MLHP,CHO,CPHC

1. TOPIC-AYUSHMAN BHARAT
OPERATIONALIZING HEALTH AND WELLNESS CENTRES TO
DELIVER
COMPREHENSIVE PRIMARY HEALTH CARE
BY DR SUDHARANI BANAPPAGOUDAR
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2. INTRODUCTION
• Worlds biggest health scheme for 10 crore family ,40 crore population is covered. It is
goodly branded as PMJAY(Pradhan Mantri Jan Arogya Yojana) Under this it has 2 major
works.
1.Providing Rs 5 Lakh towards health
2.Health care i.e. preventive , promotive services though HWCs
• It has launched it target for 2lakh HWCs development in its complete phase at
different regions so that 2 lakh CHOs will be developed . This is an new cader
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3. OBJECTIVES
• At the end of the session, Students will be able to
• 1. Describe the concepts and key components of Ayushman
Bharat
• 2. Enumerate Key elements of health and wellness
Centers(HWCs)
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4. AYUSHMAN BHARAT
• It is initiated by Govt of India to achieve universal health coverage
• Objectives
• To address health in a holistic manner at the primary ,secondary and tertiary care
systems, covering both prevention and health promotion
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5. 5
AYUSHMAN BHARAT – Rationale
PRIMARY
SECONDARY
TERTIARY
CONTINUUM OF CARE – CPHC & PMRSSM
Unmet need:
NCDs/other
Chronic Diseases Existing
services:
RMNCHA
PMRSSM
Referral
Preventive, Promotive, Curative,,
Rehabilitive & Palliative Care
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6. • 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
• 6
Rationale
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7. 7

8. DALYS RATE ATTRIBUTABLE TO RISK FACTORS IN INDIA
2016
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9. • 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
Rationale
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10. 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,
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11. • 14th April 2018-Honorable Prime Minister launched the first Health
and Wellness Centre at Jangla, Bijapur, Chattissgarh
Launch of AYUSHMAN BHARAT
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12. CPHC
through
HWC
Continuum
of Care –
Telehealth
/Referral
Expanded
Service
Delivery
Expanding
HR - MLHP
&
Multiskillin
g
Medicines &
Expanding
Diagnostics -
point of care
& new
technologies
Community
Mobilisation
and Health
Promotion
Infrastructur
e
Financing/
Provider
Payment
Reforms
Robust IT
System
Partnership
for
Knowledge
&
Implementa
tion
Key Elements to Roll out CPHC
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13. • Health & Wellness Centre – PHC
(@30,000) / UPHC (@50,000)
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
PH
C
SH
C
SH
C
SH
C
SH
C
SH
C
Comprehensive Primary Health Care Team
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14. 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
CPHC - ESSENTIAL PACKAGE OF SERVICES
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15. Family/Household and Community Level
Health and Wellness Centres
First Referral Level
Sub centres/PHC/UPHC strengthened as
HWC
General medical Consultation (at
PHC/UPHC);
Specialist consultation and First level of
hospitalization at CHC/SDH/DH
Comprehensive Primary Health Care :
Preventive, Promotive, Curative,
Palliative, and Rehabilitative and
delivered close to where people live.
Organization of Comprehensive Primary Health Care
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16. Village/Urban
Ward
ASHA/MPW
• Population Enumeration
• Outreach Services
• Community Based Screening
• Risk Assessment
• Awareness Generation
• Follow up of confirmed cases
• Counselling: Lifestyle
changes; treatment
compliance
MLHP/CHO
SHC
PHC/UPHC
• First Level Care
• Screening
• Use of Diagnostics
• Drug Dispensation
• Record keeping
• Telehealth
• Referral to MO at PHC for
confirmation/complications
• Diagnosis /
• Prescription and
Treatment Plan
• Referral of complicated
cases
• Telehealth
• Real time monitoring
CHC/SDH/DH
• Advanced diagnostics
• Complication
assessment
• Telehealth
• Tertiary
linkage/PMRSSM
Community – Facility: Maintaining Continuum of Care
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17. 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
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18. • 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
Scaling up the Certificate Course
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19. MULTI-SKILLING OF FRONTLINE HEALTH
WORKERS
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20. 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-
Addition of Skills for Frontline Health Workers
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21. 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
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22. 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
Medicines and diagnostics require early attention
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23.  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
• 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
 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-
Robust IT System – to meet diverse needs of different stake holders
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24. • “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.
Health promotion Community mobilization and Intersectoral
Convergence
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25. • 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
Promoting Wellness through Yoga
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26. 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
Health Promotion by Ayushman Ambassadors
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27. • 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
Innovation Learning Centres for CPHC
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28. 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
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29. 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
Infrastructure
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30. • 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
Quality of Care
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31. • 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 Gidelines/Training Manuals for Primary Health Care Team – being
developed
Task Forces
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32. 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
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33. • 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
HWCs in Urban Areas
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34. 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
Immediate Next Steps
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35. 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.
Key Areas for Priority Action
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36. THANK YOU
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