Health & Wellness Centres in AP

Health & Wellness Centres

Health & Wellness Centres are envisaged to provide a comprehensive set of 12 services:

1.     Comprehensive Maternal Health care services to be provided in those sites equipped to services as “delivery point”.

2.     Comprehensive neonatal and infant health care services.

3.     Comprehensive childhood and adolescent health care services

4.     Comprehensive contraceptive services.

5.     Comprehensive reproductive health services.

6.     Comprehensive management of communicable diseases.

7.     Screening and Comprehensive management of non communicable diseases.

8.     Basic ophthalmic care services

9.     Basic ENT care service

10.                     Screening and basic management of mental health ailments.

11.                     Basic dental healthcare.

12.                     Basic geriatric health care services.

Existing Staff pattern MPHA(F) +MPHA(M) HWC MLP :  Mid Level Provider (B.Sc. Nursing), to lead the Primary Health Care Team at Subcentre MPHA  (F) and (M)) and ASHAs

 Job responsibility of MLP : MLHP would be responsible for ---

Ø Implementation of National Health Programmes

Ø Administration and management at Health and Wellness Centers

Ø Provision of preventive, promotive and curative care

Ø Identification of danger signs and referral after pre-referral stabilization

Ø Ensuring quality protocols are adhered to— including implementation of Biomedical waste  disposal and Infection Control guidelines.

Ø Provision of on the job mentioning to health workers

Ø Ensuring maintenance of inventory of drugs, consumables, diagnostic and other equipment

Ø Ensuring maintenance of records, and undertaking monthly reviews of key indicators and  provide feedback to the team

Ø Participation in monthly outreach and community level meetings including engaging with  representatives of Local Government institutions/ VHSNC

Ø Any other job assigned by the Medical Officer of the PHC.

 

Institutionalizing Performance Linked Payments (PLP) for Mid- Level Health  Providers (MLHP) 

Background: The Operational Guidelines for Ayushman Bharat: Comprehensive Primary Health  Care through Health and Wellness Centres identify Performance Linked Payments as a strategy  to improve motivation levels, strengthen quality of services, enhance accountability for  population health outcomes and serve as a mechanism to identify performance and skill gaps,  at the Health and Wellness Centers at sub center level. The PLP are provided for the Mid-Level  Health Providers who will play a key role in enabling continuum of care. 

This guidance note is expected to enable the states to roll out Performance Linked Payments  for the primary care team at the HWC-SHC - A Mid-Level Health Provider (Team leader), in the  catchment population of the HWC-SHC. 

These payments are to be made on a monthly basis. Individual performance will be assessed on the basis of data obtained from existing information systems. However, states also have the flexibility to undertake independent monitoring, to validate the information systems. This  could be done through partnerships with research organizations, NGOs, State Health System  Resource Centres and medical colleges or through training the existing staff at district and block  level to undertake population- linked surveys to monitor progress on outcomes on a periodic  basis. 

The key features and suggested indicators to guide performance linked payment mechanism at HWC-SHC is explained below

1.     Level of Incentive Distribution: Sub-Centre-Health and Wellness Centres

2.     HWC-SHC - Mid-Level Health Provider as per the population of the HWC-service area. 

3.     Periodicity: Every Month

4.     Indicators for performance measurement and source of verification:The performance will  be assessed on indicators that will be amix of service utilization and coverage of  population for essential services. (Table 1). 

Key criteria for selection of indicators is that they cover essential activities related to the first  seven service packages of CPHC that have been rolled out. Thus, outpatient services for acute  simple illnesses, provision of ANC, Immunization, services, screening and management for NCDs  and TB, and management of Vector borne diseases have been included. In addition, other  public health and management functions of HWC-SHC teams such as community level meetings  for health promotion and prevention, and monthly meetings at HWC-SHCs have also been  included. 

The selected indicators are those that are reported in the RCH portal, CPHC-NCD Application,  and Nikshay. Monthly performance will be assessed on a set of 15 indicators. That have been  specified in Table 1. Additional indicators if required may be included by each State/UT linked  on their specific context.For example states having a high burden of vector borne diseases may include indicators pertaining to same. However, the total amount linked with performance  incentive for HWC would remain the same. (Refer Point 5)

 

The list of indicators will be updated periodically linked on the- experience gained from the  implementation of performance linked payments, progress on outcomes and roll out of new  service packages. 

5.     Distribution of Incentive Amount for each HWC- The monthly incentive could follow the  distribution listed below:

a.     The maximum amount of incentive for Rs 15,000/ MLHP/month as per the work  performance.

6.     Incentive Amount to be allocated for the indicators- For ease of implementation in the  early stages, all indicators are weighted equally, and the MLHP would receive Rs. 1000 per  indicator, up to a maximum of Rs. 15,000. 

