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Primary Health Care Centres: Generating Better Health Outcomes

The National Health Policy has recommended strengthening Primary Health Care delivery by establishing Primary Health Care Centresas the platform to deliver Comprehensive Primary Health Care. The Indian Government has announced that 1, 50,000 Health and Wellness Centres would be created by transforming existing Sub Health Centres and Primary Health Care Centres to deliver Comprehensive Primary Health Care and declared them as the two components of Ayushman Bharat. It was the first step in the conversion of policy articulations to a budgetary commitment of two-thirds of the health budget to primary health care.

The Report of Primary Health Care Task Force, Ministry of Health and Family Welfare, Government of India, while reiterating that primary health care is an affordable and effective path for India to Universal Health Coverage provided valuable insights into structure and processes which are required in health systems to enable Comprehensive Primary Health Care Centres.

Expanded Range of Services of Primary Health Care Centres

  • Primary Health Care Centres for pregnancy and childbirth services
  • Neonatal and infant health care services
  • Childhood and adolescent health care services
  • Contraceptive services, Family planning, and other Reproductive Health Care services
  • Management of Communicable diseases includes National Health Programmes.
  • Management of Common Communicable Diseases and Outpatient care for acute simple illnesses and minor ailments
  • Prevention, Screening, Control, and Management of Non-Communicable diseases
  • Care for Common Ophthalmic and ENT problems.
  • Basic Oral health care
  • Elderly and Palliative health care services
  • Emergency Medical Services
  • Screening & Basic management of Mental health ailments

Inputs of the Health and Wellness Centre

The following are the inputs of the Health and Wellness Centre:

Inputs of the Health and Wellness Centre

Primary Health Care Team to Deliver Services

At the upgraded SHC– A team must have at least three service providers (one Mid-level provider, at least two (preferably three) Multi-Purpose Workers – two female and one male, as well as a team member from the ASHA group.

At the strengthened PHC– PHC team as per IPHS standards. Although all the PHCs have been expected to provide 24*7 nursing care, this has not been possible in several states for various reasons. In 24*7 PHCs having inpatient care, an additional nurse should be posted where cervical cancer screening is being undertaken/ planned. In PHCs which are not envisaged to provide inpatient care, the existing nurses must receive modular training in certificate courses for primary care.

Logistics

There has to be adequate availability of essential medicines and diagnostics to support the expanded range of services to resolve more and refer less at the local levels and to enable dispensation of medicines for chronic illnesses as close to communities as possible.

Infrastructure

There must be sufficient space for outpatient care, for dispensing medicines, diagnostic services, adequate spaces for the display of communication material of health messages, including audiovisual aids, and appropriate community spaces for wellness activities, including the practice of Yoga and physical exercises.

Digitalization

Health and Wellness Centres team should be equipped with tablets/smart Phones to serve a range of functions such as population enumeration and empanelment, record delivery of services, enable quality to follow up, facilitate referral/continuity of care and create an updated individual, family, and population health profile, and generate reports required for monitoring at higher levels.

Use of Tele-medicine/IT Platforms

In pandemic times, teleconsultation would be used to improve for referral advice, seek clarifications, and undertake virtual training, including case management support by specialists.

Capacity Building

Mid Level Health Providers must get trained in a set of primary health care Centres and public health competencies through an accredited training program that combines theory and practicum with on the job training. Other service providers at the Health and Wellness Centres must also be trained appropriately to deliver the expanded range of services.

Health Promotion

Development of health promotion material facilitation behavior by engaging of community-level collectives such as Village Health Sanitation and Nutrition Committee (VHSNCs), Mahila Arogya Samiti (MAS), and Self-Help Groups (SHGs), and creating health ambassadors in schools. Enabling behavior change communication to address lifestyle-related risk factors and undertaking collective action for reducing risk exposure, improved care-seeking, and effective utilization of services of Primary Health Care Centres.

Community Mobilization

For action on social and environmental determinants would require intersectional convergence and build on the accountability initiatives under National Health Mission (NHM) so that there is no denial of health care and universality and equity are respected.

Linkages with Mobile Medical Units

Linkages with Mobile Medical Units (MMU) could improve access and coverage in remote and underserved areas where there is difficulty establishing Health and Wellness Centres. In such cases, medicines and other support could be provided to frontline workers, with periodic MMU visits. MMUs could also be linked to nearby HWCs, where medical consultations could be arranged on scheduled days for those unable to travel to referral sites. MMUs can be designed to meet the specific needs in that locality as a supplement to the HWC network. The visit calendar of the MMUs would need to be planned and displayed at Health and Wellness Centres.

Essential Outputs of Health and Wellness Centres

The following are the outputs of Health and Wellness Centres:

The Health and Wellness Centres Database

Population enumeration and empanelment imply creating & maintaining a database of all families and individuals in an area served by the Health and Wellness Centres. It is planned such that every individual is empanelled to an HWC. It also involves active communication to make residents aware of the facility.

Health Cards and Family Health Folders

It is made for all service users to provide access to all health care entitlements and enable a continuum of care. The health cards are given to families and individuals. The record of family health folders is kept at the Health and Wellness Care in paper or in digital format. It ensures that every family knows their entitlement to health care through both HWC and the Pradhan Mantri Jan Arogya Yojana or equivalent health schemes of state and central government.

Increased Access to Services

Health and Wellness Care would provide access to an expanded range of services. The availability of services will evolve in different states gradually, depending on three factors- the availability of suitably skilled human resources at the HWC, the capacity at the district/sub-district level to support the Health and Wellness Care, and the ability of the state to ensure uninterrupted supply of medicines and diagnostics at the level of HWC. States will also have the flexibility to expand the range of services to address local health problems as defined by disease prevalence.

