Health and wellness center by Dr. Jitender, MD PGIMER

Health and wellness center is one of the two component of Ayushmann Bharat. HWC ensures comprehensive, quality, and affordable care to be achieved by all.

1. Health and Wellness Center Presenter: Dr Jitender Kumar, Junior Resident Moderator: Dr Kathirvel S., Assistant Professor (For Dr JS Thakur , Professor) Department of Community Medicine and School of Public Health, PGIMER Chandigarh

2. Outline Universal Health Coverage (UHC) Role of Primary Health Care in UHC Challenges to UHC Rationale of Health and Wellness Centres (HWCs) Key elements to roll out HWC Progress so far Opportunities Challenges Way forward

3. Health and Wellness “A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” * Wellness : active process of becoming aware of and making choices towards a healthy and fulfilling life.  It is more than being free from illness, it is a dynamic process of change and growth *WHO definition of health- 1948

4. Universal Health Coverage (UHC) All people have access to effective and high-quality health services, without experiencing financial hardship (WHO) 1948 : Universal declaration of human rights Article 25 : E veryone has the right to a standard of living adequate for health, including medical care, and the right to security in the event of sickness or disability 1977 : Health for all by the year 2000 (World Health Assembly) 2012: United Nations General Assembly adopt a resolution calling for countries to toe the path of UHC 2016 : UHC became a global development agenda target - target 8 of SDG 3

5. UHC and Primary Health Care Focus of the global community: To achieve UHC, and Primary Health Care is a necessary foundation for these efforts Primary Health care: Essential health care made universally accessible to individuals and families in the community through their full participation and at a cost that community can afford * Astana Conference, 2018: Aims to commemorate the 1978 declaration, reaffirm its original principles and renew political commitment to placing primary health care (PHC) at the heart of achieving universal health coverage and the SDGs *Alma Ata Declaration-1978

6. Primary Health Care (PHC) Primary Health Care : Critical to improving health outcomes- Important role in the 1 ⁰ and 2 ⁰ prevention of diseases Comprehensive Primary Health Care reduces morbidity and mortality at much lower costs; also reduces the need for secondary and tertiary care. For primary health care to be comprehensive: needs to span preventive, promotive , curative, rehabilitative and palliative aspects of care. Primary Health Care goes beyond first contact care, and is expected to mediate a two-way referral support

7. Challenges to achieve UHC Selective Primary Health Care : limited to RCH and few Communicable Diseases- addresses about 20% of health care needs Low utilization of public health facilities: 28% in rural areas and 21% in urban areas sought care in the public sector; of which only 11.5% and 4% respectively sought any form of care at a level below the CHC Health care is fragmented –disrupts continuity of care High Out of Pocket Expenditure National Sample Survey 71 st Round, 2014

8. Challenges to achieve UHC Lack of gate keeping function – raises the load on secondary and tertiary facilities and compromises quality Epidemiologic Transition : Death from the four major NCDs –Cancer, CVD, Diabetes, and Respiratory Diseases accounts for nearly 62% of all mortality among men and 52% among women – of which 56% is premature* Unfinished Agenda of RCH and Communicable Diseases - Persistent challenge * WHO. Non Communicable Diseases; Country Profile for India; 2014

9. High Level Expert Group (HLEG) on UHC HLEG on UHC: By Planning Commission of India in October, 2010 The final framework o n achieving UHC for India by 2022: submitted on the 21st of October, 2011 The recommendations for the provision of UHC pertain to the critical areas: health financing, health infrastructure, health services norms, skilled human resources, access to medicines and vaccines, management and institutional reforms, and community participation

10. National Health Policy 2017 National Health Policy 2017 : Prioritized primary healthcare as a principal component of health system strengthening Strengthening the delivery of Primary Health Care, through establishment of “Health and Wellness Centres ” Two thirds of health budget to be committed to PHC WISH Health and Wellness Centre Model India launched  Ayushman Bharat  - one of the most ambitious health missions ever to achieve UHC

11. WISH Health and Wellness Centre Model Based on the vision of NHP,2017 Designed a solution for addressing the primary healthcare needs & launched a demonstration of a Health & Wellness Center in Rajasthan in July 2017 Features: Human Resource: 2 ANMs, 1 MPW Drugs, equipment, consumables as per the standard IPHS guidelines Swasthya ATM Use of Point of Care innovative devices for NCD Screening (Diabetes, Hypertension, Cancer)

