Ayushman Bharat- Arogya Karnataka- Health and Wellness Centres – Road map

1. Ayushman Bharat- Arogya Karnataka-Health and Wellness Centres – Road map Department of Health and Family Welfare, Government of Karnataka

2. Evolution of CPHC-HWCs in Karnataka • Started after a district health assessment in 2015-16 for Universal Health Coverage pilot districts in • Mysore a Non High Priority District • Raichur a High Priority District • Rationale – to start • Low utilization of PHCs and SCs (33% in Mysore; 25% in Raichur) • High OOPE (Average annual OOPE Rs 16,189) • Low access of Junior Health Assistants to marginalized poor households (75% in rural Raichur) Karnataka Raichur Mysore

3. Scale up of Comprehensive Primary Health Care Scale up FY 2017-18 460 HWCs functionalized (Aug 2018) Pilot phase FY 2016-17 105 HWCs functionalized FY 2018-19 Operationalization in process for 505 HWCs 132 PHCs, 71 UPHCs to converted as HWCs FY 2019-20 Approvals accorded in PIP for 766 HWCs 402 PHCs, 293 UPHCs will be converted as –HWCs under CPHC

4. Institutionalization of CPHC –HWC in State • Technical Committee and State Working Teams constituted for strategic • inputs and programme planning. • Development of operational guidelines for Dist/Taluk/PHC • Planning supplemented with Systematic Gap Analysis with Mapping of • infrastructure, equipment and supplies done using standard checklist – need based resource allocation was done. • THOs/KHSDRP Engineers inspected and provided inputs • Phase wise coverage in entire state and better performing districts/ blocks to be covered by 2025 (9000 HWCs covered) • Centralized planning, procurement through KDLWS for HWCs • with decentralizing supplies, AMC adoption , RACI matrix for quality logistic management • Involvement of PRI for • Identification of Govt buildings for HWC, NCD camps conduction, ARS fund & health promotion activities, Branding designs.

5. Branding of HWC after Institutionalization

6. Input- Local Selection and appointment of MLHPs • Prioritized BSc Nursing/Post Basic Nursing Personnel with two years of work experience as Mid Level Health Providers • De-centralized Selection process for candidates - based on written exam/interview and willingness to serve in rural and remotest areas to ensure minimum attrition and drop outs • Complete transparency of exam conduction by use of CCTV under supervision of CEO ZP and DHS • Strict adherence to timelines of one month from advertisement to filling of admission forms • Preferred Nomenclature- MLHPs (Middle Level Health care Provider)

7. Processes: Training of MLHPs and Multiskilling of Frontline Functionaries • Six month residential Certificate Programme in Public Health Nursing • accreditation by IGNOU -rolled out in Medical Colleges & State of art District Hospitals of Karnataka ( 8 PSCs) • Karnataka identified Medical Colleges as Centre of Excellence in capacity building for academic Certificate Programme • Monitoring visits were made to PSCs using a standardized checklist prepared by State Team in collaboration with NHSRC • State NHM and PHFI hand held the PSCs throughout the period of training, completed orientation of Programme in Charges and academic counsellors • IGNOU provide study materials, give assignments/ log books & conduct term end exams

8. Training under the Certificate Course in Community Health

9. Processes - Multiskilling of Primary Health Care Team • Multiskilling of ASHA, ANMs, MPW (M), Staff Nurse and PHC MOs on population based screening on NCDs • Yoga- Identification of AYUSH YOGA trainers at the District level. • Training of Trainers for Yoga lessons conducted every month at DTCs

10. Processes -Medicines and supplies • Drug MIS Indenting Application rolled out to PHCs • Medicines listed in sub-centre essential list plus as per expanded package of service have been supplied (164 listed items) • To begin with, 10% of listed Essential Drugs from PHCs were made available to HWCs • Medicines now being indented through PHC based on requirement projected by MLHPs • Medicines for DM and HTN being indented based on refills by MLHPs from PHC medicine list • District warehouses supply to PHCs within a period of 3-4 days after the requirement is placed. • Untied funds are utilized for drug procurement from local market in case of irregular drug supply

11. IT innovations Building Digital Platforms • ANMOL and NCD app institutionalized • Tablets and internet connectivity made available at HWCs. • Two representatives from each district given hands-on training by Dell Team – • who in turn have trained MOs/MLHPS/MPWs in their respective districts. • State adopted process of Integrating all • service delivery softwares • Implementation of Comprehensive software to record MLHPs activities through digital platform • NIC Bangalore is under process

