| Why was there a sense of urgency to roll out the cadre of Community Health Officers? | they were critical to the provision of expanded range of services which is an essential part of CPHC. | Fig 4. Competency score of Community Health Community Health Officers. (n=106) • Linking of CHO to MO has proven to be an effective solution for tele-consultation, which largely occurred telephonically. • All interviewed CHOs felt that this was a good career option with a chance to serve the community. None of the CHOs expressed any concerns related to their career progression. They generally reported satisfaction with their role in the health systems, though some felt that their role was not well understood or appreciated by the other members of the team. • There has been a sense of urgency to roll-out this cadre of workers as they were critical to the provision of expanded range of services which is an essential part of CPHC. | 636 | relationship | 0.970 | • There has been a sense of urgency to roll-out this cadre of workers as they were critical to the provision of expanded range of services which is an essential part of CPHC. | 28 | page=28,block=1 | 0.700 | valid |
| How are states planning to implement the expanded service packages of HWCs? | in a phase wise manner depending on the maturity of the systems and availability of resources. | HWCs would provide expanded package of services beyond the tradition RCH and communicable diseases and common ailments (Box 1). These services would get implemented in different states in a phase wise manner depending on the maturity of the systems and availability of resources. States will also have the flexibility to expand the service package to address problems of local importance based on disease prevalence and community feedback. What stakeholders said? “ While reporting is being digitalized, paper reporting is also still going on side by side for many of the services that are being provided, so it’s both.” - SO-MD-NHM (Mizoram) “State and central government programmes are running parallel, different data are collected for both of them. New Programmes keep coming up and the demand for new data increases. | 185 | relationship | 0.970 | These services would get implemented in different states in a phase wise manner depending on the maturity of the systems and availability of resources. States will also have the flexibility to expand the service package to address problems of local importance based on disease prevalence and community feedback. |
| Why did SHC/HWCs with male CHOs not offer cervical cancer screening services? | as was not acceptable by community members | The facilities reported uninterrupted NCD services during COVID 19 pandemic, where doorstep delivery of services was ensured through ASHA and community volunteers during movement restrictions. • Availability of NCD services as an added package at HWCs did not affect the pre-existing RCH related services. • All states reported screening activities for breast, cervical and oral cavity cancers being undertaken at HWCs. SHC/HWCs with a male CHOs were not providing cervical cancer screening services, which is through Visual Inspection with Acetic Acid (VIA), as was not acceptable by community members. | 560 | relationship | 0.970 | SHC/HWCs with a male CHOs were not providing cervical cancer screening services, which is through Visual Inspection with Acetic Acid (VIA), as was not acceptable by community members. | 33 | page=33,block=2 | 0.700 | valid |
| Why is there no clear evidence on the success of the gatekeeping role of HWCs? | increase in services including screening of NCDs resulted in more referral to the higher facilities | This was not very different between HWCs and non-HWCs. State differences are highlighted in Annexure table A12. • ASHAs voiced that when they take patient (high-risk pregnant women) to higher facilities, they are not given due respect as a member of the health team. This issue may become important as referrals increase. • No clear evidence was available on success of “gatekeeping” role. This was because increase in services including screening of NCDs resulted in more referral to the higher facilities. there was a perception among the doctors at Taluk and District Hospitals that they were getting “quality patients” meaning that only really those needing secondary care were coming there now. | 407 | relationship | 0.970 | This was because increase in services including screening of NCDs resulted in more referral to the higher facilities. | 35 | page=35,block=1 | 0.700 | valid |
| How does the policy propose to ensure continuity of care across different levels of healthcare? | Leveraging the potential of digital health for two-way systemic linkages between the various levels of care viz., primary, secondary and tertiary | The National Health Policy 2017 signalled a decisive change from selective to comprehensive primary health care package including geriatric, palliative care and rehabilitative care services through upgraded facilities called “ Health and Wellness Centers. It also talked about a family health card that will enable access to a defined package of services anywhere in the country. To provide comprehensive care, the policy recommends a matching human resources development strategy, effective logistics support system and referral backup. This would also necessitate upgradation of the existing sub-centres and reorienting PHCs to provide comprehensive set of preventive, promotive, curative and rehabilitative services. Leveraging the potential of digital health for two-way systemic linkages between the various levels of care viz., primary, secondary and tertiary, would ensure continuity of care. | 720 | summary | 0.970 | This would also necessitate upgradation of the existing sub-centres and reorienting PHCs to provide comprehensive set of preventive, promotive, curative and rehabilitative services. Leveraging the potential of digital health for two-way systemic linkages between the various levels of care viz., primary, secondary and tertiary, would ensure continuity of care. |
