Keeping the AB-HWC programme on track…
…to deliver on Comprehensive Primary Health Care!!
Conversation between Ms Harsha Joshi (HJ),
Dr Yogesh Jain (YJ) and Professor T Sundararaman (TS)
HJ: To introduce the topic: the Ayushman Bharat- Health and Wellness Centre (HWC) scheme, now called Ayushman Arogya Mandir (AAM) was launched in 2018 by the Central Ministry, and its main objectives was to expand the scope of primary care services, from selective healthcare delivery to comprehensive primary healthcare services. This called for upgrading the Health Sub-Centres (HSCs) and Primary Health Centres (PHCs) to provide an essential package of 12 services which were defined in the national guidelines. Earlier PHCs and HSCs were restricted to services on pregnancy and childbirth, immunization, family planning, some child health interventions and addressing tuberculosis, HIV and malaria. With HWCs, the assured services expanded to include non-communicable diseases, mental health, eye and ear care, oral health, elderly and palliative health care and elements of emergency medical care. To deliver these services the HSCs health had to be upgraded with additional human resources, especially a Mid-Level Health care Provider (MLHP), called the Community Health Officer (CHO) and additional infrastructure and corresponding increase in medicines and other consumables.
And now it is almost six to seven years after the rollout of the scheme. This is a good opportunity to look back and see how the scheme was implemented and whether it is giving us the outcomes that were conceptualized, and the challenges faced. So, could you elaborate on what were some of the critical issues that were articulated during the planning of this scheme for comprehensive primary healthcare (CPHC) so that we can look back at the origin of it and how this scheme came about. Dr Jain?
YJ: I think this question should be taken on by Sundar because he was part of this initial development. I would be more useful as a critic.
TS: In January 2015, a draft National Health Policy was put up for consultations on the Ministry of Health’s web-portal, and this articulated India’s roadmap to Universal Health Coverage and achievement of the Sustainable Development Goals on health. Also to recall, that in 2015, the Sustainable Development Goals were adopted globally, and this draft policy was aligned with that. The roadmap emphasized the shift from selective primary health care to comprehensive Primary Health Care as one of its key strategies. Though the National Health Policy was formally approved and adopted as late as August 2017, given the larger consensus on this aspect of primary health care, a 15- member multi-stakeholder expert group, was set up called to design this approach. This committee had a number of senior officials and public health experts from both public and private sector and it drew on best practices especially the CPHC model implemented by Jan Swasthya Sahyog. The committee submitted its “Report of the Task Force for Rollout of Comprehensive Primary Health Care” in late 2015. Soon after, in 2016, funding was allocated by NHM to pilot HWCs in select geographies. Guidelines for screening and NCD care were put in place and resources also increased through the free diagnostics and medicines scheme. After adoption of the National Health Policy in August 2017, this became formalized as the Ayushman Bharat-Health and Wellness scheme formally launched in February 2018 and for which MOHFW issued operational guidelines in 2018. The heart of the scheme was to make primary health care comprehensive, close to community and ensure continuity of care. The last meant that the HWC would also function as the entry point to free secondary and tertiary care services as and when required. So, the referral support and the feedback were important. Community engagement was important. And a number of preventive and promotive and public health roles that can be done at the primary care level, some are things that have to be done by inter-sectoral policies, but those that can be delivered within the health sector were part of the remit of the health and wellness care sector. The Human Resources proposed was one CHO, one female health workers with ANM qualifications (the Task Force had proposed two), one male health worker, and about 5 ASHAs. Thus, a team of eight or nine persons for a population of 5000. The HWC. This was the ambition. A budget was earmarked for this within the NHM pool with both centre and states contributing.
In 2018, when the government inaugurated the program, they also adopted an ambitious goal of upgrading existing sub-centres (then about 1.46 lakhs) and all 26 000 PHCs into about 1.5 lakh HWCs by December 2022. To achieve this challenging goal, a number of innovative measures were put in place including a certificate course on community health offered nation-wide by IGNOU.Of these, what worked best in going to scale, was the creation of an integrated nursing course by integration of a six-month module into the current three year BSc nursing courses provided the greatest numbers and proved more sustainable. The AYUSH stream was also permitted as an entry into the CHO cadre in a number of states, but met greater resistance, and only three states have persisted with this route (Kashmir, Maharashtra, and Gujarat). By 2022, almost on the dot, the department declared they have achieved a target of 1.3 lakh HWCs. This was indeed a remarkable achievement.
