Ayushman Bharat: Health and Wellness Centers:
The design, the many variants and the key barriers, and what peoples’ movements should do about it.
- What are Health and Wellness Centers?
This component of Ayushman Bharat promises to upgrade health sub-centers and primary health centers into what is called health and wellness centers. The target is 1.5 lakh HWCs, which is roughly equivalent to the total number of sub-centers in existence (1.46 lakhs). Each sub-center caters to about 5000 population. In tribal and hilly and desert areas it could cater to 3000 population or even less. This target of 1.5 lakh HWCs would, according to the government, be achieved by 2022.
Health and Wellness Centers differs from both the existing sub-centers and urban dispensary services and even the primary health centers in four important ways:
a. The primary healthcare services available to households in that area are comprehensive- NOT selective.
b. All the services are organized in a manner that ensures continuity of care. There are two types of continuity- if a patient with chronic illness comes in periodically, the center is equipped to provide follow up and medication so that the treatment can be continued without a break 365 days of the year. And secondly –vertical continuity between the primary healthcare provider and the consultant/specialist/doctor at the higher levels. For most illnesses, the doctor or specialist will see the patient and confirm the diagnosis and make a treatment plan- and then the treatment is continued by the service providers in the HWC.
c. The services at a HWC are delivered by a team- ideally of at least one Mid Level Healthcare provider or doctor plus two female multi-purpose workers and one male multipurpose worker plus about 5 ASHAs (community health workers).
d. The services are population based- not limited to individuals. The doctor in a urban dispensary, like a Mohalla clinic, or the usual general practitioner in private practice feels responsible for those who sought their care. But a HWC is responsible for the health of the entire list of households/individuals assigned to them, those who are usually resident in their area. Thus, children or adults who are at risk, and the population who need preventive services like screening for common cancers even if they appear well.
2. Why is this such a big thing. Was this not what primary health centres were always mandated to do?
A. If we are referring to the Alma Ata declaration, the answer is yes. This was exactly what primary healthcare was meant to be. However if we are referring to currently existing primary healthcare facilities and even the healthcare policy since 1993- the answer is a big NO. Sub-centers and PHCs fulfil the criteria of continuity of care and being population based for only a very selective package of services- typically immunization, and care in pregnancy, contraceptive services and care in tuberculosis, HIV, malaria and leprosy. To some extent for cataract blindness also. This accounts for only about 10 to 15 % of all primary healthcare needs. For the remaining 85% of health care needs there are NO services at the primary level- or at best very sporadic, one-time consultations with no arrangements to ensure continuity or compliance or control. Under the re-branding of this concept as HWCs, there is a potential to bring back the full notion of primary healthcare. Even within the understanding of achieving universal health coverage, the HWCs would be the main strategy.
B. Even the current list of services under the HWC is not comprehensive enough. But it makes for a big start. The 12 services listed for delivery by HWCs are as follows:
i. Care in pregnancy and child-birth
ii. Neonatal and infant health care services
iii. Childhood and adolescent health care services
iv. Family planning, Contraceptive services and other Reproductive Health Care services
v. Management of Communicable diseases including National Health Programmes
vi. Management of Common Communicable Diseases and Outpatient care for acute simple illnesses and minor ailments.
vii. Screening, Prevention, Control and Management of Non-Communicable diseases
viii. Care for Common Ophthalmic and ENT problems
ix. Screening and Basic management of Mental health ailments
x. Basic Oral health care
xi. Elderly and Palliative health care services
xii. Emergency Medical Services
The first five of these are already on the existing health sub-centers and Primary Health Centre mandate. The Health and Wellness Centre adds the other 7 services also.
Since most Primary Health Centres (PHCs) are also not providing these services, by including these in the list the government is making the point that these too should be capable of providing this list of services. The PHC would not need additional human resources if it has the level mandated by Indian Public Health Standards (IPHS), but it would need to organize its service delivery better.
3. Primary Health Care is about preventive and promotive services. But this above list of HWC services seems dominated by curative care.
a. The emphasis must remain on prevention and promotion. Inter-sectoral action on environmental and social determinants will be limited to what can be done at the level of the village through village health, sanitation and nutrition committees (VHSNCs) and with respective departments taking a lead role in their areas of accountability. Public health tasks such as vector control continue without losing emphasis. This has never been questioned nor have they been in doubt.
b. But what is added on now is “secondary prevention”. The early detection of diseases like hypertension and diabetes through screening programmes and appropriate treatment is what saves lives in a large number of non-communicable diseases. Even in chronic communicable diseases like TB, HIV, leprosy, etc, early detection and appropriate treatment has a major preventive role. So, it is quite misleading to think of preventive and curative as being in two separate silos in a public health care system.
c. Establishing such secondary prevention as part of primary health care would also give urgency to primary prevention in terms of reduction in exposure to risk factors. This would include change in diet, increased exercise, better life styles, reduced use of tobacco and alcohol and such factors. Currently very little happens in many elements of such promotive care.
d. This is not to diminish the importance of how economic policies and development policies act as determinants of ill health. But building awareness for policy changes in development policies at the state and national levels must be accompanied by and would be reinforced by local action to ensure the above elements of care as individual entitlements.
