S ection 5
Information and
Communication Technology
(ICT)
The use of standardized digital health record and establishing a seamless flow of information across all
levels of health care facilities is an aspirational goal. Such a system would take time to evolve. An IT system
has been envisioned at the Health and Wellness Centres and will need to be inter-operable with the overall
e- health architecture plans at the national and state level.
Use of Information Technology would be essential to enable efficient delivery of services at the HWCs. IT tool
would support the HWC team in recording the services delivered, in enabling follow up of service users, in
reporting to higher functionaries, and in population based analytics.
5.1. Key Functions of the IT system are as follows
5.1.1. Registration
zz Empanel all individuals and families in the catchment area and update this database regularly when
there is a new entrant into this area, or someone exits.
zz Facilitate identification and registration of beneficiaries/ families for Pradhan Mantri Jan Arogya
Yojana as per laid down criteria.
zz Ensure that every family and individual have been allotted and are aware of their unique Health ID -
which would also be used to seek services under various programmes such as RCH/ RNTCP/ NVBDCP
etc and support beneficiaries to seek services under the PMJAY.
zz Link the unique health ID with the AADHAAR ID at the back end in line with the current statute and
Supreme Court directions.
zz Identify and merge duplicates by verifying IDs.
zz Create a longitudinal health record of each empanelled individual.
5.1.2. Service Delivery
zz Record all services that are delivered at the HWC under different programmes.
zz Enable follow up of services that individual patients are receiving by recording relevant parameters,
diagnostic results, medication given etc.
zz Send SMS/ reminders to individuals about the follow up visits.
AYUSHMAN BHARAT: Comprehensive Primary Health Care through Health and Wellness Centers
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zz Facilitate clinical decision making for the service providers (based on standard treatment protocols).
zz Track and support upward and downward referrals to support continuity of care.
zz Ability to print key summary and prescription based on individual’s requirement.
zz Ability to provide standardized prescription, discharge summary and/or referral note which can be
scanned/photographed or printed and uploaded as per requirement.
zz Capture, store and transmit images to support teleconsultation, referral and follow up.
5.1.3. Management of Service Delivery
zz Capture service delivery coverage and measure health outcomes using population-based analytics.
zz Generate work plans for the teams with alert and reminder feature for services providers to support
scheduling of appointments, follow up home visits and outreach activities.
zz Use the service delivery data to validate use of services and enable Direct Bank Transfers to
beneficiaries wherever required.
zz Support Birth and death registrations and disease surveillance.
zz Capture record of other preventive and promotive services delivered, like vector control etc.
zz Send appropriate IEC/BCC messages.
5.1.4. Logistics
zz Support Inventory management and regular supply of medicines, vaccines and consumables by
linking with DVDMS – Drugs and Vaccines Delivery Management Systems.
zz Support biomedical equipment maintenance of all equipment by maintaining database for
equipment at HWC.
5.1.5. Capacity Building
zz Provide Job aids (in the form of flow charts or audio/ video aids) for continuous learning and support
of the primary health care team.
zz Support access to Massive open online courses (MOOC) and use of platform such as ECHO for regular
capacity building and problem solving for HWC teams both at SHC and PHC level.
5.1.6. Reporting and Monitoring
zz Generate population-based analytics reports for routine monitoring and to assess performance of
health care providers.
zz Support in generating performance matrix for all service providers, calculating incentives from the
service transaction data in the system.
5.1.7. Teleconsultation
zz Capture and transmit images, prescriptions and diagnostic reports for teleconsultation.
zz Support video call using platforms like zoom and skype to connect with hubs identified for
teleconsultation.
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Figure 5.1: Flow of Information
Primary Health Centre - HWC
ASHA facilitates data collection and service delivery
k
bac
d
Fee
Sub Health Centre 1 2
Households ASHA
- HWC Monthly Enable Patient
Reports Follow Up
3
Enable Population
Statistics
5
List of service Logistic
users for Supplies
follow up
4
Completed reports
submitted to higher level
Block and
District Level
Information
Programme Facility and
Systems –
Specific Area Specific
HMIS/RCH Portal
A core design principle to be followed while building CPHC IT system should be to support needs of diverse
stakeholders and strengthen service providers in undertaking their tasks with greater quality and efficiency,
and that the data required for monitoring and reviews by programme managers at different levels becomes
available.
The IT system would reduce the burden of data recording and reporting for front line workers and service
providers to less than 10% of their total time. Once the digital system has been made operational, and
all connectivity related challenges have been addressed, a gradual phase out of paper-based records and
registers can be planned, if the system can make paper prints out available to meet the requirement of
regular submission of Health Sub-Centre based reports for systems such as HMIS, IDSP, RCH portal and other
national health programme specific reports.