The problem was that this “achievement “consisted largely of a set of “branding” measures and the deployment of CHOs. Even though functionality was limited to a few criteria, footfall began to increase in hitherto dormant HSCs. But this was far short of what was required. What did not happen was the expansion of functionality to the 12 assured set of services. Of the twelve, six were pre-existing packages to which screening for diabetes and hypertension, defined as the seventh package was added and in a patchy, as of now negligible scale, the screening for three cancers- breast, cervical and oral cancer. In fact, when reporting on HWC achievement, the working guideline was that if these seven packages are achieved, then the HWC could be declared as functional- though this was far short of the objective of comprehensive primary health care (CPHC). There was a general understanding that due to variable readiness across states and the difficulties in training personnel, an incremental approach to adding services packages was necessary. However, six years down the line such incremental addition is not happening. The addition of diabetes and hypertension into the earlier available selective health care does not equal comprehensive primary health care. I think it is important to recognise that the shift from selective to comprehensive services is a problematic, that calls for a re-examination of design issues and operational challenges.
YJ: I would say that both in the roll-out and in the celebration of “achievement,” the term “Health and Wellness Centre” has got equated to infrastructure development and HR deployment and missed the expanded service assurance that we were looking at. The HWC is not in itself a concept- it is only supposed to be infrastructure locus, the final frontier so to speak, for delivering on the concept of Comprehensive Primary Health Care (CPHC). Infrastructure development and HR are necessary but not sufficient for achieving CPHC. The second important reduction was of the concept of “community basing of primary health care” wherein a designated population, a community, would receive health protection and promotion and was reduced to something like a Community-based assessment checklist (CBAC) form being filled for people over 30 years of age. There is no clarity in the frontline workers of the services that the population, especially the marginalized, have become entitled to and that the concept the HWC was supposed to provide a locus for community tethering, if I may call it that, did not happen. At least not in a structural way. Community engagement, an essential component of CPHC has been particularly weak. We should discuss that theme in another conversation.
And my third concern is this entire idea of boxing primary health care into these 12 packages. There may be many essential services between these boxes. I think the committee should have said ‘12 services and others as required’. At least, now that is the way it should be thought of. Knowing that all of it cannot be managed by primary care providers the principle of continuity of care with secondary and tertiary levels of care was built up, which I think is, besides community engagement, the other major casualty that we have not been able to fix.
Overall, we as a nation we are very happy with certain targets and optics, and achieving these numbers with “branding” and the addition of the CHO has allowed us to feel good about it. But our bars are so low that we start celebrating the success of the idea prematurely (1,2), without having delivered the outcomes that we were looking for.
HJ: What I hear is that the celebration of success in HWCs is premature, but from that I also understand that progress has been made and that further progress is feasible. Could you discuss why this movement from selective to more comprehensive has been so difficult?
TS: Many distortions that crept in during scaling-up are part of the problem. One is the emphasis on branding- which includes everything from the color of the paint applied on the walls, the signages that are put up, the content of media publicity, and more recently the change of the name to “Ayushman Arogya Mandirs” (AAMs). Many of these efforts have been resented by the states for good reasons, but most states have fallen in line since fund-flows get linked to such “achievements”. My concern here is the way it trivializes in the consciousness of the frontline health worker, the very purpose of HWCs, turning it into something of a short-term political gimmick, rather than the serious historic policy change that it was meant to be. Another distortion was the interpretation of “wellness” in the HWC, as similar to the use of the word wellness with reference to a spa. Though there is a serious dimension to yoga, placing it on a priority monitoring list, setting targets for it, and getting centres to report on such wellness could be a major distraction from the more serious priorities in terms of expanding essential services. But not much damage done, and here and there some gains. I would not worry too much about this- a bit like the emperors’ new clothes- everyone can see it for what it is, except the emperor.
To my mind the really big problem is that after decades of dealing with only vertical disease specific interventions, we don’t know to think differently when we are to add more services into the package, and the possibilities for adding vertical packages have reached their limits. Thus, adding diabetes and hypertension, meant that frontline workers had a set of additional indicators and an additional web-portal to report on, additional apps for data entry and more registers to fill, and a chain of supervisors for these activities. The package for DM and HT varied across states. In some states is only screening and upward referral, and in some there is in addition follow up for medication access and in very few states early detection and management of complications- and each expansion carries its load of administrative tasks. So exhausting is the addition of a single extra disease, that no state has the strength to even think of adding a condition like chronic obstructive pulmonary disease (COPD) the second biggest killer in the package. Only Kerala developed a viable approach to COPD (the Swaas model) but even they faltered at scaling it up.