4. The government claims that they now have about 25,000 HWCs that are functional. Are the HWCs on the ground similar to what is promised? Or like the way the Alma Ata declaration of primary healthcare was reduced to selective healthcare, are there major deviations from the conceptual framework when it comes to implementation? The World Bank and other international aid agencies and global health institutions played a key role in reducing the Alma Ata declaration to selective primary health care. What are they up to now?
Response: This number of 25,000 is probably an over-estimate where many PHCs and Sub-centers which have been taken up for upgradation are presented as if they have already achieved it. The focus of peoples health movements should therefore not be on the numbers but whether those declared as HWCs conform to what is envisaged and promised.
It is important to note that the conceptual framework on which HWCs is based is part of a progressive framework on comprehensive primary health care that has evolved over many decades and which peoples’ movements have contributed greatly to shaping. Therefore, there is great urgency for peoples’ movements to be alert to deviations that trivialize or divert from the main objectives and call out/expose such deviations. Otherwise a government that is reluctant to implement the HWC concept in full will make use of the discontent with HWCs as implemented to scuttle the whole concept itself.
Some of the main deviations and distortions in the implementation of HWCs are listed below:
A) Distortions related to what services are provided in the HWC:
i. Instead of comprehensive primary healthcare, just one or two NCDs- usually hypertension and diabetes are added into the selective package. There is no effort to move to other services at all. In some states, even for hypertension and diabetes only screening and an unstructured referral up is done. There is no feedback from the referred doctor/specialist and no effort to ensure access to medication and follow up tests throughout the year at the HWC. In some states, it is even more cynical and HWCs have become only a branding exercise. A new coat of paint is given, the name of the center is changed- but no expansion of services occurs.
ii. In some states the focus is yoga. The scheme does see yoga as an important element of promotive health- and as one element among many there is case for it. But it certainly should not be the central or main agenda, displacing the other core services that HWCs are meant for. Any efforts to expand infrastructure in terms of yoga halls etc would be a distortion of priorities. There are many local administrators or officers who may take this path- since there is much less work involved, and it can distract from the main purpose, and since there is money that can be made in infrastructure.
iii. Improving infrastructure is one important element- but it is not and should not become the central component. There are examples where the entire emphasis is on beautification- painting the walls, putting ceramic tile flooring, re-building rooms and toilets etc. Part of this happens because this is what local administrators have understood the program to be. A more negative view would be that this happens because there is more opportunity to spend and to make money in infrastructure activity. The real danger is that equating upgradation to HWCs with improved infrastructure, would lead to a betrayal of expectations. Worse, when after all this expenditure, utilization does not go up, it would become another argument to favor privatization. The reasons for poor utilization lie in the lack of appropriate services — not in the lack of ceramic flooring.
iv. In some states the attention is given to starting up a general out-patient clinic and providing medicines and even some diagnostics in it. This helps, and like in the Mohalla clinic, can even be welcomed. But without the continuity of care for chronic illness, without the population-based coverage, without the referral platforms, it will not make much of a difference. The initial welcome will soon go away because people will have to go in search of better care for their healthcare needs than what such a clinic can prepare.
v. In most states, the feeling is that we should proceed gradually to add services to the package. But gradually based on what? Now the entire healthcare system waits for central directives before any service is added on. However, there is no reason to deny any service from these 12 service areas if there is a suitable specialist who is available to confirm diagnosis, make a treatment plan and communicate it to the the staff at the HWC, and then also be available if there is any complication
B) Distortions related to Human Resources:
i. The most common distortion is to equate the HWC with appointing a mid level health care provider. The rest of the team is not even thought about or planned for. There is neither a clear work distribution, nor the requisite training. The mid level healthcare provider alone cannot make a difference.
ii. The other common distortion is to understand the mid level healthcare provider as a substitute doctor- because doctors do not go to rural areas. In most or all chronic illnesses the doctor or specialist is not substituted by the MLHP. Once the diagnosis is confirmed and treatment plan made by the doctor, the MLHP would, with the help of the team, ensure follow up Related to this distortion, is the failure to design training programmes that enable MLHPs and the rest of the team to play this role.
iii. Another problem is the debate about whether the MLHP should be a B.Sc nurse or a GNM nurse, or an ANM or an AYUSH provider, or a three year new graduate. Can dentists and physiotherapists be allowed to become MLHPs? This debate diverts us from the main features of a MLHP- which should be a) he/she should be of that locality/block/district and happy to be working there b) he/she should be trained close to their place of work and preferably in state language using standard treatment protocols — and this training should be a periodic life long process c) that he/she should be conditionally licensed only to work in primary health care within government institutions- and not to become private providers- which means that even at the time of recruitment into the training, their employment position should be assured and d) one would need them as part of a permanent workforce- and not on an ad hoc contractual basis. E) they should always be working under the supervision of doctor/doctors in the public health system. It does not really matter which allied health professional or nursing qualification they have to begin with. If these five conditions are fulfilled, they would play their role- and if these are not, whatever their qualification they would not be able to work.