12. PRIMARY SECONDARY TERTIARY CONTINUUM OF CARE – CPHC & PM JAY Unmet need: NCDs/other Chronic Diseases Existing services: RMNCHA PM JAY Referral Preventive, Promotive , Curative, Rehabilitative & Palliative Care AYUSHMAN BHARAT – Rationale

13. Ayushman Bharat 1.5 lakh sub- centres and primary health centres will be transformed as health and wellness centres by 2022 to provide Comprehensive Primary Health Care (CPHC) close to the community Cover over 10 crore poor and vulnerable families providing coverage up to Rs 5 lakh per family per year for secondary and tertiary hospitalization Health and Wellness Centers Pradhan Mantri Jan Arogya Yojana (PMJAY)

14. 14 th April 2018-Honorable Prime Minister launched the first Health and Wellness Centre at Jangla , Bijapur , Chhattisgarh Launch of Health and Wellness Centre

15. Health and Wellness Centers Sub centres covering a population of 3000-5000 PHC: Population 30000 Urban PHC: Population 50000 Health & Wellness Centre – Sub Centre Health & Wellness Centre – PHC

16. Sub Centre: Manpower (IPHS,2012) Type of Sub- centre Sub Centre A Sub Centre B Staff Essential Desirable Essential Desirable ANM/ Health Worker (F) 1 +1 2 Health Worker (M) 1 1 Staff Nurse (or ANM, if Staff Nurse is not available) 1* Safai - Karamchari 1 (Part time) 1 (Full term) * If no. of deliveries at the Sub centre is 20 or more in a month

17. Health & Wellness Centre – Sub Centre Primary Health Care Team: Mid-level health provider (MLHP): BSc / GNM or Ayurveda Practitioner trained in 6 months Certificate Programme in Community Health/ Community Health Officer ( BSc -CH) MPW F: 2 per Sub Centre MPW M: 1 to be provided from state resource 5 ASHAs as outreach team per Sub Centre Source: Ayushman Bharat: Comprehensive Primary health care through HWCs

18. PHC: Manpower (IPHS,2012) Staff Essential Desirable Medical Officer- MBBS 1 Medical Officer- AYUSH 1 Pharmacist 1 Pharmacist AYUSH 1 Staff Nurse 3 +1 Health Worker (F) 1 Health Assistant (M) 1 Health Assistant (F)/ LHV Accountant Cum DEO 1 Lab Technician 1 Health Educator 1 Cold Chain & Vaccine Logistic Assistant 1 Sanitary worker cum watchman 1

19. Health & Wellness Centre – PHC Primary Health Care Team : as per IPHS 1 MBBS Doctor at least Staff nurses Pharmacist Lab Technician MPW-F* ASHAs* Support for training of PHC staff Provision of “Wellness Room” Necessary IT infrastructure Resources required for upgrading laboratory and diagnostic support to complement the expanded ranges of services * In Urban area Source: Ayushman Bharat: Comprehensive Primary health care through HWCs

20. Current norm is one UPHC per 50,000 population All existing Urban Primary Health Centers to be strengthened as HWCs by March 2020 Frontline workers- 4-5 ASHAs and 1 MPW(F) for 10,000 population MLHP would not be required, as MO MBBS is already approved for UPHCs Explore partnerships with not for profit and private sector to provide primary health care, where UPHCs do not exist, as a gap filling measure HWCs in Urban Areas

21. Health & Wellness Centre Primary Health Care team Logistics Infrastructure Digitization Telemedicine/IT Platforms Capacity Building Health Promotion Community Mobilization HWC Database Health cards and Family Health Folders Increased access to Services INPUTS OUTPUTS OUTCOMES Improved population coverage Reduced OOPE Risk factor mitigation Decongestion of 2⁰ and 3⁰ level facilities

22. Key Elements to Roll out CPHC

23. Service Delivery and Continuum of Care

24. Sub Centre: Services (IPHS,2012) Maternal Health Services Child Health Services Family planning School health services Control of local endemic diseases IDSP National Health Programmes Minimum Diagnostic services

25. PHC: Services (IPHS,2012) Medical Care: OPD, Emergency, Referral, In patient services Maternal Health Services Child Health Services Family planning School health services National Health Programmes Training Basic Lab & Diagnostic Services Monitoring and supervision Minor surgery