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Key Requirements
Adherence to applicable standards laid down under Metadata and Data Standards for Health (MDDS) and EHR
standard developed by MoHFW.
Ensure security and data privacy by providing secured role-based access system coupled with end-to-end
encryption. The system should adhere to the data privacy and security standards as per HER standards. In
addition, a detailed logging system with essential audit trails (for critical read/write/modify/delete operations)
and error reporting (android/mobile app notifications and emails) should be made operational.
Configurability i.e., developed as a platform on which the various programs, state specific variations, family/
individual profile can be created - using metadata, configuration, pluggable user interface templates and
rules. This would support- a) Addition of new programmes, b) Change in program definition over time and c)
customization according to the local context and for various programs.
High level of interoperability to integrate with state level MIS, RCH portal and other programme systems
functional at national and state level. The integration architecture should be compatible with the recommended
approaches in the MDDS for Health document and EHR standards.
Ability to manage large data volumes i.e. approximately 6,000 active individual health service records as part
of about 1000 active family health records at Health Sub Centre level. System would be horizontally scalable by
addition of servers as to manage the high user load / data volume such that performance of the system is not
compromised.
Ability to function on offline mode – (even when Internet is unavailable for long period) and allow for auto or
manual synchronization of data without any data loss when connection is available
Application should be upgradeable via single click or auto-upgradeable by the end user without requirement of
any additional technical support.
In order to ensure smooth introduction and functioning of the IT system, there will be need to deploy a support
team that has the command over the functioning and technical details of the software system and will provide
training to the end users, systems managers at the district, block, and HWC level. This team would also support in
troubleshooting field level implementation issues from time to time.
Note – Population enumeration and database creation can start even without the software application base being
in place. The data base of the population in catchment area and the registration of the population for chronic
diseases should be started off in parallel with the upgrade of HWCs.
It is possible that data on basic demographic information may be available from existing population- based database
such as- Socio economic Caste Census (SECC), Aadhaar, Public Distribution System, National Population Register etc
and states can plan for obtaining such recently done survey data on migration if available. However, migration and
import of this data in the software system should be followed with verification by house to house visits by the field
level functionaries or verification at the time of empanelment in the Health and Wellness Centres. Authentication
of service users is also possible at the time of service delivery – by using biometric, OTP, or backend analytics of
photograph, if required.
AYUSHMAN BHARAT: Comprehensive Primary Health Care through Health and Wellness Centers
S ection 6
Planning, Location and
Infrastructure Upgrade for
Health and Wellness Centre
6.1. Road Map and Planning for HWCs
Several states are now moving forward with the implementation of Health and Wellness Centres. Overall,
the designing, upgrading and establishment of HWCs should be such that states are able to achieve an
equitable distribution of health care with an efficient utilization of resources. Steps for states to follow while
planning HWCs are discussed below. The State, District and Sub district planning would vary based on local
context and states should adopt the guidelines to suit their needs.
6.1.1 Developing a Road Map
zz The first step for each state is to develop a short to medium term road map with number of Health
and Wellness Centres that will be created over a five-year period and also develop robust and
objective annual plans with specific targets for the state and district level to improve access to the
CPHC facilities, keeping in mind local context and capacity.
zz The plan should define target of the number of facilities (PHCs/Urban PHCs/ Sub Health Centres)
that can be upgraded to effectively deliver expanded range of services on a year on year basis.
6.1.2 Phasing and Identification of Districts
zz States should plan for a phase wise scale-up indicating districts that will be included in each phase.
zz Conforming to the overall principles of equity, selection of those districts should be prioritized
in the initial phase, which align with the ‘Transformation of Aspirational Districts’ Programme of
Government of India. The programme for Universal Screening Prevention and Management of
Common Non- Communicable Diseases has been rolled out in all the states and has been prioritized
in districts where the National Programme for Control of Cancer, Diabetes and Cardiovascular
Diseases has been well implemented. An overlap of Health and Wellness Centres with districts
selected for Universal Screening of NCDs should be planned to leverage pre-existing investment in
health systems to deliver care for NCDs.
6.1.3 Selection of Blocks
zz Once the plan and phasing across the districts is clear, states should select the blocks, which would
be taken up for creating HWCs. Within a district, the programme may be commenced in good
performing blocks with human resources and better referral support. While doing so, simultaneous
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attention will be required to identify and address HR/infrastructure gaps in other blocks to gradually
include them in HWCs development plan for future phases.
zz The plan should be to take up all SHCs and PHCs within any chosen block for upgradation into
HWCs. In certain contexts, block saturation will be a challenge owing to constraints in availability of
human resources, infrastructure, and geographic inaccessibility. In such cases, in the first year, state
may plan to operationalize HWCs in 60-70% Sub Health Centres in the selected block and undertake
necessary measures to strengthen HR and infrastructure in remaining Sub Health Centres so as to
make them functional by next year. Within a block, such PHCs that are relatively well performing
with MBBS MO should be prioritized for transforming as HWC. SHCs which are linked to these PHCs
can be upgraded to HWCs to maintain continuum of care.
zz The block level plan should identify facilities, which can serve as referral centre or for the cluster of HWCs.