C) Distortions related to continuity of care:
i. The most common distortion is a complete failure to plan for the link with the doctor/specialist who shall receive the referral confirm diagnosis, make the treatment plan and rule out or manage complications, and communicate to the providers in the HWC- all according to a standard treatment protocol.
ii. The other common distortion is to assume that the providers empanelled with PMJAY will take care of this referral function. Not only does the PM-JAY not provide for such consultation, the incentive environment for the PM_JAY hospital is not to promote preventive care and avoid or delay the need for procedures. Rather, their interest is in increasing the number of secondary and tertiary care opportunities they have.
iii. A third distortion is to grossly underestimate the quantity of medicines required to provide continuity of medication and diagnostic support to patients with chronic illness. Thus, even if all persons with hypertension in a community were taking only one tablet per day, a population of 5000 with about 10% of those about 30 years having hypertension would need close to a lakh anti-hypertensive tablet. There is little effort in understanding and organizing the logistics for such increase in access to medication. The same goes for diagnostics. If the government is serious about HWCs as the route to UHC and of the promise to free drugs and diagnostics, it can certainly manage this.
D) Distortions related to Population Based Care
i. Most HWCs still limit population-based care to immunization, pregnancy, tuberculosis. There is no commitment to seek out those who have not been screened, or those defaulting on taking medicines, or those not taking care for complications etc. But ASHAs should make household visits that ensure this. And there has to be a system of documenting the health needs of different families and individuals and being able to follow it up. For example, a HWC team would know what proportion of population at risk have been screened for hypertension or diabetes, what proportion were confirmed to have that disease and how many of these are registered with the HWC for regular care, and finally in what proportion of them was hypertension controlled.
ii. There is no allocation of households to each HWC. This problem is most ….in urban areas. In rural areas there is at least an implict understanding. That would further mean that every household and individual would have a health card that indicates which is the HWC that is closest to their residence and to which they are attached. That card would also help support access for their health needs if they have any health risk or chronic illness.
iii. All of this would be greatly helped if the right ICT tools are available- but ICT tools and smart cards are not a substitute for the team building and coordination that is required. One distortion of HWCs is to equate it with introduction of ICT and smart cards. Often ICT tools add an additional layer of work for the overburdened providers without enabling local planning or decision making. Good ICT design should decrease the burden of data collections and reporting of the HWC providers. It will take quite a while to use UHC app (ICT tool) appropriately- and HWCs need not wait till then to expand the services they provide.
iv. The defnition of population should include all households and individuals usually resident in that area. Even three months residence in a year should be counted. No exclusions based on ID documentation should be permissible- since healthcare is an inalienable human right. Special care must be taken to ensure that migrants and seasonal workers are included. And if they are from another place in Indiathe continuity of care should be assured. If a person not usually resident in that area seeks care, that care should be provided. The only difference is that there is no assurance of follow up at household level to ensure compliance.
5. What should be the popular demands that peoples’ health movements should make at the level of the village/urban poor?
There is a need for popular campaigns to demand the following as an entitlement:
a. Any person with a chronic illness who needs to take medicines every day, or very often for the rest of their lives would be able to get their medicines in the sub-centre (HWC), free of costs. This is a long list. It includes medicines for hypertension, diabetes, angina, mental illnesses, epilepsy, asthma, chronic obstructive pulmonary disease, arthritis- just to name some of the most important ones.
b. If any person is detected with any of these illnesses when he or she comes for a visit for any other illness or a health check- up, they would be entitled to a reference for confirmation at the higher level (facilitated by the HWC) and they would have a treatment plan made by the specialist- with some elements of routine follow up being provided at the HWC.
c. Every person over 30 years would be actively screened at the HWC once a year for diabetes, hypertension and once in three to five years for chronic illnesses like cancer cervix, breast and oral cancers. If they are suspected of having the disease, they would be referred to a higher center and have the diagnosis confirmed and a treatment plan made. Similarly, all newborns have to be screened at the place of their birth. All pregnant women are already being screened.
d. There should be an out patient service on all 5 days of the week in the HWC- so that a much wider range of acute simple illness can be treated. This would include fever, acute respiratory infections, common infectious diseases etc.
