|Year : 2022 | Volume
| Issue : 3 | Page : 104-108
Health and Wellness Centres as a strategic choice to manage noncommunicable diseases and universal health coverage
P Aravind Gandhi, Ria Nangia, JS Thakur
Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Submission||07-Jul-2022|
|Date of Decision||18-Jul-2022|
|Date of Acceptance||20-Jul-2022|
|Date of Web Publication||15-Oct-2022|
Dr. J S Thakur
Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh
Source of Support: None, Conflict of Interest: None
Noncommunicable diseases (NCDs) are the leading cause of death globally. On its road to ensuring universal health coverage (UHC) for its population, India initiated the Ayushman Bharat mission in 2018. Under this flagship initiative, the primary health care component is being implemented by establishing Health and Wellness Centers (HWCs) across the country. HWCs are being established by converting and upgrading the primary health centers and subhealth centers. The unmet need for NCDs at the primary care level is high. Under the HWCs, NCD services are being expanded at the community and facility levels. States have brought local innovations in the NCD management. NCD ticker bags, an innovation to ensure treatment adherence, follow-up, and reduce drop-outs, are being done under the HWCs. Gaps in NCD management include a lack of awareness about NCDs' risk factors and management in rural areas and an erratic supply of NCD drugs and diagnostics. Challenges in the NCD management in the primary care settings include capacity building of the health manpower in NCD management, the flow of information for ensuring a continuum of care, and low community participation in the screening and management of NCDs. The challenges that remain in operationalizing the envisaged package in the HWCs must be acknowledged and worked upon. This will enable us to continue on the path toward UHC, stick to the action plan on NCDs, and assist us in achieving the NCD-related targets.
Keywords: Health and wellness centers, India, noncommunicable diseases, primary health care, universal health coverage
|How to cite this article:|
Gandhi P A, Nangia R, Thakur J S. Health and Wellness Centres as a strategic choice to manage noncommunicable diseases and universal health coverage. Int J Non-Commun Dis 2022;7:104-8
|How to cite this URL:|
Gandhi P A, Nangia R, Thakur J S. Health and Wellness Centres as a strategic choice to manage noncommunicable diseases and universal health coverage. Int J Non-Commun Dis [serial online] 2022 [cited 2023 Jan 26];7:104-8. Available from: https://www.ijncd.org/text.asp?2022/7/3/104/358631
| Introduction|| |
Noncommunicable diseases (NCDs) are the leading cause of death globally, with 73.4% of the total deaths being attributed to them. Low- and middle-income countries bear the major brunt of this NCD-related burden, with nearly 80% of the total premature deaths due to NCDs happening in these countries. The NCD burden on the community in terms of morbidity is also high. Around 5.67 million deaths in India have been due to NCDs, constituting 60% of the total mortality. To achieve the Sustainable Development Goals target of “reducing the premature mortality from NCD by one-third through prevention and treatment and to promote mental health and well-being, by 2030,” strategies are being framed, tested, and implemented worldwide. A global action plan to guide and achieve this target is also in place. In India, which is in the epidemiological transition phase, the relative burden of diseases is shifting toward NCDs, has started implementing the NCDs programs for a long time. From the National Goitre Control Programme of 1962 to the latest inclusion of the nonalcoholic fatty liver disease control under the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular diseases, and Stroke (NPCDCS),, India has steadily improved and added the NCD service packages being provided. In India, health-care services are provided on three levels: primary, secondary, and tertiary care. At the primary level, health care is delivered through subhealth centers (SHCs) and primary health centers (PHCs) in the rural areas and urban PHCs and dispensaries in the urban areas., The secondary level of health care comprises community health centers, subdistrict hospitals (SDHs), civil hospitals, and district hospitals. At the same time, tertiary care is being provided by medical college hospitals and institutes of national importance such as the All India Institute of Medical Sciences and Postgraduate Institute of Medical Education and Research. On its road to ensuring universal health coverage (UHC) for its population, India has initiated the Ayushman Bharat (AB) mission. Under this flagship initiative, the primary health-care component is being implemented by establishing Health and Wellness Centres (HWCs).
| Methodology|| |
To deliberate on the role of the HWCs in managing the NCDs and achieving UHC, a scientific session was organized during the National Conference of the Indian Association of Preventive and Social Medicine. Professionals in the field of NCDs and UHC shared their expertise on the topic. We conducted a review of the deliberations that happened during the session. In addition, a systematic search in PubMed was conducted using the keywords: “HWCs*,” “HWC,” “NCDs *,” “NCDs,” “Primary Prevention,” “Universal Health Care,” and “UHC.”
