Wellness clinic

Lecture Share by Dr Virendra Wankhede
MBBS, MD (Community Medicine)
MBA, MPhil (BITS Pilani)

1. Wellness Clinic Dr. Virendra Wankhede MBBS, MD (Community Medicine) MBA, MPhil (BITS Pilani)

2. What is Wellness ? W ellness center  is a place where mental and medical healthcare professionals, nutritionists and life-coaches provide a variety of treatments and services for the  health  of their clients' minds and bodies.

3. W ellness Strategy ? Effective  wellness strategies  can help alleviate both absenteeism and presenteeism, and their related costs. ... Create an organizational culture that promotes health and  wellness . Building a healthy organizational culture involves both the physical work structure and the employees' perception of the work environment.

4. difference between health and wellness H ealth  is a state of being, whereas  Wellness  is the state of living a  healthy  lifestyle

5. Examples of the Best Workplace Wellness Programs On-site fitness centres. This might be considered the granddaddy of all corporate  wellness  program  examples . ... Smoking cessation programs. ... Transit options. ... Paramedical services. ... Yoga classes. ... Lunch and healthy snacks. ... Employee assistance programs. ... Naps.

6. Ayushman Bharat (2018) Health and Wellness Centres (HWCs) C reation of 1,50,000 Health and Wellness Centres (HWCs) by transforming existing Sub Centres and Primary Health Centres as the base pillar of Ayushman Bharat C loser to the homes of people covering both maternal and child health services and non-communicable diseases, including free essential drugs and diagnostic services E mphasis of health promotion and prevention is designed to bring focus on keeping people healthy by engaging and empowering individuals and communities to choose healthy behaviours and make changes that reduce the risk of developing chronic diseases and morbidities

7. Comprehensive service package includes components of palliative, rehabilitative and geriatric care, much beyond the existing RMNCH+A services which will be leveraged through the Health and Wellness Centers (HWCs)

8. MCH Immunisation Telemedicine OPD Free Medicines

9. National Health Policy, 2017 R ecommended strengthening the delivery of primary health care, through establishment of "Health and Wellness Centres" as the platform to deliver comprehensive primary health care and called for a commitment of two thirds of the health budget to primary health care, Out of Pocket Expenditure ( OoPE ), P rimary health care is the only affordable and effective path for India to Universal Health Coverage To achieve the vision of Universal Health Coverage (UHC)

10. O n the lines as to meet SDG and its underlining commitment, which is "leave no one behind“ Ayushman Bharat is an attempt to move from sectoral and segmented approach of health service delivery to a comprehensive need-based health care service P ath breaking interventions to holistically address health (covering prevention, promotion and ambulatory care), at primary, secondary and tertiary level

11. Ayushman Bharat adopts a continuum of care approach, comprising of two inter-related components, which are – 1) Establishment of Health and Wellness Centres 2) Pradhan Mantri Jan Arogya Yojana (PM-JAY)

12. Sub Centres covering a population of 3000 -5000 would be converted to Health and Wellness Centres, with the principle being "time to care" to be no more than 30 minutes, O utreach services, Mobile Medical Units, camps, home and community-based care, but the principle should be a seamless continuum of care that ensures the principles of equity, universality and no financial hardship, Indian Public Health Standards (IPHS)

13. Key Principles Transform existing Sub Health Centres and Primary Health Centres to Health and Welllness Centers to ensure universal access to an expanded range of Comprehensive Primary Health Care services Ensure a people centered , holistic, equity sensitive response to people's health needs through a process of population empanelment, regular home and community interactions and people's participation. Enable delivery of high-quality care that spans health risks and disease conditions through a commensurate expansion in availability of medicines & diagnostics, use of standard treatment and referral protocols and advanced technologies including IT systems. Instil the culture of a team-based approach to delivery of quality health care encompassing: preventive, promotive, curative, rehabilitative and palliative care. Ensure continuity of care with a two-way referral system and follow up support.