The issue of integration of vertical into horizontal was always a challenge. We need to remember that existing staff are already fully engaged with a large set of primary care verticals- family planning, immunization, care in pregnancy and newborn, tuberculosis, HIV, leprosy, vector borne disease, blindness control and every one of these have their own indicators, web-portals, registers, supervisors and supply chains. With the addition of new staff, DM and HT could get squeezed in but the tipping point has been reached- no further new services can be entered as vertical top-down packages and some of the existing priorities get displaced.
Further instead of continuity of care we see fragmentation of functions across staff with little coordination between them. But another major problem, that we do will be unable to deal with in this conversation is the integration with public health interventions at the community level- as different from individual preventive services.
YJ: I will draw attention to two more barriers. With regards to HR, though the CHO is added, the second ANM is not in place in most states and there are huge vacancies in the first ANM and the male worker. And an even bigger problem is that though many persons are thrown together into the HWC, there are insufficient efforts to make them function as teams. In fact, if anything, we have succeeded in making them dysfunctional. And that is certainly not the way that CPHC was supposed to happen. The reasons are many. One reason is designation as some as officers and others as workers. Another is the tension between regular as compared to contractual employees, especially when the CHO is expected to lead the team. Regular workers have greater job security and better salaries, but the CHO is contractual. The other is the fragmentation of work between the staff. For example, the ASHA will fill the CBAC form, the CHO will do the BP measurement and testing for those he/she can reach, the ANM will restrict to maternal and child health and there is no connect between these fragments of care. Nor is there willingness to share the work between them especially if there is someone absent or over loaded and even more because each of the staff reports to a different chain of command. Yet another is the failure to integrate the HWC staff work with the ASHAs work in this area- often because there are different supervisory chains for each. Both the problems of the threshold number of a team of nine health workers for a population of 5000 (including the ASHAs) and forging them as a team should be seen as basic pre-requisites.
The other larger comment is the fact that we have not paid any attention to the quality of care as different from numerical measures of volumes of services delivered. We should come to that later.
HJ: As of today, as per the government, we have about 1,62,000 health and wellness centre. That is a very rapid scale up. I wanted to know your thoughts about this kind of rapid scale-up. Was this because of undue political pressure of achieving the numbers which affected the whole quality of the program-rollout, or was this initial momentum and attention actually necessary to push finances and attention of all the state program managers or governments towards this program. What’s the fine balance?
TS: So, I’m not going to call the scaling up or the political pressure as undue. I’m happy that there was political pressure to expand. But this has to be translated by administrative competence into an understanding of the rigour and follow-up measures that scaling up requires. Unfortunately target-setting and public relations management could trump some of the attention to detail and follow-up. For example, there needed to have been more rigour in the pre-service training of CHOs. Even more important we need to put in place an on-the-job mentoring program for primary care providers, also on scale. We have very good examples and best practices of this- but this has not gone to scale. A support program, intensive in initial years, but sustained in perpetuity is required. It exists wherever primary health care exists.
But the problem is also in being able to share the conceptualization down the line. Much of the implementation is administrator driven, done in consultation with senior specialists in specific diseases. We have many well qualified medical specialists who have been practising comprehensive primary care in rural settings, for many years, often in civil society. It would have helped to keep them a in the loop to develop an alternate visualisation of how to organize a response to all the chronic illnesses of a population, of which DM or HT is only a sample.
An administrator would first attend to buildings, maintenance, use of apps, job descriptions, work allocations etc. All of this is essential to scaling up, but not sufficient for the coordination and continuity of care required for quality long term prevention and management of chronic illness care. That sort of question, there is nobody to ask that!! I also fear that the increasing reliance on apps, and portals has undermined the importance of the traditional field visit by a supportive supervisor who engages with providers and community- and without this feedback, a learning-system is not established.
