Comprehensive Primary Health Care in Assam J. V. N. Subramanyam, IAS Mission Director National Health Mission, Assam Department of Health & Family Welfare 11th December 2017

Assam : Overview Total Population 3,12,05,576 (Census, 2011) Projected Population (2017-18) 3,46,01,064 Geographical Area 78,438 (sq. km) Sex Ratio 958 (per 1000 male) Rural Population 2,68,07,034 (85.90%) (Census 2011) Urban Population 43,98,542 (14.10%) Districts 33 (Health-27) No. of Villages 26,395 Goalpara Dhuburi Bongaigaon Kamrup Dispur Sonitpur Dhemaji Dima Hassao Lakhimpur Tinsukia Dibrugarh Sivasagar Jorhat Golaghat Karbi Anglong East Hailakandi Karimganj Nagaon Cachar Darrang Nalbari Kokrajhar Marigaon West Barpeta Charaideo Majuli Biswanath Hojai Udalguri Baksa Chirang South Salmara-Mankachar Guwahati

Assam : Healthcare Scenario Healthcare indicators and Investments High Reliance On Public Sector Indicators Assam India Average inpatient medical expenditure Rs. 14,810 Rs. 18,268 Distribution of hospitalization cases - Rural Public Facility 89.2% 41.9% Private Facility 10.8% 58.1% - Urban 51.5% 32.0% 48.5% 68.0% Birth Rate (per 1000 persons) – 21.7 (SRS 2016) Death Rate (per 1000 persons) – 6.7 (SRS 2016) Infant Mortality Rate (per 1000 live births) – 44 (SRS 2016) Maternal Mortality Ratio (per 1,00,000 live births) – 300 (SRS, 2011-13) Total Hospital Beds Available – 18,108 Population/Govt. Bed – 1910 Healthcare spending is 5.45 % of total state expenditure Key Insights Very High (~90% patients) reliance of rural population on public hospitals for all types of treatments – resulting high patient loads. Affordability and availability of private healthcare facilities in rural areas is limited– for both diagnosis and treatment. High Commitment for health systems strengthening. Average expenditure incurred on drugs and/ or diagnostics in public facilities per PW is Rs. 1,312/- (Source: MCTFC)

Reliance on Public Sector Health Care Out Patient In Patient Key Insights There is a increase of 11,79,319 (6%) increase in OPD in the State in the year 2017-18 compared to 2016-17 for the period from April to October. There is a increase of 78,936 (11%) increase in IPD in the State in the year 2017-18 compared to 2016-17 for the period from April to October. 45% of OPD in primary Sector/ 73% OPD and ID upto secondary level

The Challenge Assam has highest MMR Upper Assam has MMR of 404 Nagaon Darrang Morigaon Sonitpur Lakhimpur Kokrajhar Dhubri Nalbari Bongaigaon Barpeta Kamrup Rural Goalpara Hailakandi Dima Hasao Cachar Karimganj Karbi Anglong Chirang Baksa Udalguri Kamrup metropolitan Tinsukia Dibrugarh Sivasagar Jorhat Golaghat Dhemaji 404 281 254 251 Assam has highest MMR Upper Assam has MMR of 404 Upper Assam also happens to be the tea intense districts higher maternal mortality higher infection rates higher prevalence of hypertension less health seeking behaviour higher unmet needs and therefore higher rates of abortion. 190 point AHS 2012-13 134 point Within the country there are other states which are much better off with maternal health situation and these states have almost same health system and budget provisions. MMR – 300 / 100000 LB (SRS 2011-13) which translates to estimated 2100 maternal deaths per annum, i.e. 175 deaths per month; i.e. 6 deaths per day; Upper Assam districts which are also tea intense areas have higher maternal mortality, higher infection rates, less health seeking behaviour, higher prevalence of hypertension, higher unmet needs and therefore higher rates of abortion. 2000+ mothers die annually from causes related to pregnancy and delivery (Assam contributes to only 2.5% of India’s population but a whopping 5% of maternal deaths in India)

Deep Dive: Our Diverse Demography:: Difficulty Topography Tea Garden Areas Char Areas Around 20% of population. Poor health outcomes. High MMR. Inadequate numbers of Doctors, Nurses and Paramedics Around 10% of population. Healthcare remains a critical challenge. Inadequate numbers of Health Infrastructure, Doctors, Nurses and Paramedics. Hilly Areas Border Areas Two Hill Districts:Karbi Anglong and Dima Hasao Accessibility an issue with population density is very low. Manpower availability is a huge issue. Low coverage of health care services in bordering areas adjacent to Bhutan, Bangladesh, Nagaland, Tripura, Arunachal Pradesh etc.

