Assessment of health and wellness centres in hilly district of Himachal Pradesh

INTRODUCTION

The National Health policy 2017 has envisioned Health and Wellness Centres (HWCs) under Ayushman Bharat in health care system of India. In February 2018, the Government of India's announced the creation of 1,50,000 HWCs by transforming existing sub centres and primary health centres as the base pillar of Ayushman Bharat.¹ At present 741 health and wellness centres were upgraded from Primary health centres and sub centres in Himachal Pradesh.² In district Hamirpur total 59 HWCs are operational. Hamirpur district is located in hilly state of Himachal Pradesh, India with a population of 4,54,468.³ A three tier service delivery framework is proposed at the HWCs. First, the family/household and community level services, which will be delivered by ASHAs and MPWs. Community platforms such as, Village Health Sanitation and Nutrition Committees, Village Health and Nutrition Days (VHNDs), Mahila Arogya Samities, would also be leveraged. Second, comprehensive primary health care services will be provided at the HWC for at least six hours/day. Third, the referral services by referring patients to Primary Health Centre, Community Health Centre (CHC) or a District Hospital (DH)/FRUs depending on the type and severity of the illness. In Himachal Pradesh with significant geographical disparities and challenges, establishment of HWC in far-flung areas indicates a paradigm shift in government policy in addressing health-care needs through primary health-care setup. Himachal Pradesh was among nine states which were felicitated for achieving 100 per cent against the target for year 2020-21.⁴ The aim of the study was to identify the gaps in Ayushman Bharat- HWCs under various domains of service delivery.

METHODS

Study setting

A cross-sectional study was conducted to assess the AB-Health and wellness centres in district Hamirpur of Himachal Pradesh. 59 Health sub-centres or PHCs have been notified for upgradation as AB-HWCs in the district.

Sampling

A list of HWCs were procured from office of NHM Shimla and 10 HWCs fulfilling inclusion criteria were randomly selected for the assessment. 5 of these selected centres were upgraded from health sub-centres while 5 from primary health centres.

Inclusion criteria

The study included: (a) HWCs notified under Ayushman Bharat Scheme at least one year prior to commencement of study i.e.; 1^st March 2021; and (b) HWCs situated at a distance of at least 20 km from district headquarter.

Study duration

Duration of study was five months with effect from 1st March 2021 to 31^st July 2021.

Data collection

As per guidelines received from National Health Mission (NHM) Himachal Pradesh a team was constituted comprising three members i.e.; one Assistant professor and two tutors from department of community medicine. As per guidelines of NHM one visit was scheduled every month. Total five visits were conducted and in each visit one HWC (sub-centre) and one HWC (Primary health centre) was assessed.

Study tool

Study tool used was a validated checklist prepared by NHM Government of Himachal Pradesh. Checklist included six domains namely human resource, trainings of health workers, infrastructure, service delivery, and information technology and skill competencies.

Number of components were different in number under each domain. For example- if we take example of Human resource then components (checkpoints) were about sanctioned and filled up posts of medical officers, CHOs, FHWs, MHWs and ASHA workers.

Outcome indicators

Deficiencies or gaps in above domains were further categorized on the three points- Likert scale as follows: (a) high gap: only <33.3% of the components of each domain available/achieved; (b) medium gap: 33.3-66.6% of the components of each domain available/achieved; and (c) low gap: >66.6% of the components of each domain available/achieved.

Ethical consideration

Assessment had been carried out after prior permission for the district health authorities i.e.; CMO, BMOs and in charge of HWCs. They were explained the purpose of assessment and were also assured of having no legal or administrative implications based on our finding.

Data analysis

Data recorded from different variables of each domain were entered in Microsoft excel spreadsheet for further processing and analysis. For each domain, data has been transformed into the scale of 0-100% in order to determine level of deficiencies or gaps i.e.; high, medium and low.

RESULTS

Assessment of health and wellness centres was observed under six domains. Components under each domain were assessed and final results of assessment of HWCs (Primary health centres and sub-centres) represented in the form of gaps. The results of HWCs (sub-centres) and mentioned in Table 1.

In case of human resources the gap was high in three centres and medium in one centre. Most of the centres had high gap under domain of training for health workers. If we look for infrastructure then gap was medium in most of sub centres. Under service delivery the screening of only few of non-communicable diseases done the overall gap observed was high in all the five centres. Information and technology part was not good as the equipment were available but teleconsultations were none or very few in number. Skill competency of the health workers was observed as high gap.

The results of HWCs (PHCs) and mentioned in Table 2.

In Primary health centres (HWCs) the high gaps were observed for service delivery and information and technology. In Human resource and skill competencies the gap was medium. In infrastructure no gap was observed in four HWCs (PHCs). In case of skill competencies medium gap observed in three centres and high gap observed in two centres. Skill competency include knowledge, communication and technical skill of MOs and health care workers regarding screening, clinical check-ups, prescription of drugs, contraceptives, documentation, reporting and referral.