YJ: Harsha, if I may add to this. Let me give you a different take on the problems of scaling up. I can speak up for a district called Khargone in Madhya Pradesh, which has about 40% Adivasi population. Out of 700+ CHOs who are deployed, about 120 of them don’t have an infrastructure to call a HWC. They, in fact, sit under a tree, or they operate from the house of one of the ASHAs. In fact, it seems that it is not going to happen for at least a year or two more. So, the point I’m trying to drive is that even the development of HWCs as an infrastructure locus is uneven across states and districts. Maybe districts in southern states are doing better, but the central Indian states of Madhya Pradesh, Uttar Pradesh or Bihar have big gaps.
The other problem is that AB-HWCs has become another vertical program. There is a deputy director who’s in charge of HWCs without control over the HR, with the ANMs reporting to another person, and the ASHAs to yet another. He has the data from the HWC portal, but not from the NCD portal or the ASHA portal and so on. The way it’s structured, I worry whether the entire idea of comprehensive primary health care has been split into vertical shards.
HJ: Dr Jain, you gave the example of Khargone. I would add that the current rural health statistics data shows that there’s a shortfall of 22% sub-centres and 30% primary health centres in India overall, and in states like Bihar there is a 57% shortfall, and 46% shortfall in Meghalaya. The question is whether these states were ready for the same range of activities and processes, or should the approach have been different for the districts and states as per their readiness?
TS: I look at this differently. I’m going to say that, yes, there is an infrastructure problem. It’s a big problem. There is an Ayushman Bharat Health Infrastructure Mission that is trying to address it. It has its limitations, but they are seized of the problem, and they will get there. And you are quite right that this infrastructure problem is limiting outreach. I am especially worried about urban areas, and newly declared urban areas, where the population served is not delineated unlike in the rural areas.
But let us assume that 50 to 70 percent of HWCs have no infrastructure problem. Have we achieved the shift to CPHC in these areas? Must the achievement of comprehensive services in these areas wait for the development of the infrastructure in the other areas? And further, must we pose that a stage of selective primary health care is a necessary step for progress towards comprehensive care? These are autonomous of each other. Our contention is that selective health care has been bad for primary care at any stage of its development. Selective care restricts the use of skills of the qualified person in place leading to professional dissatisfaction. Selective care leads to under-utilization of the infrastructure and supply chains and human resources put in place. Even for the selective service, the lack of an approach can undermine effectiveness. If one does not take every skin lesion seriously you would miss that one in 6000 skin lesions that would be. One can argue also that if we do not take every case of COPD seriously, we will not be able to detect all cases of tuberculosis and so on. One must remember that one of the key understandings on which NHM was designed was that we needed health systems strengthening even for RCH and the national disease control programmes to be effective. But the most important reason is that it is violative of health rights to have made primary care so highly selective. If the skills and infrastructure to treat one paediatric illness is in place, the marginal costs of extending the package to treat say childhood epilepsy is negligible. It is the burden of capturing this addition on digital platforms that is intimidating- but not the addition to care. I don’t think that we should attribute the failure to move to comprehensive primary health care to the failure to develop infrastructure that will reinforce the infrastructure locus of the program. And we should not also pose that NCDs should be addressed only after we have “succeeded” with RCH and national disease programmes. That would be tacitly agreeing that the expansion of services is necessarily one by one, vertical and top down.
What we required was much more attention to on-the-job capacity building with online protocols and support for providers for all the additional services that were to be introduced. The other major gap is that for all diseases, especially where we introduce screening, the follow through in terms of continuity of care and coordination once a patient was “within the cascade of care” had to be worked out and assured much better. Work on both of these aspects has almost not begun. Considerable allowance must be made by the delay and disruption to the CPHC roll out due to the Covid pandemic. However, in my view, the bigger constraint is that the potential for simultaneous and parallel introduction of multiple services has not been adequately appreciated. This is not only a national problem. Even the WHO has to recognize that its disease specific approaches are poorly integrated with primary health care and UHC.
HJ: Okay so I’ll move to the problematic of integration of vertical programs then. This was mentioned as a goal even for National health mission. If we look at the HWC policy documents, integration is clearly part of the policy intent. So how do we work with this challenge now, with HWC itself being reduced as a vertical program at this point?
