An Assessment of Preparedness of Wellness Centers under Ayushman Bharat Pradhan Mantri Jan Arogya Yojana in Haryana

INTRODUCTION With the slogan “Healthy India, Prosperous India,” Government of India aims to promote long-term sustainable development goals (SDG). In keeping with these goals and objectives, the Indian government developed a public health insurance scheme and named it-Ayushman Bharat Pradhan Mantri Jan Arogya Yojna (AB-PMJAY). This scheme paves the way to UHC by protecting the health of low-income and vulnerable populations by lowering their financial burden during catastrophic hospital episodes and increasing their access to high-quality health treatments.[1] The Indian government revealed intentions to convert already existing primary health centres (PHCs) and sub health centers (SHCs) into 150,000 HWCs. These HWCs, which have been renamed as Ayushman Arogya Mandir (AAM), are well-placed to provide comprehensive primary healthcare (CPHC), which includes services like healthcare delivery, human resources, funding, community engagement, ownership, and governance all the way to the end user. As per the Department of Health and Family welfare, Govt of Haryana, there are around 712 functional HCWs or AAM’s (as on February, 2024) in the state against the proposed requirement of 998. Since the provision of medical assistance at a HCW depends upon the knowledge and skill of the staff available, which are usually mid-level health providers or Community Health Officer (CHO) and Auxillary Nurse Midwives (ANMs) or Accredited Social Health Activist (ASHA).[2] In order to study the preparedness of HCWs under AB-PMJAY, we conducted a cross-sectional facility assessment study in Haryana, in tandem with the assessment of knowledge and skill of two core members of the HWC team, the CHO and ANMs. Sampling The research work was conducted in 20 HWCs, four (2 urban and 2 rural) from each of five different clusters belonging to North (Panchkula), South (Mewat), Central (Rohtak), Eastern (Karnal), and Western (Hisar) Haryana. The study included 20 CHOs and 40 ANMs, and tools for assessment of skill and knowledge were developed as per HWC guideline at the National Health Systems Resource Centre, state level health care officials, and researchers at the CPHC Innovation Learning Centre in Rohtak. There were two sections to the assessment tools: the first collected demographic information about participants, while the other section had 40 multiple-choice questions that had been based on a variety of modules, study materials, and guidelines. Collection of data Standardized tools for facility assessment, such as the Service Availability and Readiness Assessment[3] or the Primary Health Care Performance Initiative tool, were used. These tools cover the various aspects of facility readiness, such as infrastructure, equipment, human resources, and service delivery. The surveyors conducted interviews with staff, observe facility operations, and reviewed documents such as registers and reports.[4,5] The study was done in compliance after ethical committee clearance and administrative consent was obtained from state, district, and block health officials before the assessments. Before conducting interviews, participants provided verbal informed consent. The collected data were analyzed using the appropriate statistical software. RESULTS Infrastructure Out of the 20 HWCs assessed in Haryana, 4 were situated in the same location as Zila Parishad SHCs. Among the 16 standalone HWCs, nine had their own independent buildings, while six were located within community-level institutions such as Gurudwaras, Seva Kendras, and Dharamshalas. One HWC was in an Anganwadi, or a child care center. A private examination room was available only at some HWC, even though each HWC had adequate space for general outpatient care. Around 60% of the HWCs shared a single room between the ANM and CHO, which was insufficient for private inspections. Infrastructure facilities such as electricity, water, and toilets were available in 90%, 85%, and 55% of HWCs, respectively. However, only 80% of the HWCs had internet facilities [Figure 1].Figure 1: Availability of Infrastructure at Health and Wellness Centres. Authors Calculations based on Primary Survey DataAvailability of human resources Only 9 out of 20 facilities had all the necessary human resources as per the rules. The deficiency is more in ANM and MPW staff. Knowledge assessment of appointed community health officer In Haryana, mostly nursing graduates have been appointed CHOs (about 68%), while the remaining 32% were Ayurvedic practitioners. On average, the CHOs scored 95% in the knowledge assessment, with the highest score in team supervision-related questions (around 95%) and the lowest in questions regarding maternal health (around 35%) and child health (around 39%). The younger CHOs (around 30 years) and those who had undergone recent training had better scores. On average, the job satisfaction rating of CHOs was around 65%. The main challenges faced by CHOs in Haryana included lack of clarity regarding job responsibilities, limited medicine supply, inadequate set-up, and technical challenges in digital data [Figure 2].Figure 2: Knowledge Assessment of CHO and ANM in various Fields. Authors Calculations based on Primary Survey DataKnowledge assessment of appointed auxiliary nurse midwives 80% holding ANM diplomas. There were 5–32 years of experience among the ANMs. It was found that ANMs’ median knowledge score was 51%, with supervisory questions scoring the highest (92%) and maternal health (15%) and family planning (20%) scoring the lowest. Those with high educational levels and younger ages (21–25) received the maximum median scores [Figure 2]. Furthermore, ANMs with more experience and time at their current position scored higher on the knowledge assessment. Delivery of services Non Communicable disease and reproductive and child health care In 9 of the HWCs, diabetes screening was conducted, but in the 11 remaining HWCs, diabetes screening was not possible due to equipment and supply shortages. None of the HWCs were providing cervical cancer screening services as they lacked private space and VIA equipment. It was found that medication for hypertension and diabetes was being provided free of cost to patients at all HWCs. However, medication for cancer was not being provided at any of the HWCs, and patients were being referred to higher facilities for further management. Reproductive and child health services All HWCs were providing antenatal care services, and iron and folic acid supplementation was being provided to pregnant women. However, only 10 HWCs had functional weighing machines to measure weight during pregnancy. Similarly, while all HWCs were providing immunization services, only 14 HWCs had functional refrigerators for vaccine storage. Postnatal care services were being provided at all HWCs, but only 6 HWCs had a private space for breast examination. In terms of family planning services, it was found that all HWCs were providing oral contraceptive pills and condoms. However, only 14 HWCs were providing injectable contraceptives, and only 2 HWCs were providing intrauterine devices. Overall, the study found that while HWCs in Haryana were providing basic NCD and reproductive and child health services, there were several gaps in service delivery, including inadequate infrastructure and lack of necessary equipment for screening and diagnosis [Table 1].Table 1: Additional challenges faced by the schemeLimitations The study was conducted among limited representative HWCs of Haryana. The study was done over a 24-week period, which may not provide an accurate reflection of the long-term effectiveness of the HWCs. CONCLUSION This study was undertaken to assess the operational gaps and bottlenecks that need to be addressed to strengthen CPHC in Haryana.[6] Success of the AB-HWC program requires interventions both at demand and supply end, such as adequate investment in infrastructure, skill development of staff, optimum use of technology, community involvement, amalgamation of locally adapted facilities and services, and creation of effective referrals. The implementation of HWCs in Haryana is a unique case due to its heavy reliance on private healthcare, with a large proportion of people seeking medical care from private institutions. However, with the inclusion of high end and costly medical procedures under ambit of AB-PMJAY like the Organ Transplantation and creating adequate awareness about the scheme, the faith of people of Haryana has definitely drifted toward the scheme.[7] Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.