More than 2 million people will benefit from the boost provided by a project to enhance government health and wellness centres in Madhya Pradesh
Pana Damor is 62, diabetic and dependent on public healthcare. For her treatment she would visit the government health and wellness centre (HWC) in Makankui, a village in Madhya Pradesh’s Jhabua district. Often, she would make the trip only to find the centre closed.
Over the past year, though, Ms Damor’s experience has been transformed. Now when she visits the HWC she meets the community health officer (CHO), who tracks her medical history, manages her condition and counsels her about a healthy lifestyle. “It’s a great relief to be attended to properly every time I visit,” says Ms Damor.
Thousands of people like Ms Damor are benefitting from a rejuvenated public healthcare system in Madhya Pradesh. The Makankui HWC is among hundreds of centres being upgraded as part of the Madhya Pradesh Health System Strengthening Project (MP-HSSP), a Tata Trusts-supported effort to strengthen the delivery of comprehensive primary healthcare in the state. MP-HSSP helps turn these upgraded centres into model health facilities that can serve as benchmarks for other centres.
Launched in early 2021, MP-HSSP is being implemented by the Trusts’ associate organisation, Collectives for Integrated Livelihood Initiatives (CInI). Currently, the initiative covers 432 subcentre HWCs and 14 urban primary health centres (UPHCs) in 23 districts of Madhya Pradesh, benefitting a populace of more than 2 million people. These numbers will go up when the initiative hits its target of 500 HWCs and 23 UPHCs.
The programme has the weight of the state behind it. It is monitored by an executive committee comprising members of the National Health Mission, the Trusts and CInI. The centres are being upgraded based on guidelines set by Ayushman Bharat and the National Quality Assurance Standards (NQAS). The Trusts, through CInI, provide the technical support to improve the provisioning and quality of services in these model centres. The state government brings in the infrastructure, ensures the necessary supplies and manages human resources.
The mandate for CInI is huge. Apart from overseeing the infrastructure improvements of hundreds of HWCs, it is putting processes in place to ensure service strengthening, quality assurance and capacity building of about 10,000 grassroots healthcare workers.
“Our task was cut out from the beginning,” says Sonal Das, general manager, central and east zone, with the Trusts. The challenges in executing the programme were significant: availability of healthcare workers in rural areas, skill gaps among the staff and inconsistent operational processes. These were compounded by community-related issues such as poor ‘health-seeking behaviour’, lack of awareness and socioeconomic distress.
To start with, CInI conducted an initial assessment of 181 HWCs serving around 1 million people in July-September 2021. The assessment spotlighted a multitude of infrastructural and process inadequacies. For instance, most centres lacked basic facilities like privacy in examination rooms, dedicated spaces for diagnostics and laboratories, functional toilets, amenities for the disabled and biomedical waste management. And there were issues with the availability of essential drugs and supplies, skills and training, record-keeping, etc.
The assessment looked at service gaps in the 12 comprehensive primary healthcare services that HWCs are expected to provide. The findings led to a three-pronged strategy: operationalising standardised protocols at the HWCs and UPHCs, building the capacity of frontline workers and enabling technology adoption.
At the heart of the system-strengthening effort is the capacity building of frontline healthcare workers. “We leveraged the support of existing government institutions and trainers to facilitate upskilling of primary healthcare workers,” says Ms Das. The MP-HSSP team has thus far trained nearly 7,500 health workers and mentored more than 2,700.
An important component of MP-HSSP has been the leveraging of existing digital platforms in the healthcare system to ensure comprehensive and continued care. The digitisation work has been initiated and will be rolled out in phases.
Mohan Prasad, an auto mechanic from Singrauli district, realised how digital records could be a boon. An asthmatic, he would buy medicines based on a prescription from his UPHC. When he lost the prescription, he became anxious. On his next visit the doctor told him not to worry as his data was recorded. “I never imagined that a machine would know more about my age, location, and disease than I do,” he says.
There is also an intense effort to improve health-seeking behaviour among rural residents. This translates into better utilisation of the health services available in rural regions and, consequently, a reduction in the load on bigger centres.
“Our team motivates and mentors CHOs, ASHAs [accredited social health activists] and ANMs [auxiliary nurse midwives] to strengthen their community engagement and drive wellness activities,” says Ms Das.”
The MP-HSSP team’s efforts over the last two years have helped change such behaviour. Says Ravina Solanki, CHO for the Unnai-Jhabua HWC: “Our centre was not in working condition earlier. But we are now able to do routine screening and provide essential health services. We want to change the perception that government centres do not deliver top-class services.”
A key service rendered by HWCs is tackling anaemia in pregnant women (by testing and administering iron sucrose). The MP-HSSP trained CHOs, sensitised staff and ensured the availability of equipment and materials. Frontline workers spread community awareness through school visits and by observing ‘village health and nutrition day’.
Kanswati Binjhori is one of those who found the best of care at the Bijhori HWC in Dindori district during her pregnancy. “I was treated with care by the CHO throughout my pregnancy,” she says. “She organised all the tests and also designed a nutritious diet for me and my baby.” Due to improved service delivery, there has been a dramatic rise in the number of expectant mothers visiting the upgraded centres.
CInI’s efforts are having measurable impact. The centres are periodically assessed on the NQAS framework for certification. From an average score of 28% on NQAS parameters in March 2022, the needle had moved to 56% by February 2023. “The improvement is heartening,” says Ms Das.
As MP-HSSP unfolds, the agenda will cover more effective utilisation of digital platforms to drive process efficiencies at the centres. A knowledge management network is being established with the expertise of government medical colleges to provide guidance to frontline healthcare workers through virtual mentoring sessions. Also in the pipeline is the setting up of a care-coordination centre to monitor programmatic indices across the range of services and enable better coordination of service delivery.
Having come a long way in the last two years, MP-HSSP plans to build on what has been learned and absorbed. Documentation of the model approach is an integral part of the programme. This will enable the sharing of ideas and processes to support the state government to achieve its end goal — replicating the model centres across Madhya Pradesh to make primary healthcare more accessible and effective.
Community health workers recount their experiences of the MP-HSSP:
“I was introduced to the concept of herbal gardens and medicinal plants, which is a part of creating a model centre. The CInI team and I worked hard and now our garden has amla (Indian gooseberry), aloe vera, neem, fenugreek, ginger, garlic, basil and patharchatta (kalanchoe pinnata).”
— Pratibha Pandey, HWC Kuchwahi, Sidhi district
“The community never counted us as a part of their village. People, even pregnant women, would travel 44-60km to
visit district hospitals. My team made it our responsibility to change this mindset and make people aware of our HWC’s services. Now the footfalls have increased. A farmer told me: ‘Please give me medicine. When I come here, I feel better.’
I am humbled by his trust. We worked hard to qualify as a model HWC and it all seems worthwhile.”
— Krishna Kushwaha, HWC Amgawan, Anuppur district
“I am concerned about the palliative care patients in my
area, so I visit them at home. An old lady was suffering from chronic diseases and mental disorders. I visited her regularly and counselled her family. Now she eats better and she even gave me her blessings. HWCs should take responsibility of the community and be patient-centric.”
— Najmeen Bano, HWC Dudhi, Shahdol district
“There was no drug forecasting here; we used to place orders after the drugs ran out. Because of this unavailability patients would have to go to far-off hospitals. Now we reorder on time and send back expired drugs. The best part is that our patient community trusts us and does not go anywhere else now.”
— Rajkumar Pal, HWC Mahaneem Chouraha, Vidisha district