6. What should be the demand of peoples’ movements at the level of policy, advocacy and agitation? What should peoples’ movements be alert about with respect to pressures from international donors and corporate India?
a. There is a great danger that the HWC can turn out to be another jhumla. The real push is on PM-JAY, while the HWC is only for show- to give the appearance of a evidence based progress towards UHC for public consumption and for international agencies like the UN. There are two key indicators of whether it is jhumla or a real action on the ground. The first indicator is the financial resources allocated to it. The second is the human resources policy.
i. Financing: By the governments own estimates it requires about 9 lakhs recurrent and 8 lakhs non recurrent expenditure- additional to what is currently spent on sub-centers and PHCs. This is a serious under-estimate — but even if we use this figure the allocation would be 13,500 crores per year or 65,700 crores recurrent plus 12,000 crores non-recurrent or about 77,000 crores over 5 years. The actual amount needed, if full HR and medicines and referral costs are included is likely to be at least twice that. But that would be about 1 % of GDP- a reasonable estimate. In the current year the allocation was only 1600 crores. In the previous year, the allocation was notional.
ii. Matching Human Resources Policies: The HR policy needs to provide resources for hiring the entire team, plus the ASHAs on a regular basis. And also we need to create HR policies which enable us to overcome the very skewed availability of human resources. Very often the government starts by stating that other than increasing HR, one can consider all options. Which means negating the whole program.
b. There is a need to identify distortions of the concept and build public and even provider understanding of what comprehensive primary health care means. Equating these distortions with HWCs would lead to loss of credibility regarding the whole idea of primary health care — and HWCs would be quietly shelved or reduced to some token level- while all the media attention etc. is focussed on the insurance scheme. An alert peoples movements and a democratic polity has a choice in how it goes about its protest ; It can demand that HWCs ought to be developed without these distortions, as the route to comprehensive primary health care and expose efforts that deviate, distort or trivialize the scheme. OR it could be dismissive of HWCs and thus add to the energies that for a variety of often varied reasons, call for ignoring if not scrapping the scheme. The PM-JAY is in no danger of being ignored- and there would be an active lobby of healthcare industry very ready to support and shape it. Every single media channel, newspaper and periodical, especially those specializing in health care, would be watching it roll out. (PMJAY covers journalists also). Comprehensive primary health care, on the other hand, does not attract such attention or support. It has no support except sections of the health policy community and peoples’ health movements. What peoples’ health movements do would therefore be critical.
c. The other big danger is the push to outsource clusters of HWCs to the private sector- and within that to the corporate sector. The BMGF (Bill and Melinda Gates Foundation) has a number of pilots and initiatives to do just this. BMGF currently leads this effort. USAID too actively supports these initiatives. Swasthya Piramal, Tata Trusts, Apollo Hospitals/enterprises are major corporate players who are interested in developing such models. The World Bank is more focussed on PMJAY. Niti Aayog has been pushing for private sector participation in HWCs — and has included a commitment to outsource at least a proportion of HWCs as part of the mandate of Aysuhman Bharat. There are also efforts to push part or all of HWCs into the National Health Authority and/or fuse it with the PMJAY platform in the name of integration. In all of these models the aim is to create a network of private providers linked to a corporate entity, which the government would contract in. The corporate agency will then engage the private providers either as a sub-contract or as employees. Till date, this approach has not succeeded. This lack of success is partly due to good sense prevailing in the ministry about their own ability to ensure that private sector abides by the contract, and partly because private players are not very keen. Part of the lack of progress in outsourcing despite political pressures to do so is because of the technical complexities of contracting a corporate consortium to provide primary healthcare. But a number of international agencies and Indian pro-industry academicians and consultancy organizations are trying to address the technicalities of contracting and promoting innovations in organizing services. This has given time and space for the public sector/healh ministry to come up with viable and visible government run HWCs.Would corporate India run better primary healthcare than what government would? Given the prevailing culture and perceptions fostered by neo-liberalism and the rise of right wing populism, many would support such a perception. But if experience and evidence is any guide, then what is far more likely is that it would, like in PMJAY, only lead to profits for private health sector, a weakening of public services and no major contribution to health.
7. Is this idea of HWCs a new idea? Has it been tried anywhere?
The name is new. But this is the basic concept of primary health care, before selective health care came along. Many nations in the world have organized care along these lines and are doing it for very long and very successfully. In the developed world, UK’s National Health Services is a model of such care- and it has been there for over 70 years. Most other developed nations also have similar arrangements for primary health care. In the developing world Cuba, Thailand and Brazil have very similar programmes. Thailand in particular is very similar to what is proposed in India. Over 95% of primary health care providers in all these nations are within the public sector- just like in India.
In fact, this is what was always meant by primary health care. Such organization of services is what peoples’ health movements have been demanding since its inception.
