• An initiative for village/community based self-reliant health facilities

• Will provide primary Info, disease detection, care and linkages

Arogya BanksA business or CSR plan

PROPOSED BY

Dr Shyam Ashtekar, MD (PSM)

Consultant Community Health

Nashik 422013

Need and feasibility

In 1940!

Need • 70% villages have no local health facility

• Villages have to purchase inferior health care, travel a distance, pay stiff costs (Rs 50- per episode) and access costsaccess costs

• Loss of daily income for two (sick+attendant)

• Major drain on rural family incomes, 2nd important cause of indebtedness

villages and docs:

2000 study in Nasik

16%

84%

villages w ithout doctors

villages w ith docs

A health system pyramid without much foundation!!

No docs for villages, not even good health workers

Many efforts on rural health: A draw?O X X

X O OX O O

O O X

Concept-Arogyabank

• We want to provide a comprehensive and winning formula

• A health facility for serving comprehensive first level care-curative, comprehensive first level care-curative, preventive, health-promotive, information needs and referral

• A PPP model at grassroots

We take our Mandate from

• Health for all by 2000

• National Health Policy 2002

• National Rural Health Mission• National Rural Health Mission

• 72-73rd constitutional amendments

• Policy on PPP (public-private partnerships)

Integrated model-PPP

• Several old and new experiments/schemes are integrated in this

• Provides a broad-frame • Provides a broad-frame for innovation and experiments

• We will technically support the network

Ownership- model

• Shared between village panchayats, public health dept, people, private sector and provider (health worker)

• Corporate ownership possible• Corporate ownership possible

• Each AB Unit–ownership with local bodies/SHGs

Objectives-to provide

• Primary medical aid for 50+ health problems

• Health information through print and e-medium

• Preventive care for important health • Preventive care for important health problems

• Referral to proper institutions and follow up

• Save some health expenditure and some access costs

Feasibility• Crying public need felt-expressed felt need!

• Many villages are deprived of health care

• 73rd amendment to constitution empowers villages

• People already spend resources• People already spend resources

• Govt schemes exist-PHW/ASHA etc-but defunct

• We need to explain the options and tie up loose ends

Location and Hardware

Locating

• 1000-2000 pop cluster and within 2 km

• Rural location (can be urban also)

• based on expressed need by Panchayat/a valid village body or groupPanchayat/a valid village body or group

• Generally we will omit village with health sub/center

• Selection on basis of participation by village panchayat/ SHGs and fulfilling conditions

Space and shelter

• The facility should have a visibleshelter-room

• Standard color code

• A small room/dome can do

Hardware

• Furniture-cupboard. table, chairs/seats

• Clinical set-wt machine, BP, thermometer etc

• Computer for health demos, with 2 hr • Computer for health demos, with 2 hr back up.

• Connectivity welcome –will start E health

• Mobile phone mandatory

Legalities

Legal support

• Mandate from 73rd amendment to constitution

• Use of MMP act section2/iv-exempting health volunteers from exempting health volunteers from MMP (no sales, no profits)

• Use of FDA schedule K, 13-use of medicines by CHWs etc

• Use of FDA schedule 23-village shop remedies

Human Resources

Better trained HealthWorker

• A trained professional health care worker (we will train)

• Man or woman, or both for a bigger populationpopulation

• Retired soldier, disabled persons can also participate

• Part time work and compensation to start with.

Use of ASHA-PHW

• Both ASHA & Pada Health Worker are existing health workers with some financial and system support

• PHW (Pada Health Worker) gets 400 Rs • PHW (Pada Health Worker) gets 400 Rs per month, little work, looking for worthwhile work and role inn the health system

ANM or MPW?

• Both Auxiliary Nurse and Male health worker are existing health workers with good financial and system supportsupport

• MPW/ANM can fit the bill if Govt system wants an experiment with Arogyabank.

Eligibility and Entry Test

• Eligibility: 10th is fine

• We may conduct an entry test, hence village panchayat can recommend 3-4 candidatescandidates

Training and accreditation

Training

• Level 1-Arogyamitra course -spread on 5 months, ODL, total 5 wks

• Level 2-palliative care, clinic assistant, emergency aid, emergency aid,

• Level 3 additional modules: select diseases, scientific massage, data-management,

• Level 4: child care, geriatric care, care for disable, even Skilled Birth Attendant

Accreditation

• Health worker: We will conduct examinations for every level annually, This will be an ODL programme with continuous programme with continuous assessment and credits

• Procedures: SOPs are ready

• Center: standard norms

Tasks & activities

Free/public paid Tasks1. First aid for emergency (free)

2. Nutrition education

3. Detection of important illnesses-anemia, HBP,DM,TB,cancers

4. Water test, water-disinfection4. Water test, water-disinfection

5. School Health

6. Assisting in RCH & NHPs (VBD, Nirmalgram)

7. AYUSH promotion

8. Referral and follow up

9. Health data

User paid Tasks

• Part-time primary care

• Detection of important illnesses-anemia, HBP,DM,TB,cancers

• Home care

• Simple lab tests, water test

• Assisting in RCH & NHPs (VBD, Nirmalgram)

Time-sharing

• 1 hour in morning and evening -for medical care to start with.