14. Emphasize health promotion (including through school education and individual centric awareness) and promote public health action through active engagement and capacity building of community platforms and individual volunteers. Implement appropriate mechanisms for flexible financing, including performance-based incentives and responsive resource allocations. Enable the integration of Yoga and AYUSH as appropriate to people's needs. Facilitate the use of appropriate technology for improving access to health care advice and treatment initiation, enable reporting and recording, eventually progressing to electronic records for individuals and families. Institutionalize participation of civil society for social accountability. Partner with not for profit agencies and private sector for gap filling in a range of primary health care functions Facilitate systematic learning and sharing to enable feedback, and improvements and identify innovations for scale up Develop strong measurement systems to build accountability for improved performance on measures that matter to people .

15. Key Elements      

16. Expanded range of services 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 including National Health Programmes Management of Common Communicable Diseases and Outpatient care for acute simple illnesses and minor ailments. Screening, Prevention, 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 and Basic management of Mental health ailments

17. Expanded Service Delivery 1. Population Enumeration and Empanelment of Families at HWC To ensure equitable population coverage and to address issues of marginalization, the frontline workers would create population-based household lists and undertake registration of all individuals and families residing within the catchment area of a Health and Wellness Centre. It is this registration that is referred to as empanelment. It is a right of anyone, resident in that area to be enrolled. 2. Organization of Services The delivery of services would be at three levels i.e., i ) Family/Household and community levels, ii) Health and Wellness Centres and iii) and Referral Facilities/Sites.

18. 3. Service Delivery Framework The services envisaged at the HWC level will include early identification, basic management, counselling, ensuring treatment adherence, follow up care, ensuing continuity of care by appropriate referrals, optimal home and community follow up, and health promotion and prevention for the expanded range of services. Care provision at every level would be provided as per clinical pathways and standard treatment guidelines.

19. Key Milestones The first HWC was launched in Bijapur , Chhattisgarh on April 18th, 2018. In the first year, over 17,000 HWCs were operationalized, more than the target of 15,000 set for FY 2018-19.

20. Roll out plan Given the magnitude of inputs required to strengthen the primary health care facilities, the operationalization of HWC has been planned in a phased manner till the year 2022.

21. Multi-Skilling of Frontline Health Workers

22. Addition of Skills for Frontline Health Workers ASHAs - 5 Days in seventh Package for NCDs in first phase + refresher and newer packages annually (15 days) MPWs (Female and Males)- 3 days for seventh package to begin with and new packages (8-12 on ENT& Opthalmology , 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

23. Training of PHC Team- Staff Nurses, Medical Officers Seventh Package(Five days for screening and Management of NCDs) 21 days for screening for Cancer-VIA for CA Cervix and further management Online Training through Massive Open Online Courses (MOOC) and Extension for Community Health Outcomes (ECHO) Other Distance mode certificate programmes in areas such as- NCD management/MCH Care/Elderly Care/Mental Health etc. to be planned in long term. Additional Incentives/ rewards can be introduced Partnerships with AIIMS/Regional Cancer Centres/Knowledge networks to act as training resource centres and provide handholding support

24. Medicines and diagnostics require early attention Diagnostics – Establishment of effective Hub and Spoke models for diagnostic services at different levels Point of care diagnostics will be expanded based on recommendations of Task Force. Medicines – Essential List of Medicines to be expanded and in place across all states MLHP to be able to dispense medicines for chronic diseases on the prescription of the Medical Officer Uninterrupted Availability of medicines to ensure adherence and continuation of care ( Eg : HT/DM/ Epilepsy/COPD) DVDMS implemented in 28 states to streamline logistics - implementation in remaining states to be completed over a period of six months - Expansion to the level of HWC- PHCs/UPHC and HWC-SHC Robust Implementation of Free drugs and Diagnostics schemes in all states to eliminate OOPE Requirement of Medicines and Diagnostics updated based on recommendations of task forces

25. Health promotion Community mobilization and Intersectoral Convergence “Health in All” Approaches – NHP 2017 Recommendations - 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 States to develop strategies and institutional mechanisms in each of the seven areas, to create “ Swasth Nagrik Abhiyan” –a social movement for health.