TS: We need to actually reclaim the conceptual clarity. The ASHA’s home visit is central to the concept. When ASHA visits a home, it is a comprehensive visit, meaning it takes care of children below five, it takes care of pregnant women and newborns, it takes care of adults, both men and women and it takes care of the elderly. For each group there is health education to be imparted: on the health risks they face and how to reduce these risks through adoption of positive health practices, and on the early signs of disease and on screening for specific illnesses, and to encourage and facilitate continuity of care for those with chronic illness. In doing so she is connected to every member of the HWC team and can send persons who need screening or medication to them. Most important she ensures that no one is left out.
Contrast this with what happens now. When she makes the visit, her work is fragmented into responding to the requirements of different vertical care managers without seeing the family and the patient as integrated. Making one visit to see the newborn in the house, another to promote screening or fill a CBAC form, and another for active case finding for TB, yet another separate visit for the elderly merely because these are different verticals is most inefficient and because of differentials in incentives and monitoring pressure, quite disconnected with the health needs. Yet this is what is the practice. The priority should be to ensure that to the home could remain a comprehensive home visit, even if her reports flow to different disease-specific supervisors. This would mean a larger time per family, and therefore a lesser number of families per ASHA.
At the Health and Wellness Centre, healthcare is of four types: (1) outpatient care for minor and self-limiting medical ailments with most of the care-seekers being walk-in patients (2) screening for chronic ailments, both communicable and non-communicable , with most of the care-seekers coming-in due to referral by the ASHA and increased community awareness, (3) follow up care including medication access for patients of chronic illness diagnosed and prescribed a treatment plan by medical officers or specialists – many of whom may have been seen first in higher centres (4) referral with facilitation of access/navigation to reach appropriate secondary and tertiary care provider who would provide the required care, free of charges. The visit to the CHO is also the pathway to access most requirements of secondary and tertiary care with financial protection.
Integration therefore requires coordination and co-operation across a district team, which in its entirety has the capacity to deliver the entire range of services envisaged, with the HWC managing the majority of care-episodes since they are close to community. The challenge in this understanding is to ensure that the specialists of the district are able to relate to HWC staff as part of the team, and that such coordination is essential for ensuring people centred health care. Where the referral support in place, there is no need for any further delay in introducing each service sequentially- they could also start up in parallel. Paradoxically the digital connects needed for such continuity are largely in place. What is missing is the understanding of why these connects have been put in place, and some system of coordination along the care pathways.
To sum up, HWCs provides some components of healthcare autonomously, but most of the care the HWC team provides is as part of a chain of care- which is comprehensive, which ensures continuity and which is well coordinated.
I further submit that monitoring each activity of the peripheral staff is not going to deliver this. Nor can it be solved by tinkering with payment mechanisms. The required organization of healthcare services would however be greatly assisted by suitable right to healthcare legislation. As a start we should have a policy and systems in place such that if the referral hospital is out of bed space or specialist time, then there is a mandatory referral to the next nearest place which would usually be a public provider, but could be supplemented by private providers who are contracted in for this purpose. A right to health care act would enable, assure and fix accountability for such referrals.
Telemedicine could have played a big role in the connects between levels of care. Unfortunately, telemedicine too has been caricatured and trivialized into “reporting-five-tele-medicines-per-day” on the e- Sanjeevani portal. So once again, the portal entry of a normative activity, has become a substitute for the concept of how telemedicine could act as a gateway to a higher care. I think such misunderstandings are due to the rapid scale up without adequate inputs into building conceptual understanding in the leadership. Otherwise, you cannot have this sort of very mindless target setting.
YJ: If I can add to this. If we were trying to integrate care at each level then we have to address the issue of parallel reporting structures. It is often jokingly said that ASHA has become a Durga, for she has 12 parallel functions to perform. In practice she has only one- a comprehensive home visit, but by her having to report into over 15 different supervisors on parallel vertical packages, we have created this image. In the HWC, maternal and newborn care is under the ambit of the ANM, although the CHO too is a qualified nurse, she does not even come into the picture. I have seen at times two health staff sitting in two adjacent rooms. Even if there is a woman having difficulty in labour, they would not even ask the other CHO in the adjacent room, who’s also a senior nurse by primary training, to come for help. Because that is a level of disintegration that we have reached. Further all communicable disease care is under the male MPW and NCDs are under the CHO, and the ASHAs are not seen as part of the HWC team. I remain hopeful however that if we work hard, we can integrate it. We could develop CHOs and MPWs- both male and female, as generalists, who could look after most functions, – not only be disease category, but also from preventive, promotive, curative and rehabilitative care. Without the primary healthcare workers working as team, we can forget about integration.