• The health worker will do his/her livelihood activities in the daytimelivelihood activities in the daytime

• Public interest activities to be timed as per inputs/supports

Drug kit and supplies

Consumables

• 20 primary care medicines each from allopathy, Ayurveda, Homeo

• National Health program supplies like DOTS, malaria remedies, like DOTS, malaria remedies, condoms, pills etc

• Herbal remedies

• Wound care material

Fever Aspirin/Pamol Tribhuavnkirti, Guduchighanvati Belladona Tulsi kadha, w arm w ater, tepid sponging

old injury pain/muka mar Aspirin/Pamol Arnica 30

Toothpain Aspirin

RS Common cold paracetomol* tribhuvankirti allium sepa ST3/ST3/LI19/LI4 Lemon grass tea

URTI Aspirin/Pamol Sitophaladi, tribhuvan***, Ginger+honey or jaggery

URTI-productive Cozal+pamol Sitophaladi, Milk+haldi, Jeshthimadh, adulsa

childhood LRTI Cozal+pamol Milk+garlic

LRTI adults Cozal+pamol Steam inhalalation

Tonsillitis Cozal+aspirin/pamol Mirc IR

Asthma attack# Salbutomol-inhale/tab Sitophaladi Rein17/LU7 Breathing exercises,

GIS Acidity Gellucil** Sootshekhar***

Hiccoughs Jaggery

child dirrhea ORS Jaiphal (balghuti)

Diarrhea-adult Furazolid+ORS Kutajghanvati Arsenic alba Cofee,

Constipation triphala churna, Arogyavardhini LI4/ST36/ST6 Aamla, Rajgira bhaji,

Constipation-child Gheee/oil by mouth at night

w orms albendazole

dysentery-amebic metronidazole Kutajghanvati Merc Cor Cofee,

dysentery-w ith blood Cozal+dicylomine Kutajghanvati Ghee

Nausea/motion sickness Ipicac Moravala

vomiting/ motion sickness domperidone sootshekhar Arsenic alba

Pain-abdomen-adult Dicyclomine#& para Mag phos

Indigestion, gases Hinguastak churna ST36/P6 for appetite

Pain-abd-baby (criyng)# Hing appl/murudsheng

skin Boil Arogyavardhini Hepar sulf

Inf w ounds Cozal+dressing triphala w ash+neem oil calendula papaya, aloe

Itch/alleregy/insect bite CPM

Fungal infection w hitfield /miconazole

Scabies-dry Gammsacb

Urinary Burning urine sodamint dhaniya paani, kulatha kadha

Hemopoietic Anemia Fersolate

Other infect disMalaria chloroquin China 30 chirait-kadha

Jaundice & fever Pamol Arogyavardhini Bhi-amalki kalk

conjunctivitis Tetra eye drops

ear infection Cozal+Para+CPM

Wax in ear Hydrogen peroxide

Fem Repr sys Vaginitis GV+Metro pessary# Triphala w ash Crushed garlic petal

dysmenorrhea Paracetomol

Lactation(to boost lactation) Shatavari kalp

Emergencies dog-bite soap w ash

snake bite Elastic bandage

Chest pain (acute)# IsobarbideT+aspirin

Ushnatavikar Burning, piles, nosebleed Chandrakala Barf for nosebleed

Supplies

• Standard purchase from listed store for allopathy and Ayurveda & Homeopathy

• Home /local remedies• Home /local remedies

• NHP (programs) supplies from primary health center /subcenter

• Explore periodic Network supply

Panchayat links

• Mandated by 73rd amendment

• Contractual worker for specified period and tasks

• Panchayat shares owenership

• Space is owned by panchayat

Info bank and software

Software

• Common clinical protocols

• CDs for health information-e book

• E-learning modules for HW and • E-learning modules for HW and people

• Slideshows and Videos on health

• Info on health facilities with contacts

Mobile connectivity

• Use of mobile mandatory

• For information exchange and networknetwork

• Broadband connectivity will offer extra advantage.

• Back up by experts

• Referral links

Continuous health education through

• Arogyavidya: CD

• Print-outs, printed pamphlets

• Meetings• Meetings

• Refresher training

• Posters

• SMS /voice narratives on cellphone.