26. Care in Pregnancy and Child-birth Neonatal and Infant Health Care Services Childhood and Adolescent Health Care Services Family Planning, Contraceptive Services and other Reproductive Health Care Services Management of Communicable Diseases: National Health Programmes General Out-patient Care for Acute Simple Illnesses and Minor Ailments Expanded Service Delivery

27. Screening, Prevention, Control and Management of Non-communicable Diseases Care of Common Ophthalmic and ENT problems Basic Oral Health Care Elderly and Palliative Health Care Services Emergency Medical Services including Burns and Trauma Screening and Basic Management of Mental Health Ailments Expanded Service Delivery

28. Community – Facility: Maintaining Continuum of Care Population Enumeration Outreach Services Community Based Screening Risk Assessment Awareness Generation Follow up of confirmed cases Counselling: Lifestyle changes; treatment compliance First Level Care Screening Use of Diagnostics Drug Dispensation Record keeping Telehealth Referral to MO at PHC for confirmation/complications Diagnosis Prescription and Treatment Plan Referral of complicated cases Telehealth Real time monitoring Advanced diagnostics Complication assessment Telehealth Tertiary linkage/ PM JAY Village/Urban Ward SHC PHC/UPHC CHC/SDH/DH ASHA/MPW M LHP/CHO

29. Expanding Human Resources - MLHP & Multi-skilling of Frontline Workers

30. Community Health Officer (CHO) : BSc in Community Health/ a Nurse (GNM or BSc )/ an Ayurveda Practitioner Trained in a six month , IGNOU/State Public Health/ Medical Universities accredited “Certificate Programme in Community Health” to build competencies in public health and primary care Selection process: Attract competent and motivated candidates- Preferential Local Selection Career progression pathways : At least up to district level Mid Level Health Provider (MLHP)

31. Roles: Ensure all households in service area are listed, empanelled Clinical care Coordination for care / case management as per T/T plan Provide medicines Screening for chronic conditions, enabling confirmation of diagnosis, treatment initiation, ensure adherence, counseling Coordinate and lead local response to public health emergencies Support the MPW and ASHAs on their tasks Reporting Coordinate with Community platforms Mid Level Health Provider (MLHP)

32. Skills appropriate at that level should be available within the team at the HWC Services are assured to the population and the team is able to resolve more at their level including through telehealth with fewer referrals MPW (M & F): Skills to function as paramedics for undertaking laboratory, pharmacy and counseling functions HWC-PHC staff : Skills to function as ophthalmic technicians, dental hygienists, physiotherapists Multi-Skilling of Frontline Health Workers

33. ASHAs: 5 Days in Package for NCDs in first phase + refresher and newer packages annually (15 days) MPWs(Female and Males): - 3 days for package for NCD to begin with and new packages (ENT & Ophthalmology, Oral, Elderly and Palliative, Basic Emergency Services and Mental Health) to be added - Joint training of MPWs with ASHAs wherever possible - Reporting and Recording information using digital applications-Additional 3 days Addition of Skills for Frontline Workers

34. 5 days for screening and Management of NCDs 21 days for screening for Cancer-VIA for CA Cervix and further management Other Distance mode certificate programmes in areas such as- NCD management/MCH Care/Elderly Care/Mental Health etc. to be planned Training of PHC Team

35. Medicines and Diagnostics

36. Essential Drug List: to be expanded and in place across all states MLHP: Dispense medicines for chronic diseases on the prescription of the Medical Officer Uninterrupted Availability of medicines to ensure adherence and continuation of care DVDMS implemented in 28 states to streamline logistics Robust Implementation of Free drugs and Diagnostics schemes in all states to eliminate OOPE Medicines

37. Sub Centre: Drug List (IPHS,2012) Drugs: ORS T. IFA-large & small T. Folic Acid T. Septran - Pediatric T. Zinc sulphate Syp . IFA Syp . Vitamin A T. Albendazol T. Paracetamol