12. Service delivery work flow

13. Organization of Work Processes/Service Delivery Flow for RMNCH+A *Concurrent monitoring of HWCs by PHFI

14. Organization of Work Processes/Service Delivery Flow for RMNCH+A--- cont’d

15. Communicable Diseases- Service Delivery workflow

16. Communicable Diseases- Service Delivery workflow – cont’d

17. Non-Communicable Disease- Service Delivery workflow

18. Non-Communicable Disease- Service Delivery workflow

19. MLHP- Weekly Schedule

20. Jr. Health Assistant (ANM)/ ASHA- Weekly schedule-

21. NCD Screening by Nurse Mid Level Healthcare Providers

22. Programme Outcomes: Pilot blocks -Progress at the HWCs: (12 Essential Service Packages (February 2018- Jan 2019))

23. Programme Outcomes- Pilot blocks Month-wise total OPD attendance at HWCs in T. Narsipura and Lingasagur

24. Programme Outcomes- Pilot blocks average daily footfalls (each month) at HWCs in T. Narsipura and Lingasagur

25. NCD screening, treatment and follow-up

26. Accomplishments phase-1(2018-19)

27. Top 10 Causes (diseases) of out-patient attendees in HWCs

28. Perspective from the field- ASHA The concept of CPHC as perceived by ASHA • “people get health facilities closer to their homes”. • HWC serve as a facility where people can avail treatment for acute simple illnesses. • MLHP commonly referred to as “UHC Doctor” and are responsible for the overall functioning of HWC • ASHAs mentioned that “in case if a patient does not come for follow-up visit to HWC”, then we make home visits and counsel patients to visit HWC *Concurrent field visits by PHFI

29. Perspective from the field- ANM • The concept of CPHC as perceived by ANM is healthcare services which are easily accessible to people so they don’t have to spend money. • On being probed about how MLHPs has reduced your work they reported that earlier due to workload stipulated number of ANC and PNC visits could not be completed. With MLHPs in place, ANMs can complete these activities • Follow-up medicines for HT, Diabetes were issued by MLHPs at SHC in ANMs absence including IFA – reduced the burden on ANM

30. Perspective from the field- MLHP • MLHPs have Adequate knowledge about own roles and responsibilities as well the other members of HWC team • Quality of training received by ASHA and ANMs was satisfactory as the were able to effectively do risk assessment for NCDs • Strengths- • “We get good support from ASHA and ANM” • “They motivate people to attend NCD camps, to go to HWCs” • “Monthly meeting with MO” • “people from State and district visit our center and see the service delivery and enquire people if we are taking money from the public” Challenges- “Sometime we will not have few drugs except for BP monitoring and blood sugar measurement other services are recently provided”

31. Findings from the field- PHC MO • Satisfactory knowledge about the programme and expected roles and responsibilities of HWC team and their work distribution • PHC MO encouraged patients to visit HWC first (before approaching PHC) • Coordination mechanism followed- Weekly meetings at PHCs have been able to address issues of confront . Many instances demanded Direct intervention by MO • Team Management- 70% of the teams reported cordial working *Concurrent field visits by PHFI

32. Fund allocation and Expenditure done by State (in lakh Rs)

33. Challenges • Rationalization of human resource deployment and Pay structure • Need to consider additional MPW (M) each for 1 SHC • State has 1 MPW(M) /10000 population. • Additional structure for HWC clinic for MLHPs- storage facilities for logistics. • Role conflict management at SHC level • Compulsory Placement of Medical officers and specialists • at aspirational C PHCs/CHCs – for continuum of care • IT based innovation-integration • Also for rationalization of drugs

34. Way Forward • Recruitment policy • Role conflict management policy – C& R formation. • Grievance management under district nodal officers • Capacity building cell at each district to have regular induction training to new MLHPs (including replaced MLHPs of drop outs) • Regular orientation and re-orientation of District Health team and MLHPs. • Standard Operating Procedures for management at HWCs pertaining to packages • Ensuring adequacy of regular supply by integrating with KDLWS software. • Strengthening IEC activities- flip/ flash charts, signage's, AV aids, announcements for campaign modes • IT based management with integration of all health care functionalities

35. Arogya Karnataka- Ayushman Bharat: Universal Health Coverage for APL and BPL families(CPHC, Secondary & Tertiary Care Services) HWC MLHPs - Treatment/ Referral/ Follow up PHC MO – Primary Care/ Treatment/ referral Community Arogya Karnataka ASHA/ ANMs- referral/ follow up CHC/ GH Specialist – Primary & Secondary Care Treatment/ referral Medical College/ Tertiary Hospital District Hospital Specialist - treatment Specialist –Secondary & Tertiary Care Treatment/ referral

36. Projected future outcome • NCD screening of all the individuals above 30 years • especially belonging to the vulnerable sections of the society. • Increase in daily OPD footfall at each HWCs and population coverage • to address Communicable diseases with passive stimulated surveillance • Reduce OOPE burden for families on the secondary and tertiary healthcare facilities • through early intervention and prompt referrals • Provision of basic health services at patient’s doorstep • follow-up drug services to chronic illness, continuum of care •  Strengthen follow-up and referral mechanism • with adoption of IT innovation and software integration.

37. Thank you