I would really wish that there is integration at a higher level too-the Directorates and the NHM, and at the district level. That is a more difficult battle. At the moment, we have this opportunity to recover the spirit of integrated care in Health and Wellness Centre staff because they are still relatively new to the system.
HJ: Policy statements also uphold the team-based approach. I wonder how this team-based approach as described by you, matches with what the policies project. There is also this newer team-based incentive which the government has introduced as a finance mechanism to build the teams. However, I note that the indicators defined are still task-and-personnel specific. So, you have an NCD-related target which the CHO looks at, and the ANC-related target which ANM looks at. Does this give us an adequate measure of HWC performance? What are the current ways and limitations of understanding the performance of HWCs?
YJ: So, Harsha, I would frame it like this – We haven’t had and we don’t have in the foreseeable future, measures of accountability, and thus monitoring has been reduced to data entry in a series of web-portals. This tool of offering people incentives per piece/fragment of a primary care activity drives this. The extensive deployment of information technology tools becomes convenient to document individual activities, but they end up ensuring that we don’t have accountable systems. For example, we know that performance-based initiatives have been claimed by ASHAs for almost all newborns in their care, but surveys indicate that in practice only half or less of the required home visits have taken place. And the same way I can say for accountability of processes having been done at a health and wellness centre level. It doesn’t seem to be the way forward.
Team-based incentives also can be ineffective. Teams can also game the system. I am not against team-based incentives but they are not effective tools for integrating the staff into a team. The other barriers we talked of like designations, contractual status, multiple reporting authorities, rigid work allocations and above all the conceptual clarity on how primary healthcare achieves health outcomes must be independently worked on.
TS: I’ve been noticing a peculiar pathology in many of the states I’ve been visiting. I find that there is an increasing disconnect between “entering data into the portal” and the “services you provided to people” though one would assume that the former must reflect the latter. Incentives are explicitly linked to the former. For example, if one asks the question- have ASHAs communicated the importance of screening for cervical cancer, the answer may be that ASHAs have completed over 70 percent of the CBAC forms required and all the data is entered. Filling the CBAC form is no longer a tool of identifying persons at risk for screening, much less for health education- it is an autonomous activity that carries with a Rs 10 incentive per form and supervisors ensure its full achievement. Even more peculiar, there is an app for recording NCD services. If asked what is the achievement for say cervical cancer screening, they could report say that we have made an entry for 1200 women. But if we then ask- how many have you actually screened- they replied- “No, no, sir, that we are planning to do later”. The emphasis from above has been so focussed on “please ensure that you enter the data on the portal,” that it has lost the connect with “please ensure that you provide the services to the people”. Yes, this is bizarre. But data on portals is the only truth and field visits with feedback are passé !!!.
I don’t think anybody at any level intends this, and I would not know how widespread this is but this illustrates, at least at caricature, the problems in place. Providers increasingly see the maintenance of data in the portal and app as their main role, and since this relates to some disconnected fragment of care, one loses sight of the larger questions of patient centred care and health outcomes. The time they are spending on data recording and reporting is now disproportionately higher than the time spent in provision of healthcare.
HJ: So then how does one monitor the programme. Are you suggesting that the apps and the data portals are more harmful then helpful.
TS: My first suggestion is to reclaim the strength of field visits by supportive supervisors. Then during the field visits the supervisor reports on extent and quality of coverage for each of the 12 or more packages. Somewhat like what was happening in a Common Review Mission of the NHM, or the grand rounds of a hospital but more frequent, decentralized and system wide. This would require a well-integrated supervisory structure, instead of another stand-alone cadre. Data collection is essentially for supporting the provision of better quality and continuity of care, but as a collateral it would help in the monitoring visit.
This IT-based, name based granular data collection of every possible activity in every health encounter into centrally managed portals has become an obsession. I do not think we can get away from it. But we should at least acknowledge that this form of digitization is not helping in identifying or solving problems on the ground, or providing support. At best this whole process of digital monitoring is a “panopticon”-type surveillance system where you expect frontline workers to observe a normative behaviour merely because their actions are notionally being observed. Potentially we can reduce the data requirements of central monitoring to one or two portals and about 100 indicators (from nearly a 1000 now) and dispense with the rest. But that is the subject of another conversation.