| Health and Wellness Centres for Comprehensive Primary Health Care|| |
HWCs are being established by converting and upgrading the PHCs and SHCs. It is targeted to establish 155,000 HWCs by 2022, by upgrading 130,000 SHCs and 25,000 PHCs. HWCs focus on moving from selective primary health care to comprehensive primary health care. At present, the overall health expenditure is majorly out-of-pocket expenditure by the people, which is similar to the findings from other countries, while the government's share constitutes around 30%. Although the majority of the government spending is toward primary health care (51.5%), it still falls short of the required allocation. The commitment toward this end is also reflected in the National Health Policy to spend the two-thirds of health budget on primary health care. Adequate and sustained financial allocation is essential for the achievement of UHC. There will be two types of HWCs: HWC-SHC and HWC-PHC. The HWC-SHC is to be headed by a community health officer (CHO), a new cadre of health-care workers created under the initiative. Under the CHO, Auxillary Nurse Midwife and Multi-purpose Health Workers at the HWC-SHCs will deliver the expanded health services package. As of April 29, 2022, 118,169 PHCs and SHCs have been converted into HWCs all over the country. The existing limited package of health services at the primary care level is undergoing a paradigm shift toward a comprehensive package of primary health care (CPHC) services incorporating preventive, promotive, curative, rehabilitative, and palliative care. NCDs management services form an indispensable and integral part of this UHC.
| Current Scenario of Health and Wellness Centres in Noncommunicable Diseases Management|| |
As a part of the comprehensive health-care services provided under this HWC initiative, NCDs services are being expanded at the community and facility level. The role of HWCs in comprehensively managing the NCDs for achieving the broader objective of expanded service delivery under the UHC has to be explored under the individual domains of service delivery, human resource, logistics, and the operational issues and challenges surrounding them., The unmet need for NCDs at the primary care level is high. Strengthening primary health care through HWCs will act as an effective gate-keeping mechanism in controlling the patient load at the secondary and tertiary level health centers. It is to be noted that the package of the NCD services provided through the HWCs is dynamic and will be ever expanding which puts India on the right path of UHC. eSanjeevani, the flagship telemedicine service of India, can be expanded to include the HWCs for the patients to access referral consultations without physically reaching the secondary and tertiary care centers. This telemedicine initiative shall play a more significant role even within the primary care setup, wherein the CHO heading the HWC-HSC (Health sub centre), who is not a physician, may take the advice and guidance of HWC-PHCMO (Primary health centre medical officer) through the telemedicine. Continuum of care, which has a significant role in NCD management, will be done by establishing upward and downward referrals back to the community level. Under the AB-HWCs, 37.35 crore individuals have received NCD drugs, 13.08 crore have availed diagnostic services, and 0.63 crore wellness sessions were also conducted under the HWCs, by March 19, 2021. In terms of overall screening, 19.01 crore, 15.74 crore, 10.34 crore, 5.07 crore, and 3.41 crore population have been screened for hypertension, diabetes, oral cancer, breast cancer, and cervical cancer, respectively, till April 29, 2022. [Supplementary File 1].
As India is a federal country and health is a state subject, it is naturally expected from the states to take ownership and innovate the implementation of the NCD management. Living up to the expectations, states have also brought local innovations in NCD management. NCD ticker bags, an innovation to ensure treatment adherence, follow-up, and reduce drop-outs, are being done under the HWCs. Recent assessment done in 18 states shows that the HWC has helped tremendously in providing COVID-19 and non-COVID care, including the NCD services. There is also a convergence of different sectors for the PHCs level.