38. Essential Drug List for Sub Centre HWC Category Drugs Oxygen Anaesthetic Lignocaine Analgesic Diclofenac , PCM Anti allergic Cetrizine Chlorpheniramine Anti helminthes Albendazole DEC Antibacterial Ciprofloxacin Gentamycin Metronidazole Amoxycillin Antifungal Fluconazole Anti malarial Chloroquine Primaquine ASP Combi pack Anemia IFA, FA Category Drugs Topical Clotrimazole , Gen Vilot , Povidone Iodine, Silver Sulpha Vitamins Vit A, Vit C, Vit K1 Cholecalciferol GI Medicine Domperidone , Dicyclomine ORS, Zinc Sulphate Contraceptives Ethinylestradiol + Norethisterone , IUDs Condom, Ethinylestradiol , LNG Oxytocics Methylergometrin , Misoprostol ENT Medicines G. Ciprofloxacin, G.N Saline , G. Xylometazoline , G. Wax-solvent ear drops

39. Establishment of effective Hub and Spoke models for diagnostic services at different levels (Hub- Central Diagnostic Unit at CHC/ Block PHC for 20-30 HWCs) - minimize the movement of the patient - improve the timeliness of reporting Point of care diagnostics will be expanded Diagnostics

40. Robust IT System – to meet diverse needs of different stake holders Patient centric : Unique Individual ID Individual health record Family health folder Facilitates continuum of care through alerts Facilitates access to patient care information Service Providers : Enables continuity of care Generates workplans /serves as job aids Facilitates follow up and compliance to treatment Decision Support System for service providers at various levels Programme Managers: Dashboard for monitoring at different levels Provide monitoring reports to assess performance for payments

41. Health Promotion, Community mobilization and Intersectoral Convergence

42. NHP 2017 Recommendations - Coordinated action on seven priority areas for improving the environment for health as part of CPHC: Swachh Bharat Abhiyan Balanced, healthy diets and regular exercises Addressing tobacco, alcohol and substance abuse Yatri Suraksha – preventing deaths due to rail and road traffic accidents Nirbhaya Nari –action against gender violence Reduced stress and improved safety in the work place Reducing indoor and outdoor air pollution “ Swasth Nagrik Abhiyan” –a social movement for health “Health in All” Approach

43. General Population : Targeted for primary prevention Population at Risk : Regular screening of adults for NCDs Individuals with Symptoms : Early identification of symptoms, prompt referral and follow up of cases Population with Known Disorders : Individual and family counselling - for treatment compliance and lifestyle modifications Target Groups for Health Promotion

44. Yoga to be mainstreamed into the health care delivery system Close coordination with Ministry of AYUSH Pool of Local Yoga Instructors at the HWC level to be identified Training and certification of local Yoga Teachers Weekly/monthly schedule of classes for Community Yoga Training Provision for incentive for these YOGA teachers Promoting Wellness through Yoga

45. Health Promotion by Ayushman Ambassadors Age appropriate, skill-oriented, theme based, graded curriculum for the teachers 2 teachers in every school as “ Ayushman Ambassadors ”, trained to transact health promotion/disease prevention through interesting activities for one hour every week 20 hour sessions delivered through weekly interactive classroom-based activities All Tuesday - Health and Wellness Day in the schools Students will act as Health and Wellness Messengers in the society

46. Flexible financing Performance based Payments : For MLHP: Contractual - About 40 % of total salary (Rs. 40,000) of MLHP to be linked with performance Regular- Difference between Rs. 40,000 and existing salary to be linked with performance Facility Budget: Increase in untied funds for HWC –Sub Centres to Rs. 50,000 Incentives after getting NQAS certification

47. Branding / Colour code Infrastructure Upgrade for Health and Wellness Centre

48. Citizen Charter Space for – Examination room with adequate privacy and Telehealth Diagnostics and medicine dispensation Wellness room Waiting area IEC Labour room at delivery points Infrastructure Upgrade for Health and Wellness Centre

49. 3-4 Alternate prototype designs will be provided Display boards – Contact Details of Primary Care Team and referral centres Jurisdiction of Gram Panchayat/ Urban Local body representatives Infrastructure Upgrade for Health and Wellness Centre

50. Provision of Patient Centred Care Enable Patient Amenities at HWC Adhere to standard treatment guidelines and clinical protocols for care provision Achieve Indian Public Health Standards with regards to HR, infrastructure, equipment, service delivery and supplies National Quality Assurance Standards for HWCs will be developed Patient satisfaction to be captured through IT systems Quality of Care

