Build­ing In­dia’s new health base

Strength­en­ing sub­cen­tres at the vil­lage level will free up gov­ern­ment doc­tors for ter­tiary care and re­duce the pa­tients’ out­of­pocket health ex­pen­di­ture sub­stan­tially

Hindustan Times (Bathinda) - - Nation - Sanchita Sharma let­ters@hin­dus­tan­

NEW DELHI: Prepa­ra­tions for Ayush­man Bharat be­gan two years be­fore Union fi­nance min­is­ter Arun Jait­ley an­nounced the gov­ern­ment’s flag­ship health in­sur­ance programme in his 2018 Bud­get speech. The train­ing of a new cadre of com­mu­nity health of­fi­cers to staff health sub-cen­tres that serve a pop­u­la­tion of 5,000 be­gan across many states in sum­mer 2017, set­ting the stage for treat­ment of sim­ple fever, in­fec­tions and pain, and early di­ag­no­sis and timely re­fer­rals to hos­pi­tals at the vil­lage level.

Ayush­man Bharat of­fers up to ~5 lakh cash­less cover for hos­pi­tal­i­sa­tion to 100 mil­lion poor and vul­ner­a­ble fam­i­lies for 1,354 treat­ment pack­ages, but with dis­trict hos­pi­tals and med­i­cal col­leges un­der­staffed and over­bur­dened treat­ing peo­ple for sim­ple in­fec­tions like di­ar­rhoea and vi­ral fevers, there is a des­per­ate need to strengthen pri­mary health ser­vices so peo­ple get ba­sic treat­ment within a 2-3 km ra­dius of their homes.

Around 80% of In­dia’s 1.04 mil­lion reg­is­tered doc­tors of mod­ern medicine (al­lopa­thy) work in cities, home to 31% of the coun­try’s pop­u­la­tion. For the 69% ru­ral pop­u­la­tion that is de­pen­dent on gov­ern­ment health­care ser­vices, the al­lo­pathic doc­tor-pop­u­la­tion ra­tio in the gov­ern­ment health sec­tor is 1:11,082, as against the World Health Or­ga­ni­za­tion’s (WHO) rec­om­mended ra­tio of 1:1,000.

“With the pri­mary health­care sys­tem in In­dia col­laps­ing, peo­ple turn to pri­vate doc­tors, who are of­ten quacks. Strength­en­ing health sub­cen­tres at the vil­lage level will free up doc­tors for ter­tiary care and re­duce pa­tients’ out-of-pocket spend­ing on health­care sub­stan­tially, as the need to go to pri­vate prac­ti­tion­ers, clin­ics and hos­pi­tals will fall, which has been val­i­dated last year by the pi­lot uni­ver­sal health cov­er­age (UHC) project in Tamil Nadu,” said Ta­pasvi Puwar, as­so­ciate pro­fes­sor, Indian In­sti­tute of Pub­lic Health, gand­hi­na­gar (IIPHG).


The UHC project launched in three ru­ral blocks in Tamil Nadu in early 2017 by the Cen­tre for Tech­nol­ogy and Pol­icy at Indian In­sti­tute of Tech­nol­ogy, Madras, demon­strated that strength­en­ing health sub-cen­tres that en­sur­ing trained per­son­nel, ser­vices, ba­sic in­fra­struc­ture and medicines were al­ways avail­able, re­duced the de­pen­dence on pri­vate hos­pi­tals dras­ti­cally and low­ered the out-of­pocket ex­pen­di­ture of the pa­tient as well as the cost of care in­curred by the gov­ern­ment.

The project, which was launched in Shoola­giri block in Kr­ish­na­giri dis­trict, Vi­ral­i­malai block in Pudukkot­tai, and Vep­pur block in Per­am­balur, led to out-of-pocket spend­ing fall­ing be­tween 77% and 92% across blocks. The num­ber of pa­tients vis­it­ing out-pa­tient de­part­ments and pri­vate hos­pi­tals also halved in eight months of the project rolling out, with pa­tients’ foot­fall drop­ping from 51% to 21% in Shoola­giri, from 48% to 24.2% in Vi­ral­i­malai, and from 41% to 24% in Vep­pur.