While field visits for administrative priorities are important, what I am suggesting are “mentoring” visits that bring back this people-centeredness of care: better coordination, better continuity, close to community and comprehensiveness to the centre of consideration. This should go along with team building of the ASHAs and HWC staff into a team and of the district specialists, medical officers and HWC staff also into another team.
HJ: So talking about patient-centeredness, can we also talk more about the overall quality of care and how the current government mechanisms like the NQAS certification are working. NQAS certification is being rapidly scaled up to reach all 1.6 lakh HWCs. Is this helpful.
YJ: This clichéd phrase says it all: “we are hitting the target but missing the point.” You achieve the target and facilities get a certificate, but we do not know whether the care now provided is more effective, and whether it is provided with compassion, comfort and convenience, and safety of the service user and community in mind. Once again, a step in the process has become the goal and it has become disconnected with the objective.
TS: I agree with YJ. NQAS, though well-designed, is again getting bizarrely misinterpreted as it scales up- largely because assessors are ill equipped to understand the concept and spirt of total quality management. For example, in some states assessors ask to see 72 registers maintained for NQAS as a pre-condition for certification. Providers do not understand why and the list of registers have absurdities in it, but once again, they are responding helplessly to what they see as another set of whimsical requirements. NHSRC, the lead organizer of the programme, on the other hand officially clarifies that they need only 7 registers. It turns out that the assessors have mis-interpreted an NQAS guideline on document requirements to mean exclusive documents linked only to NQAS- instead of merely inspecting the documents already maintained and obtaining relevant information from staff interviews. This requirement for a dedicated set of documents is very much in line with every vertical programme demanding its own set of registers. And NQAS instead of ensuring quality in all existing programmes sets up NQAS certification as another parallel and pointless vertical.
But this is not to undermine the importance of quality or the need for standardized instruments to assess and measure. Many studies have shown that clinical correctness of healthcare provided could be so low that healthcare utilization no longer implies health outcomes. Addressing this means much better mentoring support for the team. NQAS implementation must be readjusted to capture these two elements -clinical effectiveness and patient-centred care as the priority- and the tools must serve the objectives rather than as ends in themselves.
HJ: There is very little discussion of these issues in the growing literature on HWCs and CPHC. There is however growing concern about the feasibility of the entire strategy. There is also considerable discussion on the lack of readiness of public services to make the transition to comprehensive care and therefore a new case made for a return to selective care albeit with a more expanded package. There is also a strong view that strategic purchasing from private sector, given the private sector’s strengths in innovation and outcome orientation could address many of these problems better.
TS: Indeed, there is a clear and present danger of reversal to selective health care – recent Lancet Commission Report on Global Strategy 2050, recommends a modified selective approach, and one of its premises is that the reasons for poor progress lie in “a general lack of realism about what UHC entails…. But as we have pointed our selective care is neither effective nor efficient, and further sequential introduction of various vertical targets have reached their limits.
A few brief words on public sector as the problem and purchasing from private sector as the solution. Primary health care, as discussed earlier is too much of a public good, for market based commercial private sector to get interested. An alternative approach proposed is of strategic purchasing from a bundling of primary, secondary and tertiary healthcare in what is called an “integrated health care network”. This is also a non-starter, but not for the lack of trying. No successful examples of this approach on scale exist. The broad understanding, which we do not have the space to discuss further here is that the critical limitation is not in the nature of ownership or financing, but in the conceptualization and the organization of care. While there is space to contract in not-for-profit providers in niche circumstances, on scale CPHC has to be based on public financing and public provisioning, an understanding that is central to the National Health Policy, 2017.
However, we need not lose hope with comprehensive primary health care approach, because of the many mis-steps pointed out. All said and done, it is only five years, of which two were Covid pandemic years, and we should rework this program and with the better infrastructure base now available to build back better. And we have to build health systems as learning-adaptive systems, systems that continuously learn from feedbacks and take corrective action. As the Thai saying goes- “health systems are leaking ships that have to be repaired when they are still sailing.” The good news is that there are many positive practices in states, and even within districts, as local teams come up with great solutions and these provide great opportunities to learn from. I would also encourage referring to the CPHC guidelines published by Meghalaya state as well as to the Positive Practices on developing Primary Care Oriented Health Systems- published by WHO-SEAR. We must also remember that one of the main reasons for the success of the NHM was its openness to criticism, learning and innovation.