7.     Service Delivery Output for incentive payment- The service delivery outputs as included in  Table 1 have been graded at two levels of achievement: 75% and 100% for 8 out 15  indicators. Performance linked payment that is to be disbursed for each indicator will  correspond the level of achievement.

 

8.     Illustration for Calculation of incentives-*

	Assessme nt  Indicator	Definition	Source  of  Verificat ion/  Reporti ng	Service  Delivery  Output to  receive 75% of  Incentive  Payment	Service Delivery  Output to  receive 100%  of Incentive  Payment	Maximum   incentive   allocation for  each   personnel (Rs)  at 75%   achievement	Maximum   incentive   allocation for  each   personnel   (Rs) at 100%  achievement
1	Number  of OPD  cases in  the  month	No. of  OPD cases  including  new and  old cases	NCD  applicati on	Min. 300  OP/Month	400  OP/month	MLHP=750	MLHP=1000

 

Based on standard assumption that there fifteen indicators and monthly incentive allocated 

 

9.     Key principles to assess performance: 

➢ Indicators for performance measurement of the primary care should be easily  verifiable. The selection of indicators is such that report for these indicators can be  verified from the existing information systems such as- RCH Portal/Registers, NCD  Application of the CPHC IT system, NIKSHAY, IDSP reports, meeting records submitted to  PHC Medical Officer. 

➢ Ensuring that data is fed accurately and regularly in the information system at each level  is a collective and individual responsibility of the HWC. 

 

10.            Process-

➢ The PHC Medical Officer under whose jurisdiction the HWC-SHC is assigned or (any  other suitable representative as decided by the state) will be responsible for assessing  the performance of the HWC-SHC . He/ She will-

a.     Ensure that MLHPs/MPWs are trained in using the CPHC IT system for online auto compilation and transmission of performance data for HWC-SHC team.  However, till the time such a system is in place, MLHPs will use the data entered in the respective information system to submit performance reports on service delivery outputs for the particular month in a standard format developed by the state.

b.     Ensure release of performance- linked incentives within one month of submission  of performance report by MLHPs. 

c.      Use the performance monitoring mechanism to identify the areas of  improvement for the primary care team at the HWC-SHCand provide the  necessary handholding and support to improving the performance and overall  service delivery at HWCs. 

d.     Undertake monthly visits to every HWC for field level monitoring visits and use  these visits to handhold and mentor HWC-SHC team. 

 

11.            Mode of Validation

a.     Local-PHC-MO will assess and validate the records submitted by MLHPs with the  reports from information systems- RCH Portal/Registers, NCD Application of the  CPHC IT system, NIKSHAY, IDSP reports, meeting records submitted for performance- linked payment. 

 

External- (i) Existing mechanisms of 104 Call Centre etc. can also be used to validate team  performance data reported by MLHPs. (ii) States can also opt to assess service use and  satisfaction by random surveys of service users through telephone surveys, (iii) States may also  opt for nominating an independent committee comprising of officials and civil society  representative to validate the quantity and quality of service delivered by HWCs. This  committee can evaluate the performance quarterly or bi annually to ensure that no conflict of  interest arise, during the process of performance- linked payment. 

12.            Ensuring timely payments 

Though external validation is essential to check fraudulent reporting; in any given circumstance monthly payment of incentives to MLHPs and frontline functionaries should not await call centre linked validations. 

13.            Possible Action for False reporting by MLHPs:

MLHP as team leader would be accountable for submitting performance reports of HWC-SHC team. He/she should be given one warning if an instance of false reporting of performance indicators is identified from the call-linked validation of performance reports. Any repeat of falsification could result in deducting the amount from their salaries, and a third instance could  lead to termination of service contracts of MLHPs if continuous false reporting is observed  despite warning.

Table 1 Suggestive List of Indicators to Assess Monthly Performance of HWC-SHC for Service  Utilization