“Health sub-cen­tres are the build­ing blocks of pub­lic health­care as they are the first point of con­tact with the com­mu­nity. When ser­vices there are avail­able and re­li­able, pa­tients come. Look at pri­vate doc­tors, they close shop af­ter the last pa­tient leaves. With ANMS (aux­il­iary nurse mid­wives) and health work­ers ab­sent or away on field duty three times a week, sub-cen­tres are of­ten found locked. The CHO’S role is fixed, they have to be at the cen­tre to en­sure peo­ple get treat­ment,” said Dr Dileep Mavlankar, di­rec­tor, IIPHG, which is of­fer­ing a six-month cer­tifi­cate course in com­mu­nity health to cre­ate com­mu­nity health of­fi­cers (CHOS) to run health sub-cen­tres.

The new cadre of CHOS is trained as mid-level providers who will work with ANMS, Ashas (ac­cred­ited so­cial health ac­tivists) and male health work­ers to en­sure ev­ery 5,000 pop­u­la­tion gets ba­sic medicine, di­ag­no­sis and treat­ment. The programme, de­vel­oped by IGNOU in col­lab­o­ra­tion with the min­istry of health and fam­ily wel­fare, aims at im­prov­ing the knowl­edge, skills and com­pe­ten­cies of in-ser­vice reg­is­tered nurses and Ayush prac­ti­tion­ers to of­fer pri­mary health­care ser­vices, in­clud­ing pre­ven­tive and pro­mo­tive care, at pe­riph­eral level.

“The programme was de­vel­oped with nurs­ing ex­perts, med­i­cal ex­perts, so­cial sci­en­tists and ed­u­ca­tion­ists from var­i­ous re­lated dis­ci­plines to train CHOS in com­pre­hen­sive pri­mary care, in­clud­ing seven sim­ple pin­prick tests for malaria, di­a­betes and haemoglobin, among oth­ers, based on pro­to­cols ap­pro­pri­ate to sub-cen­ter level,” said Puwar.


The first batch of 27 CHOS trained at IIPHG grad­u­ated in July and have been be­gun work at Health and Well­ness Cen­tres (HWCS) across Gu­jarat. The sec­ond group of 400 stu­dents is be­ing trained in batches, with each get­ting 736 hours of train­ing, which in­cludes 448 hours of prac­ti­cal train­ing at ev­ery level of pub­lic health de­liv­ery, from pri­mary health cen­tres to dis­trict hos­pi­tals and med­i­cal col­leges.

“We work closely with the pan­chay­ats, ANMS and Ashas to tell peo­ple they can get medicines and treat­ment in the vil­lage. We don’t sup­port for skype con­sul­ta­tions with the med­i­cal of­fi­cers at PHCS, we use our per­sonal phones, but that will come once more pa­tients come,” said Mamta Pan­chal, a CHO posted at the Godhra HWC in Gu­jarat.

“Proac­tive reach­ing out with ser­vices and pro­vid­ing im­me­di­ate re­lief will cre­ate greater aware­ness and im­prove health-seek­ing be­hav­iour. We’re us­ing tech­nol­ogy in a big way to digi­tise, sup­port and eval­u­ate pro­grammes, in­clud­ing us­ing third­party eval­u­a­tion, to in­crease ef­fi­ciency and op­ti­mise reach,” said Jayanti S. Ravi, health com­mis­sioner and prin­ci­pal sec­re­tary, health and fam­ily wel­fare, Gu­jarat.

The Na­tional Skill De­vel­op­ment Cor­po­ra­tion is si­mul­ta­ne­ously util­is­ing Prad­han Mantri Kaushal Ken­dra and other Skill De­vel­op­ment Cen­tres un­der the Min­istry of Skill De­vel­op­ment and En­trepreneur­ship Skill In­dia Frame­work to train 100,000 Ar­o­gya Mi­tras at each em­pan­elled pub­lic and pri­vate hos­pi­tal to pro­vide sup­port in ben­e­fi­ciary ver­i­fi­ca­tion, au­then­ti­ca­tion, query man­age­ment, grievance re­dres­sal and han­dling emer­gency cases.

“We are ex­tend­ing health cov­er­age to the pop­u­la­tions of the US, Canada and Mex­ico put to­gether and need young peo­ple with the right skill sets and knowl­edge to en­sure ser­vices reach peo­ple. Ayush­man Bharat is the world’s largest health­care cov­er­age programme, we need to en­sure it’s also the world’s most ro­bust health­care cov­er­age programme,” said Ja­gat Prakash Nadda, Union health and fam­ily wel­fare min­is­ter.


As­so­ciate pro­fes­sor Dr Ta­pasvi Puwar with in­ser­vice reg­is­tered nurses and Ayush prac­ti­tion­ers un­der­go­ing com­mu­nity health train­ing at the Indian In­sti­tute of Pub­lic Health, Gand­hi­na­gar, Gu­jarat.

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