Ayushman Bharat brought us the concept of 'Health and Wellness' centers, 1.5 lakh of them to be established in the country. As per the operational guideline of Ayushman Bharat, primary health centers and sub-centers would be converted to HWCs. The principle of HWCs would be a seamless continuum of care that ensures the principles of equity, quality, universality and no financial hardship. It looked like a great concept on papers, so I was always inquisitive to know, how it would be operational.
I was taking the poster presentation of the students for summer internship when one student told me that his project was to help convert a PHC into a HWC. I was curious. How did you go about it, I asked him?
For the next hour and a half, what he explained to me, I am tempted to share it with everyone. As per the guideline, the HWCs would be providing an expanded range of services, which would include screening, prevention and management of non-communicable diseases, Ophthalmic, ENT, Oral care, emergency services, elderly care and mental health care. These services would be executed through, Mobile Medical Units, Tele-medicine, Partnership with NGOs and Corporate, electronic recording of data and reports, and emphasizing health promotion.
I saw a lot of opportunities there. Physician or general practitioner at HWC, could act as a gatekeeper. We could have a family doctor for a population of 2500. This family doctor would be equipped to do basic diagnostic, through simple, cost effective diagnostic methods, available at PHC itself. For complex diagnostic procedures, sample could be taken and be sent to a nearest empaneled diagnostic lab. A network of diagnostic services could be created.
A referral could be generated through these centers and nearby private and public hospitals could connect through internet and a specialist through, internet technology could look at a patient's reports and could generate a referral for him.
CSR expenditure could be directly sourced by HWC, as a potential source of funding for establishing infrastructure.
HWCs could be directly linked with schools, private and public for health promotion initiatives. We could have an elderly care home and a child care home attached to HWC.
HWC would be the first point to generate health data, for every patient with a unique identification number, same data could be accessed any where in the health system. The data thus generated would help researchers and innovators.
Database would help in generating accurate demand and supply predictions for the drugs.
Alternative medicine, Yoga and other wellness techniques could be made instrumental through 'Wellness Rooms'. Nutritional solutions through PPPs could also be planned and delivered as per the requirement of the population.
Nithin Shanbhogue, my student, informed me that he was a part of a team at a leading development agency which helped the Jharkhand Government in establishing Health and wellness centres, in Jharkhand. He was a part of a team which conducted supportive supervision on nine functional criterions - 1)Infrastructure and Branding, 2)Human Resource and Training, 3)Expanded services, 4)Drugs, 5)IT system - teleconsultation, 6)Health Promotion wellness activity - Yoga, 7)Population Enumeration and NCD screening, 8)Community outreach activity - school health programs, VHSNCs etc, 9)IEC material
He found out the infrastructural gaps, whether the existing building was owned or rented by the state, whether it had enough space to house, IPD, OPD, Yoga room, supply of drugs, electricity, water, mobile network, tablets, computers and other facilities. Where-ever the gaps were found he had brought it to the notice of State Nodal Officer, who took necessary measures to fulfil the gaps, the budget allocation for which had already been made. Apollo group of Hospitals is already running tele-medicine outlets at PHCs in Jharkhand.
He assisted in doing the population enumeration at the HWC. NCD screening was done after the population enumeration was cmpleted. ANMs selected the high risk patients and they will be sent to Community Health Centres. Training of ANMs has been completed for gathering the health data of the community on a tablet in digital form, and the training of ASHAs is in progress. 'Community Based Assessment Checklist'(CBAC) forms were available on tablets. Patient data thus collected, will be stored in a national database, which would be bifurcated at state and district level. A unique ID will be generated for every patient and his test results and diagnostic details will be saved by that ID. Referrals will be generated based on that. A monthly report will be prepared by frontline health workers and Community Health Officer posted at HWC, will send it to the state. District Program Officer, State Nodal Officer and doctors will have an access to data and reports. CBAC forms, duly filled up will be saved in a family folder. A micro-plan for fixing a day for NCD screening has been executed at select HWCs. The OPD data will be collected real time and will be stored in the database.
An NCD tool kit has been supplied to the HWC, which contains Glucometer, Tongue Depressors, BP instrument, and anti-diabetic, anti-hypertension and anti-epileptic drugs. A community health officer will be posted at each subcentre. A bridge course on community health of six months has been designed by IGNOU to train CHOs in their jobs. For the purpose the program study centres have been established.
AYUSH will take care of the Yoga centres. A fixed schedule would be generated to conduct Yoga sessions.
HWCs will have several backward forward linkages. India's foray into digital health through HWCs, will provide huge opportunities in future. AI will be developed, Innovation will be done, supply chains will become more effective and the cost of care will be reduced. It will provide the necessary data for research. We will leapfrog to the advanced health systems. 'Winnable battles' would be fought and won, because of reporting of real time data.
I have always believed that my country does not have the resources(given the huge population) to provide universal health care, through curative care models that exist in US and other developed countries. The very thought is pinching, that some people will have to go without care, because of resource constraint.
WE CAN find new models based on preventive health care, technology enabled new methods, digital health and more sustainable resources. Networks will help us build sustainable models, and the new challenges put forward by climate change and microbial resistance will be better handled. I tried to picture the backward-forward linkages of HWCs in my mind and I have tried to put it on paper.
As a result of technological interface, hospital space will shrink. A lot of convention services provided by the hospital can be outsourced. Many startups will contribute to shrinking of the hospital space by entering into the space of laundry services, food supplies, infection management, financial services, TPA management, patient tracking, tele-medicine, homecare, diagnostics, advocacy and research. Big data will enable leapfrogging to advance health systems, that would enable targeted interventions in the area of nutrition, lifestyle change, behavior change, environmental awareness and zero inventory or waiting time scenarios. It will enable, large scale diagnostic labs to be established, unique breakthroughs in genetic engineering, disease management and development of drugs. A diverse and IT enabled country like India can become a hub for healthcare innovation in future. Artificial intelligence and seamless flow of data through block chains will bring about unique research opportunities, both on the preventive as well as curative side. Many dimensions to continuum of care will open up.
After many Sunny Days, this came as a respite of the first shower of the rain. Fresh smell of the dampened earth outside, is filling up my room, as I write this piece.
Hope, manifests in many ways, and fills up the heart surreptitiously ! Hail!