		Assessment  Indicator			Definition	Source of  Verification/  Reporting		Service  Delivery  Output to  receive 75%  of Incentive  Payment		Service  Delivery  Output to  receive 100%  of Incentive  Payment
1		Number of OPD  cases in the month			No. of OPD cases  including new and  old cases	NCD  application		Min. 300  OP/Month		400  OP/month
2		Proportion of  estimated  pregnancies  registered			Numerator: Number  of pregnant women  registered for ANC Denominator – Total  no. of estimated  pregnancies	RCH Portal/  Sub Centre  register		60% of the  estimated  pregnancies  registered		80% of the  estimated  pregnancies  registered
3		Proportion of  Pregnant Women  registered who  received ANC			Numerator - No. of  pregnant women  who received ANC  services (as per  schedule) in a  month  Denominator - Total  no. of registered  pregnant women  whose ANC is due  that month	RCH portal/Sub  Centre RCH  register		80% of the  pregnant  women  received ANC  as per  schedule		100% of the  pregnant  women  received ANC  as per  schedule
4		Proportion of  Children up to 2  years of age who  received  immunization			Numerator - No. of  children who  received  immunization (as  per schedule) in a  month  Denominator - Total  no. of registered  children whose  immunization was  due that month	RCH portal/Sub  Centre RCH  register		90% of the  children  received  immunization  as per  schedule		100% of the  children  received  immunization  as per  schedule
5		Proportion of High risk pregnant  women who  received follow-up  care			Numerator - No. of  high-risk pregnant  women who  received follow up  care (as per  schedule) in a  month  Denominator - Total  no. of high- risk  pregnant women  identified	RCH portal/Sub  Centre RCH  register		100% of high-risk pregnant  women who received follow  up care
6		Proportion of  Newborns who  received HBNC  visits			Numerator - No.of  newborns who  received visits (as  per schedule) as per  HBNC schedule Denominator - Total  no.of newborns	RCH portal/Sub  Centre RCH  register		80% of  newborn  received  HBNC visits		100% of  newborn  received  HBNC visits
7.		Proportion of  above 30 years  individuals  screened for  Hypertension*			Numerator - No. of  individuals screened  for Hypertension Denominator-Total  population above 30  years of age	NCD  application		Cumulative monthly 8%  increment(SCREENING) of  above 30 individuals  screened for HTN and to be  repeated every year.
8.		Proportion of  above 30 years  individuals  screened for  Diabetes*			Numerator - No. of  individuals screened  for Diabetes  Denominator-Total  population above 30  years of age	NCD  application		Cumulative monthly 8%  increment (SCREENING)of  above 30 individuals  screened for Diabetes and to be repeated every year
9		Proportion of  Patient of HTN on  treatment			Numerator - No. of  HTN patients who  received follow up  care  Denominator - Total  no. of HTN/ patients	NCD  application		30% of  patients who  received  treatment			50% of  patients who  received treatment
10		Proportion of  Patient of DM on  treatment	Numerator - No. of  DM patients who  received follow up  care Denominator - Total  no. of DM/ patients		NCD  application	30% of  patients who  received  treatment		50% of  patients who  received  treatment
11		Proportion of cases  referred for TB  screening	Numerator-Number  of suspected TB  cases referred for  diagnosis/  Denominator Total number of  patients attended in  OPD		Nikshay/HWC  records	Minimum 3% cases identified from OPD should have  referred for screening of TB
12		Notified TB  patients who  received treatment  as per protocols	Numerator - No.of  TB patients who are  on regular  treatment as per  protocol  Denominator - Total  no.of TB patients		Nikshay/TB  treatment card	100% of patients on  treatment
13		VHND held against  planned	Numerator - No.of  VHND attended  Denominator - Total  no.of VHND held		Self- reported  in CPHC NCDapplication	MLHP should monitor at  least two VHNDs in a month  for performance- linked  incentive
14		Village meetings  (VHSNCs)/MASheld	Numerator - No.of  VHSNC / Village  meetings attended  as per plan Denominator - Total  no.of VHSNC/  Village meetings  held			MLHP should monitor at  least two VHNSC meeting in a  month for performance linked incentive
15		Monthly meetings  held at SHC- HWCs	Organized monthly  meeting with  Primary Care Team at Sub centers HWCs  to monitor the  following 1. Review of work  plan for current  month. 2. Updating work  plan for the next  month.  3. At least one  technical session  held for capacity  building of the  primary health care  team.			One meeting held at the SHC HWC and should be attended  by MPWs and all ASHAs

Bridge Course undergone by the MLHP

• 6 month course — by IGNOU

• Course Outline —

• Theory classes and hands-on Practicum training at Programme Study Centers and Health  Centers (District Hospitals, CHCs, PHCs, Sub-centers, etc.) identified and accredited IGNOU. • In addition, community visits would also be conducted for field- based assignments and  research projects.

 

Site	Activities
District Hospital & CHC	Case management, Understand  Functionality, HR pattern, lab services,  records & reports, M&E, etc.
Orientation visit to Primary Health Centre	Case management of general medical  conditions, ambulatory, Infrastructure &  equipement, functioning of PHCs
Orientation Community visit to Sub  Centers and Community	Antenatal, postnatal, camps, management  & referrals, Health education, observe  VHNDs and functions of ASHA in field.
Visit to DPMU, BPMU, PRIs, centers where  the programs are being implemented	Understanding the system of Health  planning & Management: Village Health  Action Plan – Role of PRIs, VHSNCs,  Observation of activities undertaken under  the National Health & Family Welfare  programs

 

 

Mid level health providers are posted in the sub centers in the initial phase.

All the sub centers except headquarters sub centers will be converted into e-sub centers by March 2019.

The PHC Medical Officer is overall incharge of MLHP and MLHP should report to Medical Officer for any queries.