| Gaps in the Noncommunicable Diseases Management at the Primary Care Level|| |
Lack of awareness about NCDs' risk factors and management in rural areas is also a major gap. Lack of timely supply of drugs and diagnostics has been reported as a gap in NCD management., Elias et al., in their study from Karnataka, reported the lack of laboratory facilities stock-outs of medicines at PHCs, which act as a deterrent to accessing services from the public health facilities. Deficiency in the equipment for the NCD screening is being managed with the help of providing the HWC toolkit with 29 items at the HWCs. Village-wise, population-based screening for NCDs has been implemented through conducting camps to improve the screening rate. To prevent the loss to follow-up of the screen positives and diagnosed cases, an objective format has been developed and implemented in the state of Punjab for all NCD patients. The loss of the patient in the NCD care cascade due to referral to the PHCs for initiating the treatment can be prevented by establishing telemedicine service at the HWC-SHC level. Delivery of free medicines for the NCD management is being done through the HWC-SHCs at the village level. To ensure availability, the supply chain of the drugs and diagnostics can be guaranteed through a robust delivery system wherein a vehicle directly from the warehouse delivers to the HWCs. Other challenges faced in implementing HWCs include the capacity building of the team and coordination of the supplies and the lack of multisectoral coordination. The National Multisectoral Action Plan for the NCD management must be tailored to the state and district level. An HWC-level multisectoral committee must be formed within each district, leveraging the existing Jan Aarogya Samiti and its members. This will enable the HWCs to emerge as the hub of comprehensive-promotive, preventive, therapeutic, and rehabilitative NCD management. Biomedical waste management also poses a great challenge, as a camp-based approach for NCD screening generates waste at the field level, requiring regular and safe transport of the wastes back to the HWCs.
| Challenges and the Road Ahead|| |
Yet, the HWC initiative is not without challenges. There is a need to build human resource capacity with a continued need for training. In general, adequate, skilled, and equitable distribution of human resources for health has been a significant issue in India, posing a challenge to the HWC initiative. Many states such as UP, Gujarat, and Rajasthan have conducted specific training programs to improve the capacity and address the issue. Yet, the lack of training modules for NCD management and incorporating the expanded NCD package into that module are challenges. The flow of information is another challenge since a two-way reporting and feedback system is a must. This ensures a continuum of care approach with well-established referral and back referral linkages. Life-course approach for NCDs will assure that the promotive aspect of NCD management will be taken up at the school level. A periodic review mechanism is a must to assess the adherence to the treatment availed by the patients.
Community participatory groups such as Village Health Sanitation and Nutrition Committee (VHSNC) and Mahila Arogya Samiti (MAS) have been less involved in the NCD management. This poses a significant challenge, as the participatory approach can improve the population-based screening yield and referral adherence. The lack of standard treatment protocol for NCDs is a challenge from the health system side. It affects the decision-making as well as the quality of care. This can be rectified by widespread dissemination and sensitization of the NPCDCS treatment guidelines and the World NCD Federation guidelines. The trust deficit between the patients and the health providers has also been reported. Greater community participation by actively involving the VHSNC and MAS by conducting the NCD screening camps during the village health days and MAS meetings, involving the VHSNC in formulating an NCD referral and continuum of care plan for the village can improve the screening coverage and build the confidence between the community and health-care system. The service delivery in NCDs and UHC in India can be strengthened further through HWCs. It is essential that HWCs, UHC, and NCDs are interlinked in their objectives and activities. Evidence suggests that a public health approach is needed for NCD management, and they are best delivered through PHCs. The approach must shift the focus from medical care to health care, and the scope must be broadened beyond just curative services. The learning of community participation from the management of COVID-19 can be applied under the HWCs to promote greater dividends in the NCD management of India. The HWCs need to focus on a participative and local level multisectoral approach to address the five major risk factors for NCDs – Tobacco, alcohol, physical inactivity, inappropriate diet, and air pollution. Both for UHC and NCDs, their approach and objective to increase accessibility, availability, affordability, and quality are common. The NCD services at the HWC level are being made free of cost, which will make the services affordable to the patients. The quality of the services must be ensured by mandating internal and external accreditations such as National Accreditation Board for Hospitals and Healthcare Providers for the HWCs.
| Conclusion|| |
HWCs are a game-changer for universal access to CPHC as it empowers both service provider and the community. Although HWCs are a suitable approach for UHC, they are not sufficient unless an additional package of services, adequately trained human resources, and a strengthened referral with a continuum of care is ensured. The challenges that remain in operationalizing the envisaged package, across the country in all the HWCs must be acknowledged and worked upon. This will enable us to continue on the path toward UHC, stick to the action plan on NCDs, and assist us in achieving the NCD-related targets under the national and international plans.
| Acknowledgment|| |
We want to express our sincere gratitude to all the speakers of the scientific session: Dr. MA Balasubramanya (Advisor Community Processes and Comprehensive PHC NHSRC, MoHFW), Dr. Poonam Khattar (Professor, Department of Communication, National Institute of Health and Family Welfare, New Delhi), Dr. Chandrakant Lahariya (World Health Organization, India), and Dr. Areet Kaur (Director, National Health Mission, Punjab) for sharing their expertise. We would like to acknowledge the World NCD Federation's technical support during the scientific session.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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