NDA government’s flagship health programme Ayushman Bharat has two components – the tertiary care Pradhan Mantri Jan Arogya Yojana and also the less heard of primary care component comprising health and wellness centres. The target is to set up 1,53000 such centres.
Health secretary Preeti Sudan talks about what is intended as the very foundation of India’s health system.
Health and wellness centres are a component of Ayushman Bharat but all we hear about is PMJAY. Why is that?
Strengthening of existing SHC/ PHC and UPHCs as Ayushman Bharat Health and wellness Centres (AB-HWCs)to deliver comprehensive range of services requires a lot of groundwork. Till now, our primary healthcare was more focussed on maternal, newborn child care and selected communicable diseases. With the launch of AB-HWCs, the vision is to expand the range of services available closer home, by adding services related to non- communicable diseases, Mental health, ENT, Opthalmology, Oral health, Geriatric and palliative care and Trauma care in a phased manner. This would enable us to deliver primary health care which is comprehensive as well as universal.
However, in order to equip AB-HWCs to deliver CPHC, substantial inputs are required in terms of expanding the range of medicines and diagnostics, infrastructure strengthening, availability of skilled HR and training lakhs of workers, creating IT systems to facilitate continuum of care and paradigm shift in terms of nature of services and its delivery.
These efforts are critical to develop HWC as the first port of call for primary health care for the community. AB-HWCs being primary health services focussed, require far more complex ground work than what was required for PMJAY. Also PMJAY being the world’s largest public health insurance programme, garnered a lot of attention, and this should have been too. Catastrophic expenditure on healthcare can be traumatic especially for a family that is barely making ends meet. With PMJAY now there is assurance that Govt. will pay for hospitalization expenses. It has brought relief to lakhs and thus should be in the news.
The conversion of 1,50,000 Sub health Centres and Primary Health Centres to Health and Wellness Centres has been planned in a phased manner. The target for FY 18-19 was 15,000 HWC, and over 17,000 was achieved till March end and as of today, 20,622 AB-HWCs are functional across the country.
So what is your idea of infrastructure?
The idea is to upgrade the existing available infrastructure at SHC/ PHC/ UPHCs such that there is an examination room with adequate privacy, a wellness room, adequate space for medicine storage, designated space for diagnostics and medicine dispensation and a waiting area.
In addition, repairs and renovation of the building are being undertaken along with branding of Health Wellness Centres to create awareness in the community about the “new” components of AB-HWCs.
What are the challenges and how are you overcoming them?
Human resource remains our biggest challenge. TheSHC- AB-HWCs, will be manned by Community Health officer (CHO). They can be a BSc or Ayurveda Practitioner trained in 6 months Certificate Programme in Community Health. Changes have been made to the nursing curriculum such that for 2020, the nursing graduates can man our HWCs.
So far, 8531 CHOs have been appointed at AB-HWCs and about 3000 more are expected to be posted by end of September 2019. Nearly 13,000 CHOs are expected to enrol in the upcoming batch. About 261 programme study centres have been notified by IGNOU and 111 Programme Study centres have been notified by state universities in states where the programme is being run by state universities. In addition, all basic and post-basic nursing colleges and universities have been recently notified to integrate CHO training in existing curriculum of nursing. This will enable production of over 40,000 eligible candidates annually to serve as CHOs.
The expanded range of services would also require training of the new as well as existing service providers and frontline workers. We have entered into MOU with ECHO Trust India, to utilize the virtual tele-mentoring platform for capacity building. This could serve as an adjunct module to the conventional methods of classroom teaching and support expediting the training roll out.
Another area that requires improvement is the STREAMLINING OF LOGISTICS SUPPLY to ensure uninterrupted supply of medicines and diagnostics. We already have an online inventory management system functional in most states till PHC level, this is now being extended to the SHC- AB-HWCs level to facilitate forecasting of requirements and supporting timely supply.
What is the tele consultation module?
We have created a National Medical College Network of 50 colleges. Each of these will be given a catchment area of AB-HWCs to mentor and give tele-consultation services. States are being supported under NHM to create hubs at medical colleges and linked with AB-HWCs as spokes to improve clinical care coordination. Some states like Himachal Pradesh, Andhra Pradesh, Odisha and Telanagana have already started their Tele-consultation services. Tele radiology as a part of tele-consultation at the PHCs and CHCs has shown promising results as consultation with tertiary care facilities has meant absolutely accurate diagnosis.
Can you share the screening data from AB-HWCs?
As of August, 2019, we have screened over 1.63 crore people for hypertension and 1.43 Crore for diabetes. We find that 8% new cases have come up for Hypertension and 11% for diabetes. About 79 Lakh individuals have been screened for Oral Cancer, 54 Lakh for breast cancer and 37.5 Lakh for cervical cancer.
What is the status of Integration with PMJAY?
A strong primary health care system is essential for the success of PMJAY; follow up and support of patients discharged from secondary and tertiary care team will need the Health and Wellness Canters to be engaged. This will lead to improved health outcomes with follow-up facilitating treatment adherence and life style modifications. The level of integration with PMJAY is currently being strengthened.
A task force under the chairmanship of JS (Policy) has been constituted to provide guidance on empanelment process, continuum of care and seamless IT system integration between the two key components of Ayushman Bharat and the task force is expected to give the recommendations shortly.
Do Ayushman Mitras in hospitals need training on AB-HWCs too?
Integration of services is crucial. The upward movement of patients will happen but on coming back to the primary/village level, they should know that basic preventive services are available at the AB-HWCs. As we are training our ASHAs on PMJAY, we could think of component of training to the Mitras on AB-HWCs and follow up care services also. We will await report of the task force.
When you say 20000 plus AB-HWCs are functioning, do you take states at face value?
Based on the data shared by states, about 20622 AB-HWCsare functional today. This is derived from the data collected on critical parameters like availability of HR, training of HR, availability of medicines and diagnostics and infrastructure strengthening. Since HWC is a new and evolving initiative that requires significant efforts and reorganization of work flows,
Periodic reviews and VCs are held with states to discuss the state specific issues and solutions. Periodic field visits are also undertaken to review the planning and functioning of AB-HWCs by MoHFW, technical partners and states themselves. Regional Workshops are being conducted with the States/UTs to ascertain the progress made and sort out the implementation issues and also to enable cross learning among the States of the best practices in AB-HWCs implementation.
Is the different chain of command for the two arms of Ayushman Bharat impacting continuum of care?
There is no demarcation of chain of command at the State level, usually the same Principal Secretary (Health) looks after both the programmes. There are Nodal Officers for different components. At the GoI level, it is important that a separate authority is carved out for the job as there is too much load on the Department in any case. I am glad there is a different chain of command for PMJAY, because here at the Ministry, we are already handling multiple activities.
It is important that these two function in-synergy to ensure that the community is able to access care at all levels i.e., primary (through AB-HWC), secondary and tertiary through PMJAY (for identified beneficiaries). Though there are separate institutional arrangements to manage the two components, there is a common understanding to work in partnerships for enabling universal access to care for the community.