51. Monitoring Community based Monitoring Facility based Monitoring

52. Roll Out Plan of HWCs

53. HWC Portal (https://ab-hwc.nhp.gov.in/) Key Features: Facility wise information on all functionality criteria Daily Reporting on service utilization Monthly Service Delivery Reporting Format HWC and CPCH planning sheet NIN and RCH Code mapping HWC – CHO / MO Directory Platform to upload photos, videos AB-HWC, 3 rd Regional Workshop, Amritsar; Punjab, 5 th & 6 th September,2019

54. Functionality Criteria Criteria for PHC- HWC:   MBBS MO in position + Training on NCD completed for MO or Staff Nurse + Diagnostics available + Medicines available + Branding completed if the facility is in Government Building Criteria for SHC-HWC:   CHO in position + Training on NCD completed for MPW(F) and ASHA Diagnostics available + Medicines available + Branding completed if the facility is in Government Building  HWCs Progressive HWCs Operational HWCs Progressive + Screening of NCDs: Hypertension, Diabetes, Oral Cancer, Breast Cancer started  

55. NCD Screening status as per AB- HWC Portal   State Name Chandigarh Haryana HP Punjab Total- all states Community Outreach Individuals Empanelled 425657 124997 86480 24301255 CBAC Filled 155963 67303 589909 15989930 Hypertension Screening 3038 44180 149607 262494 15440445 Newly Diagnosed 10 4198 15926 55115 1279294 On Treatment 7584 30374 76767 7058852 Diabetes Screening 1336 37889 82970 151105 14456811 Newly Diagnosed 7 3138 9983 27666 1572479 On Treatment 5676 16926 50003 3127345 AB-HWC, 3 rd Regional Workshop, Amritsar; Punjab, 5 th & 6 th September,2019

56. NCD Screening status as per AB- HWC Portal   State Name Chandigarh Haryana HP Punjab Total- all states Oral Cancer Screening 1101 19816 28210 59313 7680756 Newly Diagnosed   8 9 131 15128 On Treatment 45 43 735 10218 Breast Cancer Screening 605 10013 7532 44163 5293008 Newly Diagnosed 57 3 232 20408 On Treatment 17 4 538 9742 Cervical Cancer Screening 386 2923 3169 15858 3730142 Newly Diagnosed 60 1 146 17785 On Treatment 7 3 416 10075 AB-HWC, 3 rd Regional Workshop, Amritsar; Punjab, 5 th & 6 th September,2019

57. Based on- Data entered on HWC Portal which reflects readiness and initial service delivery at HWCs. Combined score determined from weightage linked with seven criteria Done on quarterly basis Overtime the scoring criteria will be refined to reflect service delivery ,quality and outcomes. Process for Ranking of HWCs

58.   Criteria Definition Weightage 1 % of SHCs, PHCs and UPHCs operationalized as HWCs out of total SHCs, PHCs and UPHCs in the state Source – HWC Portal Numerator – Number of SHCs/ PHCs and UPHCs indicated as progressive on HWC portal Denominator - Number of SHCs and PHCs and UPHCs available in state 25% 2 % of HWC functionality criteria met against the total target functionality criteria Source – HWC Portal Numerator – Total number of criteria met by the HWCs   Denominator – Total number of criteria estimated based on number of HWCs proposed on HWC portal 20%  

59. Criteria Definition Weightage 3 % of population enumerated (against the target population) under HWCs Source – CPHC – NCD IT application Numerator – Number of individuals reported under population enumeration for all HWCs Denominator – Total population under the health facility 15%   4 % of Pregnant Women who received full ANC Source – RCH portal / ANMOL Numerator – Number of pregnant women who received full ANC checkups (at least 4 ANC checkups) Denominator- Total number of pregnant women registered under the facility 5%  5 % of institutional deliveries Source – RCH portal / ANMOL Numerator- Number of pregnant women who delivered in a health care facility (public and private both) Denominator- Total number of pregnant women reported under the health facility 5%

