Making Health & Wellness Centres of India Work
HWCs aim to build upon what has been started under NRHM/ National Health Mission (NHM). However, considering even in the past, the similar attempt to strengthen PHC services have met partial success, more is needed to ensure that AB-HWCs does better than the initiatives in the past. Therefore, it will be important that learnings from past are used and challenges identified, and focused attention is given to effective scale up. A few approaches could be as follows:
First, give sufficient attention, visibility and priority to AB-HWCs as vehicle to strengthen primary health care services. Of the two components in ABP, the HWCs seem to be getting comparatively less attention, in spite of being recognized that cPHC can take care of up to 80% of health needs [30, 38, 39]. AB-HWCs is also a more difficult component to implement than insurance-based AB-PMJAY. Getting less public and political attention may appear a minor issue but may result in lower prioritization. There is a need to bring attention back on AB-HWCs and make these politically visible through advocacy and evidence. There is role for technical experts, professional associations and civil society representatives in ensuring that cPHC is not lost in the noise for more secondary and tertiary care services. People also need to demand for better primary healthcare services from their elective representatives.
Second, develop a detailed ‘primary health care investment plan’ for India and Indian states. The policy announcements are often equated with political will. The real test of the ‘political will’ is whether policy announcements have been followed by commensurate, sufficient & sustained financial allocation. In 2015–16, around 45% of total government spending on health was allocated to PHC services [40]. Though National Health Policy (NHP) 2017 has proposed to increase government funding for PHC and health services, the reality is that government funding for health in India has increased only marginally in last two decades. Similarly, the state government spending on health, proposed to be increased to 8% of state budget has remained at 5% of state budget since 2001–02 and increased very marginally [41]. There is a need for more and active public attention and prioritization to increase govt funding for health in India and Indian states. The initial allocation to AB-HWCs in union budget while may be sufficient in the beginning; however, with each passing year the recurrent expenditure for each HWC would be needed. This requires a detailed ‘primary healthcare investment plan’, preceded by, a detailed cost analysis for PHC services in India. In addition, there is a need for capital expenditure for setting up additional GPHCFs to address the shortage of facilities and meeting the health care needs of growing population, especially in urban areas [42].
Third, the service availability through AB-HWCs need to be continuously upgraded and made locally adapted to meet 80% or more health needs. In most of the HWCs set up till now, one additional package of services [the seventh package of non-communicable diseases (NCDs)] has been included. However, 5 more packages need to be added and assured. In efforts to achieve the number-based targets for AB-HWCs, for every financial year, focus should not be lost from already established HWCs. The provision of services through these facilities, the utilization by public, assured availability of providers and functioning as per guidelines need to be ensured through continuous oversight, monitoring and innovations. Another approach could be that all the eligible GPHCFs in single geographical area, a block or tehsil, need to be made functional simultaneously to increase utilization and change the perception about government facilities.
Fourth, focus on demand generation for health services through mechanisms such as community participation and social accountability. Getting the facilities functional or strengthening supply side through HWCs (or other similar state specific initiatives) is important; however, it is unlikely to generate utilization; specifically when the previous encounter of people with these facilities has not been pleasant. Simply an upgrade of government health facility might not be enough. People need to come to the health system and experience the change, which will contribute to further demand genration. The supply side strengthening through PHC needs to be augmented by demand generation. This can be achieved with increased and active community involvement; accountability and involving local body representatives and civil society organizations in the process, from the very early stage. In backdrop of recent policy dialogues and approaches adopted for Swachh Bharat Mission (clean Indian mission) and the approach to behavioral economics of nudge need to be examined for suitable adoption in health sector [43–45].
Fifth, the entire process should be guided by use of evidence to scale up interventions and services. A recently published study reported a few common characteristics of better functioning government facilities in India, which included (a) an assured package health services with ‘limited intention to availability gap’; (b) Appropriate mix & sufficient availability of providers; (c) continuum of care with functional referral linkages; (d) initiatives to achieve quality standard; & (e) community engagement [46]. There is similar evidence from countries such as Brazil; Ghana and South Africa [47–49]. Mohalla Clinics of Delhi and Basthi Dawakhana of Telangana, are empirical evidence that people start attending the government facilities if the facilities are made functional and the services are available in an assured manner, people prefer PHC over complicated and overpowering large hospitals. These initiatives have become popular amongst people and brought poor, marginalized, women and children to government health care system [50–52].
Sixth, ‘continuum of care’ through coordination between two arms of ABP will contribute to effective utilization. Establishing a functioning referral linkage between HWCs/PHCs and from secondary and tertiary care services including AB-PMJAY should be focus for policy design and implementation. A good coordination between AB-PMJAY and AB-HWCs is not only imperative for streamlining access to care but will be pivotal in providing timely and quality care to the target beneficiaries. A few indicative approaches for ‘continuity of care’ could be: one, common process for registration of patients at AB-HWCs as well as for AB-PMJAY, through common health identifier with community linkage and registration; two, awareness generation for beneficiaries at grassroot level. Three, the training curriculum of Accredited Social Health Activist (ASHA) and other field workers should include a module on AB-HWCs and services and provisions under AB-PMJAY. For a forward referral, AB-HWC can become source of information for AB-PMJAY beneficiaries; fourth, develop effective and two-way referral and inclusion of some outpatient components in AB-PMJAY benefit package and fifth, AB-PMJAY and AB-HWCs to analyse disease and population health risks and trends. The service delivery approach should be beyond referral and the PHC systems need to facilitate the care seeking by proactively seeking appointments for patient going to next level of facilities. Once the treatment plan is prepared at next level of facility, the referral back to PHC level should also be ensured for continuity of treatment and required follow up. This could prove extremely essential and important in context of NCD (including diabetes, hypertension) services.
Seventh, AB-HWCs also need to have dedicated focus on population-based and public health services. It is not a PHC service, if focus is on curative services at facility level only. A well-functioning PHC system needs to cater to those who are not attending the health facilities. People in communities with undiagnosed health conditions need to be identified and brought to treatment, is also part of PHC services. Establishing All India Public Health management Cadre could be one complementary step [3, 53].
A few more suggestions on how to make AB-HWCs more effective and better functional are provided in articles published earlier [1, 30, 45, 46].