DISCUSSION

The objective of HWCs is to deliver high-quality preventive, promotive, curative, rehabilitative and palliative care services. In spite of the pandemic, Government of Himachal Pradesh has operationalised health and wellness centres. It was seen in study that Medical officers were posted in all primary health centres but community health officers are not posted in most of the Health and wellness centres (PHCs and SCs). The reason is that every year 360 CHOs pass out after undergoing selection process and the CCH course. There are 741 sub centres/PHCs are upgraded to health and wellness centres. Till date only two batches have been passed out so by February 2022 when 3^rd batch will pass out and after that all the vacant posts of CHOs will be filled up. Similar findings were also observed in the study done by Rathod et al.⁵

The training mentioned under Ayushman Bharat programme could not be imparted to health care workers who appointed after November-December in year 2019 as WHO declared the outbreak as Public health emergency of International Concern on 30 January 2020, and a pandemic on 11 March 2020 in March 2020.⁶

Almost all the workers got engaged in COVID-19 pandemic. HWCs (PHCs) have better infrastructure as compared to HWCs (SCs) in most of centres outlook of building is good with both painting and branding but the internal infrastructure in both type of institutions PHCs and Sub-centres was not good as minor repair work was pending and inner side of the walls was not properly painted. More over workstations were well organised in half of the centres. The painting and branding of only existing HWCs (SCs) was done but the expansion of infrastructure have been not done. The design and infrastructure of sub-centres (AB-HWCs) was not constructed as per guidelines issued by government of India.

The equipment of telemedicine was available but telemedicine consultations are not done at all. As per health care workers including MOs, they were engaged dedicatedly in prevention and control of COVID-19 pandemic but it was also observed that even before the pandemic some institutions which are understudy had not done the teleconsultations. Screening of only hypertension and diabetes is done but screening of cervix, breast and oral cancer is not done at all. At present in females the most common malignancies are breast cancer and Cancer cervix and high mortality is being registered in these diseases. As per study done by Swaminathan et al there is a common observation that the rural areas in India are neglected in providing proper NCD care.⁷

The CBAC forms of population above 18 are not filled up which is a primary duty of Health workers and ASHA worker who is supposed to support female health worker in this task. There is need of training for screening of these diseases. The reporting and documentation of NCDs is not satisfactory. In skill competency the theoretical knowledge and practical application needs to be improved. The medical officers can take lead to increase the skill competencies of CHOs and other health care workers. Expected activities regarding health and wellness centres could not be done due to COVID-19 pandemic. Now hopefully the COVID-19 pandemic is in end stage and we can predict better outcome from these HWCs for community in future.

Limitation

Study was conducted in only one district of Himachal Pradesh.

CONCLUSION

The aim of HWCs was to provide the comprehensive primary health care closer to their homes. Staff working in Health and wellness centres have to provide continuum of health care to community. In present study it is seen that target to upgrade AB-HWCs have been achieved in district Hamirpur of Himachal Pradesh but still there are gaps in the form of human resource, infrastructure, trainings and skill competencies etc. To fill up these gaps there is need of focussed and target oriented determination by state health department. Even under the shadows of COVID-19 pandemic the dedication of government should be appreciated that government continued the process to upgrade PHCs and SCs to HWCs.

Recommendations

As mentor after inspection of these health and wellness centres following are the recommendations- (a) full fill the sanctioned posts in health and wellness centres at the earliest in these centres on priority basis; (b) especially in sub-centres (AB-HWCs) there is only painting and branding there is need of expansion of infrastructure with required modalities; (c) training of staff members working in HWCs as early as possible in order to achieve the objective; (d) monitoring and mentoring of CHOs, Health workers regarding NCDs prevention activities; (e) CBAC form is a very important screening tool for five NCDs and tuberculosis. District and block health authorities should dedicatedly focussed and monthly target should be given to health workers and ASHA workers; (f) there is need to improve skill competencies through hands on training of these health workers posted in these institutes; and (g) all deficiencies in health and wellness centres to be filled up in a fixed time line.

Funding: National Health Mission, Himachal Pradesh

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Ministry of health and family welfare, Government of India. Ayushman Bharat Health and wellness centre, 2019. Available at: https://ab-hwc.nhp.gov.in/home/aboutus. Accessed on 05 September 2021.
2. 2. Ministry of Health and family welfare New Delhi India. Status of operationalised Health and Wellness centres in India, 2021. Available at https://pib.gov.in/PressReleaseIframePage.aspx?PRID=1706945. Accessed on 26 September 2021.
3. 3. Wikipedia. Hamirpur district, Himachal Pradesh, 2021. Available at: https://en.wikipedia.org/wiki/Hamirpur_district,_Himachal_Pradesh. Accessed on 21 August 2021.
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7. 7. Swaminathan K, Veerasekar G, Kuppusamy S, Sundaresan M, Velmurugan G, Palaniswami NG. Noncommunicable disease in rural India: Are we seriously underestimating the risk? The Nallampatti noncommunicable disease study. Indian J Endocrinol Metab. 2017;21(1):90-5.