| How do Community Health Officers generally feel about their career option? | All interviewed CHOs felt that this was a good career option with a chance to serve the community. | Fig 4. Competency score of Community Health Community Health Officers. (n=106) • Linking of CHO to MO has proven to be an effective solution for tele-consultation, which largely occurred telephonically. • All interviewed CHOs felt that this was a good career option with a chance to serve the community. None of the CHOs expressed any concerns related to their career progression. They generally reported satisfaction with their role in the health systems, though some felt that their role was not well understood or appreciated by the other members of the team. • There has been a sense of urgency to roll-out this cadre of workers as they were critical to the provision of expanded range of services which is an essential part of CPHC. | 205 | summary | 0.970 | • All interviewed CHOs felt that this was a good career option with a chance to serve the community. None of the CHOs expressed any concerns related to their career progression. | 28 | page=28,block=1 | 0.700 | valid |
| How do ASHAs help ensure continuity of care at the community level? | support in follow up for compliance to treatment and community mobilization for life style changes and behaviour modifications, through regular home visits (back referral) | Continuity of care is one of the key tenets of primary health care. Continuum of care spans for the individuals from the same facility to her/his home and community, and across levels of care. Ensuring care from the level of the individuals/ family through to the facility level can be ensured by a team of workers from ASHAs to manage at the community level to specialist at the district level. ASHAs are mandated to support in follow up for compliance to treatment and community mobilization for life style changes and behaviour modifications, through regular home visits (back referral). Multi-purpose workers/ CHOs can fix appointments with consultants, use tele-consultation to improve availability of higher-level care and maintaining the care continuum, by addressing physical and geographical access. | 418 | summary | 0.970 | ASHAs are mandated to support in follow up for compliance to treatment and community mobilization for life style changes and behaviour modifications, through regular home visits (back referral). | 34 |
| What is the reason patients choose subcentres over PHCs when HWCs are functioning effectively? | they get things in their own village | Teleconsultation Kaise Karenge” – CHO Uttar Pradesh“ “We have noticed that if HWC is working well, if the CHO is really good, then the OPD load in PHC has decreased as patients are now going to subcentres, like hypertensives…. If they get things in their own village, they won’t come to PHC except if they are really sick – SNO Meghalaya Initially therefore the load at the higher centres will increase because you are identifying more people. Once things have been managed and settled, then | 230 | summary | 0.970 | If they get things in their own village, they won’t come to PHC except if they are really sick – SNO Meghalaya Initially therefore the load at the higher centres will increase because you are identifying more people. | 34 | page=34,block=6 | 0.700 | valid |
| How are blood samples from peripheral areas transported to the main lab in Chhattisgarh? | blood samples from periphery are transported in insulated boxes to the main lab located at district hospital. | Access to medicines and diagnostics • Absence of electronic indenting at SHC level. • Poor access to diagnostics An electronic indenting and stock keeping at the sub centre level using the e-aushadhi portal. (Andhra Pradesh) Mobile vehicle mounted laboratory to villages. (Manipur) Hamar Lab Initiatives based on a Hub and Spoke Model where blood samples from periphery are transported in insulated boxes to the main lab located at district hospital. (Chhattisgarh) Expanded range of services • Lack of access to emergency care • Lack of Integrated care 104 Mobile medical services with a centralized roster of doctors for making monthly visit to all SHC-HWCs. (Andhra Pradesh) Bike ambulances used to provide emergency medical interventions in field. These bikes are available for carrying medicines, vaccines, diagnostics and other field travel. “First responder” role has been added to it. | 341 | summary | 0.970 | (Manipur) Hamar Lab Initiatives based on a Hub and Spoke Model where blood samples from periphery are transported in insulated boxes to the main lab located at district hospital. (Chhattisgarh) Expanded range of services • Lack of access to emergency care • Lack of Integrated care 104 Mobile medical services with a centralized roster of doctors for making monthly visit to all SHC-HWCs. |
| How did client satisfaction with HWC services compare to non-HWC services? | much higher among those who received services from HWCs as compared to those who received services from non-HWCs | Key Findings Overall • The launch of AB-HWC has enabled translation of the vision of moving from selective to comprehensive primary health care package enunciated in the National Health Policy 2017. • The implementation of AB-HWC scheme is on track in most states with a clear roadmap for achieving targets set for December 2022. • Overall, there has been an improvement in equity in access, despite existing constraints such as infrastructure availability and status of peripheral health facilities. • Effective communication was noted from district to PHC-HWC and SHC-HWC resulting in translation of policy decisions into action, faster and better. • Client satisfaction with the services provided was much higher among those who received services from HWCs as compared to those who received services from non-HWCs across all the four parameters measured – treatment, medicines, diagnostics and cleanliness. | 704 | comparison | 0.920 | • Client satisfaction with the services provided was much higher among those who received services from HWCs as compared to those who received services from non-HWCs across all the four parameters measured – treatment, medicines, diagnostics and cleanliness. |