The referral center may vary for different services depending on the nearest site where the necessary
skills are available. Thus, the MO in the PHC would be adequate for initiating treatment for chronic
communicable diseases but for attending to a patient with a serious mental illness/NCD, consultation
with concerned specialists at the nearest facility would be needed. However, the bulk of such referral
needs are likely to be attended at the Sub-Divisional Hospital, a FRU- CHC or a Block PHC.
zz Sub Health Centres for upgrading as Health and Wellness Centres should be prioritized:
a. Where a community of about 3000- 5,000 populations is not within the reach of a PHC/ Block-
PHC /CHC or a Sub-Divisional Hospital within 30 minutes.
b. Where population coverage of Sub Health Centres could be lower but access available to serving
population is constrained due to geographic access or otherwise and travel time to reach the
Sub-Centre from the most remote place in the coverage area is more than half an hour.
c. Where progress of health indicators is significantly lower than the block/district average due to
social and cultural barriers of access such as the case of tribal hamlets, villages with high density
of marginalized and vulnerable population groups etc.
zz The Sub Health Centres situated within a distance of 1-2 km from the referral centres could be
upgraded as Health and Wellness Centre at a late stage if required.
zz However, population covered by these centres should be linked with the designated referral centre
and population empanelment, health risk profiling and other outreach activities for CPHC services
will continue to be provided by the team of Multi-Purpose Workers and ASHAs.
6.2 Infrastructure for Health and Wellness Centres
zz Ensuring adequate infrastructure for the delivery of Comprehensive Primary Health Care and Health
and Wellness Centres would need to cater to a population size as per IPHS norms for Sub Health
Centers- one per 5000 population in all areas and one per 3000 in tribal, hilly and desert areas. Where
currently sub-centers are catering to much larger population, their numbers need to be increased.
zz Planning for infrastructure upgrade succeeds the finalization of number and type of facilities
designated as Health and Wellness Centres. Most states have completed the development of
infrastructure for PHCs/Additional PHCs, UPHC but there will be a need to undertake minor civil
repair and infrastructure upgrade for existing buildings for meeting necessary gaps in enabling
these centres to deliver patient friendly services.
zz Patient reception and registration centers, citizen charters, electronic display boards for services,
provision of sitting arrangement of patients, other amenities in the waiting area, TV screens for health
communication, facilities for people with disabilities, provision of privacy for patient examination
area/ examination table, good quality lab, pharmacy, a wellness room for conducting physiotherapy/
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Yoga sessions, rehabilitative services, separate toilets for males and females etc. may be included in
infrastructure upgrade.
zz Major civil infrastructure upgrade would largely be required for developing the Sub Health Centres
as Health and Wellness Centre. Essential requirements for strengthening a SHC to serve as a Health
and Wellness Centres are:
A well-ventilated clinic room with examination space and office space for Mid-Level Health
Provider/Community Health Officer.
Storage space for storing medicines, equipment, documents, health cards and registers.
Designated space for lab/diagnostic.
Separate male and female toilets.
Deep burial pit for Bio Medical Waste Management.
Proper system for drainage.
Assured water supply that can be drawn and stored locally.
Electricity supply linked to main lines or adequate solar source, inverter or back-up generator as
appropriate.
Patient waiting area covered to accommodate at least 20-25 chairs.
Repairs of roofs and walls, plastering, painting and tiling of floors to be undertaken as per
requirement.
Space/room for Yoga if adequate space for expansion is available.
Adequate residential facilities for the service providers.
Rain water harvesting facilities may be planned if required.
zz Once the numbers of SHC to be upgraded as Health and Wellness Centres are final the identified
blocks will need to systematically map Sub Health Centres: with and without buildings.
zz For a PHC- HWC, infrastructure would be as per current Indian Public Health Standards.
zz The concerned Block Medical Officer and a representative from the Engineering wing at the district
level will do a joint site inspection and complete gap analysis for repair/renovation in existing
buildings. The analysis should be based on the essential requirements stated above and will support
in estimating necessary financial resources.
zz A costed prototype for planning civil modification of existing Sub Health Centres buildings and new
construction will be made available by Ministry of Health and Family Welfare, Government of India.