What are Hindrise Goals for Primary Health Care?

Our NGO for healthcare in India, Hindrise Social Welfare Organization, is lending the highest level of healthcare support to less privileged men and women all over India’s remotest regions. We already have initiated many programs related to healthcare in rural and undeveloped areas of the country.

Improved Population Coverage

Active empanelment and database will improve the population coverage. The HWC database can enable HWC staff to monitor and identify the left out population and improve national health programs coverage.

Awareness about Catastrophic Health Expenditure

Improved access to the expanded services closer to the community, assured availability of medicines & diagnostic services, and linkages for care coordination with Medical Officers across levels of care would reduce the community’s financial hardships.

Risk Factor Mitigation

Health promotion efforts by the primary health care team would support in addressing the risk factors for diseases.

Decongestion of Secondary and Tertiary Health Facilities

A strong network of HWCs at the sub-district level would facilitate resolving more cases at the primary level and reduce overcrowding at secondary and tertiary facilities for follow-up cases as well as serve a gate keeping function to higher-level facilities.

Improved Population Health Outcomes

Improved availability, access, and utilization will contribute to equitable health outcomes measured through periodic population-based surveys for key indicators listed.

Increased Responsiveness

Provision of the primary care team will be based on principles of family-led care including dignity and respect for individuals and communities with particular focus on marginalized, information sharing, encouraging participation, including an intersectional collaboration that will lead to increased trust-building, comfort in access to care and enable addressing social and environmental determinants.

Infrastructure for Health and Wellness Centres

  • Ensuring adequate infrastructure for the delivery of Comprehensive Primary Health Care and Health and Wellness Centres would need to cater to population size as per IPHS norms for Sub Health Centres- one per 5000 population in all areas and one per 3000 in tribal, hilly, and desert areas. Where currently sub-centres and Primary Health Care Centres are catering to a much larger population, their numbers need to be increased.
  • Planning for infrastructure upgrade succeeds the finalization of the number and type of facilities designated as Primary Health Care Centres. Most states have completed the development of infrastructure for PHCs/Additional PHCs, UPHC, but there will be a need to undertake minor civil repair and infrastructure upgrade for existing buildings for meeting necessary gaps in enabling these centers to deliver patient-friendly services.
  • Patient reception and registration centers, citizen charters, electronic display boards for services, provision of a sitting arrangement of patients, other amenities in the waiting area, TV screens for health communication, facilities for people with disabilities, provision of privacy for patient examination area/ examination table, good quality lab, pharmacy, a wellness room for conducting physiotherapy/ Yoga sessions, rehabilitative services, separate toilets for males and females, etc. may be included in infrastructure upgrade.

Primary Health care Centres- Infrastructure Facilities

  • The concerned Block Medical Officer and a representative from the Engineering wing at the district level will do a joint site inspection and complete gap analysis for repair/renovation in existing buildings. The analysis should be based on the essential requirements stated above and will support in estimating necessary financial resources.
  • When new construction is being planned, the location of HWCs should be decided through a consultative process involving the community, gram panchayat members, community forest rights committees, frontline health functionaries, Block Medical Officers, and others. Construction of new buildings should preferably be undertaken in a central location with high population density and not in the villages’ peripheral sites. Acquiring land for this purpose would be a priority for the district.
  • To save time and optimize resources, identification of government buildings available with other departments could be prioritized for operationalization HWCs after necessary renovation.
  • Old, dilapidated buildings should be considered for renovation only after careful review of resources required. Wherever existing sub-centers are in a dilapidated condition, it will be more cost-effective to plan for a new HWC.
  • Private buildings could be taken on rent, maybe as an interim measure. However, the buildings identified should adhere to the specified infrastructure norms for strengthening a sub-health centre to serve as a Health and Wellness Centres as much as possible.

Essential Requirements to Strengthen an SHC to Serve as a Health and Wellness Centres

Major civil infrastructure upgrade would largely be required for developing the Sub Health Centres as Health and Wellness Centre or Primary Health Care Centres are:

  • A well-ventilated clinic room with examination space and office space for Mid-Level Health Provider/Community Health Officer.
  • Storage space for storing medicines, equipment, documents, health cards, and registers
  • Designated space for lab/diagnostic
  • Separate male and female toilets.
  • Deep burial pit for BioMedical Waste Management
  • Proper system for drainage
  • Assured water supply that can be drawn and stored locally
  • Electricity supply linked to main lines or adequate solar source, inverter or back-up generator as appropriate
  • Patient waiting area covered to accommodate at least 20-25 chairs.
  • Repairs of roofs and walls, plastering, painting, and tiling of floors to be undertaken as per requirement
  • Space/room for Yoga if adequate space for expansion is available
  • Adequate residential facilities for the service providers
  • Rainwater harvesting facilities may be planned if required.

Conclusion

There is global evidence that Primary Health Care Centres are critical to improving health outcomes. It has an important role in the primary and secondary prevention of several disease conditions, including non-communicable diseases. Comprehensive Primary Health Care Centres provision reduces morbidity and mortality at much lower costs and significantly reduces the need for secondary and tertiary care.

For primary health care Centres to be comprehensive, it needs to span preventive, curative, rehabilitative, and palliative care aspects. Primary Health Care Centres goes beyond first contact care. It is expected to mediate two-way referral support to higher-level facilities (from first level care provider through specialist care and back) and ensure follow up support for individual and population health interventions.