts working, mentors visit fortnightly Weekly tele review of services/stocks/funds/problems Monthly meeting at block for helpPhase2 Upgraded week long training programmes (L2) Enhancement of work/stocks/logistics Review and feedback
  62. 62. Remember• Network ownership and branding is crucial• Quality, reliability, connectivity important• PPP model can be a win-win• Urban program will add value
  63. 63. This Arogya Bank is a true storyAt village Pofala, ta Fulambri, Dt Aurngabad, Dr Ambedkar Vaidyakiya Pratsithan & Hedgewar hospital has started an Arogyabank . The trained paramedic issmt Chaya Krushna Gade, 22yrs, at her own home some 9 month back
  64. 64. Thanks Dr Shyam Ashtekar Nashikemail: 9422271544