26. Promoting Wellness through Yoga Yoga to be mainstreamed into the health care delivery system, Close coordination with Ministry of AYUSH/Department of AYUSH at the state and district level. Pool of Local Yoga Instructors at the HWC level to be identified Training and certification of local Yoga Teachers to be steered by Department of Ayush Weekly/monthly schedule of classes for Community Yoga Training at the HWCs Provision for additional remuneration to in house yoga teacher or in sourced yoga instructor

27. Innovation Learning Centres for CPHC Support centres for testing innovations and learning for scale up, where CPHC will be provided to the population of one block. Key roles To generate knowledge and evidence Building capacity of primary health care team and at district level to organize effective interventions for CPHC To deploy a team for required change management for CPHC Selected ILCs - Jan Swasthya Sahayog-Chhatisgarh TISS- Mumbai Charutar Arogya Mandal, Gujarat AIIMS-New Delhi Catholic Health Association of India-Telangana

28. Flexible financing - Performance linked compensation to service providers Aligning payment to performance (Suggestive) For MLHP- Contractual - About 37.5% (up to Rs. 15,000) 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 T eam Based incentives as per existing guidelines Facility budgets – Increase in untied funds for HWC –SHC to Rs. 50,000 Incentives after getting NQAS certification – guidelines under preparation Capitation based payments to health facilities to be explored

29. Infrastructure Branding / Colour code 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 4. 3-4 Alternate prototype designs will be provided 5. Display boards – Contact Details of Primary Care Team and referral centres Jurisdiction of Gram Panchayat/ Urban Local body representatives

30. Quality of Care Key principles - 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

31. HWCs in Urban Areas Current norm is one UPHC per 50,000 population All existing Urban Primary Health Centers (roughly 4000) to be strengthened as HWCs by March 2020 Where dispensaries exist, they could be upgraded to serve as H&WC, based on the HR available and geographical context Frontline workers- 4-5 ASHAs and 1 MPW(F) for 10,000 population - trained to deliver preventive and promotive services through outreach, including monitoring drug compliance for chronic diseases. 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 Financing – to be worked out with state consultation in the workshop

32. Immediate Next Steps Strengthen Programme Management (2 consultants in small states and 3-5 in big states as per requirement) Leverage technical support from Training institutions/ Research Organizations / SHSRC/ Medical Colleges District level – District Coordinator in selected districts as per requirement (with atleast one block saturation with HWC) Based on annual Targets of HWCs- commensurate selection/ enrolment in IGNOU Certificate Programme in Community Health Completion of training of ASHAs, MPWs, PHC Staff-Medical Officers and Staff Nurses in NCD Undertake gap analysis against the requirement of equipment/medicines/ consumables Prioritize Implementation of Seventh Package-NCD Care Roll out of IT Systems and Training of Providers in NCD App/MO Portal

33. Key Areas for Priority Action Appoint Senior State Nodal Officer : Director/Additional Director/Joint Director level officer Periodic reviews by Principal Secretary at all levels Road Map for converting all SHCs to HWCs by Dec,2022 Annual Plans for financial year 19-20, 20-21, 21-22 and 2022-23 (up to December,2022) Prioritizing Aspirational Districts/ NPCDCS Districts Block Saturation with HWC and linkage to appropriate referrals Create HR policy for MLHPs Resources Mobilization from non –Health sources - Sources-MP-LAD/MLA-LAD/MNREGA/Urban Local Bodies/PRI/ State Development Programmes/District Mineral Funds/District Innovation Funds/CSR etc. NHM funds could be used to leverage some of these sources

34. How to start your Wellness Center Find your focus Determine start up costs Keep it simple Identify your target market Let your services guide your space selection Get proper licenses and insurance Look for the right location Name your health and  wellness center

35. References - https://ab-hwc.nhp.gov.in/home/aboutus INTERNAL BRANDING PACKAGE FOR HEALTH AND WELLNESS CENTRES, AYUSHMAN BHARAT, Pg 6, USAID