• House-journal

Academic

• The flexi-learning model (ODL) with accreditation,

• use of IT based learning

• low-cost adult learning –lifelong learning

• Deconstruct and ring type model with increasing complexity level

• Epidemiologically fitted for needs

Economics of Arogyabanks

A) Development funds-• Human Resource development/ unit costs

Selection

Training & accredit 5000Training & accredit 5000

Level2 training 5000

10000

B) Capital-funds

furniture Netw ork 5000

equipment Netw ork 5000

starting kit Netw ork 1000

Computer Netw ork 30000Computer Netw ork 30000

cellphone& cdNetw ork 4000

Corpus Netw ork 5000

60000

C) Operational Costs

annualised

Honorarium PHW/ASHA payment 24000

Drug refills revolving fund 1000

HEd material 1000

Operationl exp

HEd material 1000

maintenance 1000

travel 1000

28000

Costs and returns: Some Guestimates

•10 illness services daily- at Rs average 10s, brings

2500 per month. (drug costs are extra)

•Tests and other services: 1000 per month

•Out of 3500, 2000 will go to paramedic

•1500 will go to overheads and network profit per •1500 will go to overheads and network profit per

month. Rs 500 for monitoring

•Rs 12000 annual profit, on a capital of 60000.

•We plan to start 100 centers, hence about 12 lakh

proceed per cluster of 100 (say half a district)

Additional Pay for the health worker (3h/day/6day per week)

• Village retainership through panchayat funds/untied funds (300 pm) for 1 hr daily

• Task payment from Public Health dept • Task payment from Public Health dept for national programs (about 300 pm) for 1 hr daily

• User fees for other personal health needs (about 1400 pm) for 1 hr daily

Overheads

• This factor will depend upon the network size and spread

• A 100 unit network should require two full timers to look after and two full timers to look after and coordinate

Outcome and cost-efficiency

• Primary care for 70% needs at 30% costs (less than access costs),

• Will reduce irrational care by unqualified persons

• Preventive care of enormous value to people and nation

• Will reduce hospital loads, hence improve efficiency

• Early care will reduce morbidity

• Follow up tasks will improve outcome

• Public health system gets a foothold in community

Monitoring and quality

• Code of conduct for care providers

• Technical work monitoring by network agency

• Social and cost monitoring with village body

Network and management

Network

• A close network of 100 centers will maximize use, impact, visibility and viability

• Professional and info-management, • Professional and info-management, supplies

Management- Various models

• Stand-alone units

• Small area networks

• Large are networks• Large are networks

Corporate Social Responsibility

• CSR can add value and management inputs

• CSR can create this unique contribution to health systemcontribution to health system

Linkages with Public health system

• Links with MPW, ANM, Health visitor and PHC doctors

• Links with Anganwadi

• Village sanitation and water supply committee

Stakeholder priorities

Peoples’ priorities

• People need to get good quality care

• At low cost

• Timely• Timely

• Humanitarian

• Accountable services

• Referral and follow up support

Health Worker priorities

• Should get quality training, some life saving skills

• Reasonable earning for part time work-about 1000-2000 at leastwork-about 1000-2000 at least

• Respectable role, popular utility

• Hold interest of community

• Safety from hassles

Public health system should

• Appreciate the complimentary role of this network

• Be ready to contract out work and provide support and suppliesprovide support and supplies

• Deliver timely payments for program tasks

Steps and phasesGramP passes resolution for the AB & gives undertaking

Village has ASHA/PHW & enroles in AM-YCMOU 6m prog OR

or the ASHA/PHW passes in Entry test equal to L1

Preparation Selects-prepares one room/shelter/hut

Logo painting

Team visits and Okays

Undertaking of the HCProvider

Computer system donated-trial runComputer system donated-trial run

Network provides basic kit and equipment (15000)

Candidate gets mobile if connectivity is available

Phase1 (1yr) AB starts working, mentors visit fortnightly

Weekly tele review of services/stocks/funds/problems

Monthly meeting at block for help

Phase2 Upgraded week long training programmes (L2)

Enhancement of work/stocks/logistics

Review and feedback

Remember

• Network ownership and branding is crucial

• Quality, reliability, connectivity importantimportant

• PPP model can be a win-win

• Urban program will add value

This Arogya Bank is a true story

At village Pofala, ta Fulambri, Dt Aurngabad,

Dr Ambedkar Vaidyakiya Pratsithan & Hedgewar hospital has started an

Arogyabank .Arogyabank .

The trained paramedic is

smt Chaya Krushna Gade, 22yrs, at her own home some 9 month back

Thanks

Dr Shyam AshtekarNashik

email: shyamashtekar@yahoo.comemail: shyamashtekar@yahoo.com

9422271544