Universal Primary Health Care In Assam Accessibility: Coverage of Population Accountability: Content of Services Affordability: Financial Risk Protection

National Health Policy, 2017 envisages attainment of highest possible level of health and well being for all at all ages ,through a comprehensive preventive and promotive health care orientation in all developmental policies, (Content) and universal access to good quality health care services (Context) without anyone having to face financial hardship as a consequences (Comfort)

The 3 C’s of Comprehensive Primary Heath Care in Assam Context Content Comfort Saturated Sub Centers Including Riverine PHC Community Health Officers (CHO) as MLP Mobile Medical Units (MMU) 150 PPP Tea gardens Boat Clinics Sanjeevani (VHOP) Preventive, Promotive and Curative CHO as MLP delivering basket of services NCD Screening MMU Services Boat Clinic Services Health Systems Approach-RNTCP/NLEP Free Drugs with almost 200% increase in drug budget Free Diagnostics with Universal coverage Atal Amrit Yojana/ AAN/Susrusha CHD programme-5000 Surgeries Mission Smile

CONTEXT: CONTENT

Tea Garden MMU- 320 Tea gardens reached Line 1 Line 2 Line 3 Advance schedule fixed day fixed time services – Mobile Hospital for 5 days. If required, 108/102 ambulances shall be utilized for referral for higher treatment. MMU will move to each line of the Tea garden and organize camps.

Assam: Mobile Medical Units (MMUs) (HWC on Wheels) Providing Last Mile Connectivity Complete package Of Services in MMU Hitherto Un Covered Areas for last 70 years-760 Gardens To provide comprehensive primary health care services along with diagnostics facilities – MO+ Tea Garden areas -80 MMU Non tea garden areas- 50 MMU Average 50-60 OPD close in the labour lines of TG checking High anemia and TB too. Performance up to Nov 2017 Number of camps held = 3,924 Number of Patients = 2,83,378 Advance Fixed Day Schedules in the specified tea Gardens/ HTR Villages. The MMU team conducts health check up and updates the record in the Family Health Card. Community mobilization done to ensure service provision and utilization through existing ASHA/ANM/DME, DCM, BCM, and other health officials Package: MCH+ Communicable disease + NCD services Lab and diagnostics Services provided Patients suffering from Communicable and Non Communicable diseases are being linked with the existing National Disease Control programmes. (STS/STLS of RNTCP) Referral Linkages with help Desk at Secondary/Teritary Centers

Assam: Boat Clinic (Floating HWC) Reaching the Riverine Pockets Package of Services To provide health services to the communities residing in the remote river islands (Char/Chaporis) Boat Clinic Services started in 2008 15 Boat Clinics functioning in 13 Districts 4-5 days on the river continuously moving from one island to another 2 MO , 2 GNM/ANM, 1 LT, 1 Pharmacist , 1 Crew master and Assistant Health Camps : Avg. 18 camps per month General Health Check up Laboratory Services Routine Immunization Ante natal check up/ Post natal check up Vitamin A Supplementation OCP distribution/Condom distribution IUCD – Counselling/Laparoscopic sterilization – Counselling Awareness campaigns

Assam: Boat Clinic (To reach the unreached) Year wise camps in Boat Clinic Year wise patients treated in Boat Clinic

Sanjeevani – Village Health Outreach Programme Sanjeevani –Fixed Day Outreach services Package of Services provided by Sanjeevani Outreach screening services for Promotive care along with NCDs Diabetes, Hypertension, Epilepsy, Asthma, testing for DCP-Tuberculosis & Malaria 80 Sanjeevani units are providing services at the doorstep of 62 lakhs population. Each MHU- manned by ANM, Laboratory technician, Pharmacist, Paramedic, Registration & Measurement Officer and Driver. Basic diagnostic equipment (HB meters, Gluco-meters, Manometers, Digital BP, random blood sugar, Urine albumin, HB etc. and free medicines. Screening of communicable, non-communicable and life style diseases through laboratory investigation Providing treatment of chronic and minor ailment on the service points Continuous counseling and social mobilization Behavior change communication activities. Outcome (From 2011-12 to November 2017): Number of patients visited = 1.05 Crores Hypertensive cases screened = 6,45,845 Diabetic cases screened = 15,17,158

Community Health Officer (CHO) : A step ahead to reach the unreached Background of Community Health Officers (CHOs) Job Responsibilities of Community Health Officers Curative Care – regular OPD, treatment of communicable & non communicable diseases Maternal Health Services – ANC, Delivery & PNC Child Health Services - Manage cases of Asphyxia, Prevent Hypothermia and infection, promotion of breastfeeding etc Family Planning Services – awareness generation RNTCP ( to detect symptoms of TB cases) NLEP ( to identify suspected case of Leprosy ) NIDDCP ( to promote intake of Iodized salt during OPD hours ) NPCB ( to identify children with refractive error and referred to PHC) To handle shortage of Doctors in hilly, riverine, bordering and tea garden areas State enacted the Assam Rural Health Regulatory Authority (ARHRA) Act, in 2004 to provide a 3.5 yr diploma in Rural Health Care and Medicine (DMRHC). IMA Challenged and Government of Assam has again notified The Assam Community Health Professionals’ (Registration and Competency) Act, 2015 on 29th May 2015 declaring CHO as B.Sc Community Health professional Team: MPW (M and F) and ASHAs The legislation notified (a) services/ procedures to be provided by the CHOs, (b) Illness to be treated and © medicines to be prescribed.