HJ: I remember one of the program managers telling me that we have the risk of making CHO a liability rather than an asset, and it’s stuck with me because the district program managers do fear that. So, are these challenges teething issues, or are they more systemic?
YJ: I would say that we need to professionalise our health professionals. We are learning with the ASHAs. We offer career progression in the form of ASHA facilitator or entry into ANM training. I think career progression for CHOs also has to be thought of and done. One suggestion would be to even offer them a diploma course in family medicine, which some countries in the world have done. There could be also other ways of supporting them through individual as well as team mentoring and integrating them better. As of now, I feel that the entire health system is still ambivalent about this CHO, whether to reject or to assimilate and count them as an integral member of the team. I think it is in the best interest of the system that one should remove all this ambivalence and include the CHO as an integral member of the entire team. But the public health system itself has to evolve an understanding and develop this role.
And to conclude I too will reiterate, that with all its problems the AB-HWC centre is a big step forward. The 146,000 health sub-centres have transformed and we will never think of them the same way again. They have become much more alive and the mid-level health care providers have brought in much more enthusiasm and optimism and a willingness to provide services at the village level. It’s too early to celebrate achievement, but it certainly is a beginning in the right direction. And it would be such a huge lost opportunity if the ministry were to only focus its attention on the naming and the branding !!!
Further Reading
- National Health Policy (2017), Ministry of Health & Family Welfare, Government of India
- Ayushman Bharat – Comprehensive Primary Health Care through Health and Wellness Centers, Operational Guidelines (2018)
- Ayushman Bharat – Health and Wellness Centres, Assessment in 18 States, NHSRC (2022)
- Tripathi, N., Parhad, P., Garg, S., Biswal, S. S., Ramasamy, S., Panda, A., … & Keshri, V. R. (2024). Performance of health and wellness centre in providing primary care services in Chhattisgarh, India. BMC Primary Care, 25(1), 360.
- Das, J., Hammer, J., & Leonard, K. (2008). The quality of medical advice in low-income countries. Journal of Economic perspectives, 22(2), 93-114.
- Jamison, D. T., Summers, L. H., Chang, A. Y., Karlsson, O., Mao, W., Norheim, O. F., … & Yamey, G. (2024). Global health 2050: the path to halving premature death by mid-century. The Lancet, 404(10462), 1561-1614.
- Understanding Comprehensive Primary Health Care: The Meghalaya Way .
- Positive practices in developing primary health care-oriented health systems – A collection of case stories from the WHO South-East Asia Region.
- WHO, South-East Asia Regional Strategy for Primary Health Care: 2022-2030.
Editors Note: Though we have given a number of references, we note that many of our observations are based on field visits by Harsha Joshi, Yogesh Jain and T. Sundararaman, and of the peer reviewers to a modest number of HWCs across over nine states and discussions with field managers. We also acknowledge that Dr. T. Sundararaman and Dr. Rajani Ved, (then the ED, NHSRC) were chairperson and member-secretary respectively of the Task Force on Roll out of Comprehensive Primary Health Care whose Report is a basis for the formulation of this scheme. Yogesh Jain was one of the core leaders and organizers of the CPHC model organized by JSS which is referred to in the Task Force Report.
Acknowledgements: To Dr Shalini Singh and Dr Rajani Ved for their extensive peer review and edits and Ms Roubitha David for assistance in recording and transcription.
About the Participants:
Harsha Joshi is a public health practitioner working in the field of primary health care and health systems research in India. Currently, she is working as a program officer with the India Primary Healthcare Support Initiative (IPSI) project led by Johns Hopkins University- working in five states. She has previously worked with the National Health Systems Resource Centre (NHSRC), where she was involved in the early phases of design, implementation, and documentation of learnings from the Government’s flagship initiative of ‘Health and Wellness Centres’ for comprehensive primary health care. She has a keen interest in ‘Health policy and systems research’ and is a grantee of the India HPSR fellowship. Harsha holds an MPH degree from Tata Institute of Social Sciences, Mumbai, and has over seven years of work experience working with government and non-government organizations.
Very well articulated..indepth observation of the field setting and dynamism.. to have team with an accepted team leader is great concern.
all the dialogue should be put to the ears of those who need to hear.
Things will happen, if the public health scientists can emerge from their silence and say boldly what the government should do with the support of administrators who also need full orientation on public health implementation.