60.   Criteria Definition Weightage  6 % of Newborns who received HBNC visits Source – RCH portal / ANMOL Numerator- No. of newborn (0-28 days) who received HBNC visits as per the schedule (0, 3, 7, 14, 21 and 28 days) . Denominator- Total no. of newborn reported under the health facility 5%  7 % of Children up to 2 years of age who received full immunization Source – RCH portal / ANMOL Numerator- No. of children up to 2 years who received full immunization (BCG, measles, and 3 doses each of polio and DPT ) Denominator- Total no. of children up to 2 years reported under the health facility 5% 8 % of Individuals over 30 screened for Hypertension against the target under HWCs Source – CPHC – NCD IT application Numerator – Total no. of individuals screened for Hypertension Denominator – Total no. of individuals over 30 (estimated using 37% of the total population reported under each health facility) 5%

61.   Criteria Definition Weightage 9 % of Individuals over 30 screened for Diabetes against the target under HWCs Source : CPHC – NCD IT application Numerator – Total number of individuals screened for Diabetes Denominator – Total number of individuals over 30 (estimated using 37% 4 of the total population reported under each health facility) 5% 10 % of Individuals over 30 screened for oral cancer against the target under HWCs Source : CPHC – NCD IT application Numerator – Total number of individuals screened for Oral Cancer Denominator – Total number of individuals over 30 (estimated using 37% 4 of the total population reported under each health facility) 5% 11 % of women over 30 screened for breast cancer against the target under HWCs Source : CPHC – NCD IT application Numerator – Total number of women screened for Breast Cancer Denominator – Total number of women over 30 (estimated using 49% of the total population over 30) 5%

62. Rank State Name 1 Andhra Pradesh 2 Telangana, Punjab 3 Arunachal Pradesh, Haryana 4 Sikkim, Tamil Nadu, Gujarat, Chhattisgarh 5 Jharkhand, Assam, Maharashtra, Odisha 6 Meghalaya, Uttar Pradesh, Rajasthan, Karnataka 7 Kerala, Manipur, Tripura, Goa, Mizoram, Jammu and Kashmir 8 Bihar 9 Himachal Pradesh, Uttarakhand, West Bengal 10 Madhya Pradesh 11 Nagaland Ranking based on first two criteria Percentage of SHCs, PHCs and UPHCs operationalized as HWCs out of total SHCs, PHCs and UPHCs in the state Percentage of HWC functionality criteria met against the total target functionality criteria State Rank

63. Rank UT Name 1 Daman & Diu 2 Chandigarh 3 Dadra & Nagar Haveli 4 Puducherry 5 Andaman & Nicobar Islands UT Rank Ranking based on first two criteria

64. Kayakalp Scheme For Health and Wellness Centers Scores based on: HWC upkeep Sanitation and Hygiene Support services Hygiene Promotion Waste Management Infection Control Beyond Facility Boundary State No. of HWCs Operational in HSC Award Category A 10-25 Rs 1 Lakh Category B 26-50 Winner- Rs 1 Lakh Runner up- 50K Category C > 50 Winner- Rs 1 Lakh 1 st Runner up- 50K 2 nd Runner up- 35K

65. Evaluation of AB-HWCs for NITI Aayog’s State Health Index 67 An independent authority to conduct an evaluation of least 2 % of the functional AB-HWCs in each State / UT is to be conducted. Planned for Q4 – January 2020-March 2020 AB-HWCs made functional Dec 2019 will be covered ToRs will be finalized in consultation with States shortly IIT / IIM / AIIMS / ICMR / State specific CSOs / DPs would be coopted During this process VHSNCs / MAS / SHGs / PRI would also get oriented on Social Audit.

66. Areas of Opportunities Expansion of Primary Health Care to CPHC Up gradation of Infrastructure Employment Opportunities Fostering Partnerships Inter- Sectoral Convergence Improved Knowledge and Awareness Research Opportunities Monetary Gains

67. Challenges Low public health spending Community involvement and trust in these centers Lack of required human recourses especially in rural areas Recruitment of the required no. of health workers Existing no. of rural health facilities not sufficient to meet the population norms- New facilities to be build Challenges related to development and implementation of IT system

68. Way Forward A much higher level of public health spending in general and much higher outlays for HWCs in particular Proper recruitment, comprehensive training, effective control and oversight and timely and adequate payments for the various health functionaries An effective and efficient management structure for the HWCs

69. Way Forward Commensurate physical infrastructure and human resources in the sub-centers and the Primary Health Centers converted into the HWCs with the growing needs of the regions A mechanism for tracking referred patients , on treatment follow up patients Research to evaluate the outcome/ impact of HWCs

70. Thank You…