Community Health Officer (CHO) : A step ahead to reach the unreached Year wise Trend of OPD Year wise Deliveries conducted by CHOs Key Insights At present 562 CHOs (+129 to be added) are working under NHM mainly in High Priority Districts and difficult areas. They helped increased case load of Institutional Deliveries. It changed the community’s perceptions towards sub centre. State proposed to implement Health & Wellness Centres through CHOs.

To Strengthen the CHO Sub Centres as First Post of Call New Service Delivery Requirement 691 CHO SCs will be strengthened to HWCs in the current FY. Training Module to re-orient all 680+CHOs under process List of Equipments and Consumables – is being prepared after gap analysis Drugs – 1 month availability is being ensured Monitoring tool – Key Performance Indicators Reporting Formats – Comprehensive reporting format developed for HWC 12 Services

COMFORT

Financial Risk Protection: Reducing OOPE National Free Drugs Services Free Diagnostic Services Free Diagnostics Services: CT-Scan services X-Ray Services- CR Laboratory Services- Hub and Spoke “Universal coverage” to all population visiting public facility. Outcome – Number of patients received benefit (up to 9th December 2017): CT-Scan = 53,611 X-Ray = 2,08,634 Laboratory Services = 1,03,056 Essential Drugs List (EDL) has been revised by Govt. of Assam - Number of free drugs has been increased from 238 to 407 (Total 731 as per dosage form/strength /packing). 95% availability in all facilities. 1 month stock of NCD drugs upto SC/ H&WC level. Assam Medical Services Corporation Limited (AMSCL) established for single window procurement. Drugs Stock availability is uploaded on weekly basis for public viewing of drugs in the NHM website as well as monitoring of stock position.

Financial Risk Protection: Providing Solace Atal Amrit Abhiyan (AAA) Sneha Sparsha For children below 14 years of age (for families with annual income less than Rs. 2.50 Lakh) State Govt. bears expenditure of very high-end specialized treatment of 10 earmarked diseases such as Bone Marrow Transplant, Cochlear Implant, Liver Transplant, Kidney Transplant, Artificial Limbs, Blood Cancer, Specialized Eye Surgery, Tumors, Neurological Anomalies & Thalassemia. The scheme started in 2013-14 “Atal Amrit Abhiyan” - a pioneering State wide Health Assurance Scheme - launched on 25th December 2016. Covers 6 (six) life threatening diseases (Cardiovascular diseases, Cancer , Kidney diseases, Neo natal diseases, Neurological conditions, and Burns) First individual floater scheme - Financial benefits upto Rs 2 Lakhs per individual per annum. Smart card based cashless service in all enrolled private and public hospitals Outcome 85,86,855 beneficiaries enrolled including minors under the scheme till 30th November 2017 9337 beneficiaries already received benefit Rs 143 Crores Budgeted in first 1 year Outcome 316 children received benefit till date

Mission Smile: Bringing Smiles to millions Free Surgeries For Cleft lip and Palate- SATURATING STATE OF ART GCCC aimed at providing comprehensive cleft care- NOT JUST SURGERY Guwahati “Comprehensive” Cleft Care Centre- a state of the art Centre set up to work towards a ‘Cleft Free Assam’ Free Surgeries are conducted for children having cleft lip and cleft palate . Services provided: Surgeries Speech therapy consultations ENT consultation Dental consultation and treatment. Cleft Nutrition Programme: Total 17,403 children received free operation since 2008-09 till October 2017.

CHD Programme : 5000 lives saved Lives Saved under CHD Free Operations For Children Having Congenital Heart Disease Started in 2010 Free operations for children having congential heart disease ( Increased Learning outcomes) Each Child may undergo more than one operation State Government bears “all” medical expenses, to and fro fare for the patient and a guardian, and other expenses during treatment for the patient (OOPE) Free operation conducted for 4,811 (200+ screened for operation recently) children having Congenital Heart Disease conducted at Narayana Hrudayalaya, Bangaluru and Kolkata.

Way Forward For CPHC MANY Silos of activity pools  Health Systems approach??--> Facility and Patient Centric Care instead Primary health care needs to play the “Gate keeper coupled with Public Trust” Electronic Health Records Family Health Cards More Money is available when other departments properly converge.. Ex: MSDP building SCs, SC electrification HR Multi Skilling in primary health care holds the key Lab Strengthening-RNTCP/IDSP/NCD Curative to Preventive /Promotive Approach

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