1. 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

2. Assam : Overview Total Population 3,12,05,576 (Census, 2011)
Projected Population
( )
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

3. 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) – (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, )
Total Hospital Beds Available – 18,108
Population/Govt. Bed – 1910
Healthcare spending is % 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)

4. 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 compared to for the period from April to October.
There is a increase of 78,936 (11%) increase in IPD in the State in the year compared to for the period from April to October.
45% of OPD in primary Sector/ 73% OPD and ID upto secondary level

5. 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
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 / LB (SRS ) 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)

6. 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.

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

9. 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)

10. 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

11. CONTEXT: CONTENT

12. 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.

13. 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 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

14. 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

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

16. 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 to November 2017):
Number of patients visited = 1.05 Crores
Hypertensive cases screened = 6,45,845
Diabetic cases screened = 15,17,158

17. 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.

18. 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.

19. 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

20. COMFORT

21. 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.

22. 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 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
“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

23. 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 till October 2017.

24. 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.

25. 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

26. Thank You