zz States and district should consider the earmarked fund support of 7 lakh/SHC-HWC or 4 lakh PHC-
HWC as a pooled grant rather than fixed grant per facility for infrastructure modification.
zz When new construction is being planned, location of HWCs should be decided through a consultative
process involving community, gram panchayat members, community forest rights committees,
frontline health functionaries, Block Medical Officers and others. Construction of new building should
be preferably undertaken in a central location with high population density and not in peripheral
sites of the villages. Acquiring of land for this purpose would be a priority for the district.
zz To save time and optimize resources, identification of government buildings available with other
departments could be prioritized for operationalizing HWCs after necessary renovation.
zz Old dilapidated buildings should be considered for renovation only after careful review of resources
required. Wherever existing sub-centres are in dilapidated condition, it will be more cost effective to
plan for a new HWC.
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zz Though financial provision for repair and new construction are made available under the National
Health Mission, resource mobilization for new construction could also be explored from different
government programmes such as- Members of Parliament/Members of Legislative Assembly Local
Area Development Scheme, Labour component support available under Mahatma Gandhi National
Rural Employment Guarantee Act (MNREGA), District Mineral funds wherever applicable, Untied
funds available with Local Self Governments in urban and rural areas, District Innovation Funds and
other state government development programmes. Funding under NHM say, 50% support, should
be provided to leverage support from above mentioned potential sources. Support from Corporate
Social Responsibility and philanthropic organizations, NABARD, special funds like tribal affairs,
minorities may also be explored.
zz Convergent action will be needed at district level to identify land for new construction of HWCs. The
MLHP/MPW (M/F) should be involved in site selection. This should be close to community and have
access to essential amenities.
zz Private buildings could be taken on rent, may be as an interim measure, however; the buildings
identified should adhere to the specified infrastructure norms for strengthening a sub health centre
to serve as a Health and Wellness Centres as much possible.
AYUSHMAN BHARAT: Comprehensive Primary Health Care through Health and Wellness Centers
S ection 7
Medicines, Diagnostics
and other Supplies
The credibility of a Health and Wellness Centre rests on the availability of essential medicines and diagnostics
for a wide range of health care needs of the population served by the HWC. In line with the paradigm shift
envisaged, the HWC will provide a broader range of services and this necessitates expanding the list of
essential medicines and diagnostic services currently available.
7.1. Medicines at HWC
Medicines listed as per essential list of medicines for a PHC/Sub health Centre need to be ensured at
respective HWCs. Additional medicines will be required at the HWC as the range of services expands.
Suggestive essential medicine list for a SHC-HWC is at Annexure 1. The indicative list of medicines is as per
National List of Essential Medicines 2015, this will be updated periodically based on new protocols and
states will have the flexibility to adapt the list as appropriate.
Certain medicines for treatment of identified patients with chronic diseases (Hypertension, Diabetes Mellitus,
Epilepsy, Chronic Obstructive Pulmonary Disease, Mental Disorders, and patients requiring palliative care)
can be indented by the Mid-Level Health Provider, from the PHC/referral center essential medicine list. For a
patient suspected of a chronic disease, confirmation and initiation of treatment will be by the Medical Officer
at the PHC or a higher referral centre. However, for continuation of treatment, medicines will be dispensed at
SHC-HWCs by MLHP to avoid patient hardship and ensure that the clinical condition is monitored regularly.
Based on the records in the health folder (electronic/manual), the MLHP will generate each month, a list of
patients on treatment for chronic illnesses in the population served by HWC. The IT system envisaged at the
HWC level would help the MLHP in stock management and estimating the requirement of medicines based
on actual caseloads. According to the patient list, the MLHP can indent medicines from PHC- EML/ referral
centre- EML for a three - month period per patient. The medicines are provided every month to the patient.
Patients would be encouraged to come to the HWC so that their health status can be monitored. Home
based distribution is recommended only for patients who are not able to travel. A list of these medicines is
attached in Annexure 2.
7.2. Diagnostics to be available at HWC
The HWC should have the capacity to deliver a minimum range of basic diagnostics and screening capabilities
for conditions that are mandated to be screened/treated at this level. Diagnostic services as per the Guidelines
for National Free Diagnostic Initiative need to be available at HWC (SHC-7 and PHC-19 investigations).
In addition, a Peak Flow Meter and Snellen’s and Near Vision Chart are recommended for inclusion at SHC-HWCs.
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7.2.1. Point of Care Diagnostics
There is a plethora of diagnostics, several of them are “point of care” that are currently available. However, the
choice of those that need to be included should be taken after validation and Health Technology Assessment.
On completion of HTA, states may consider use of the innovative diagnostics solutions from those empanelled
through Government E-Market Place. Pilots on use of innovative diagnostics solutions may be planned and
linked to innovation portal of NHM for further validation and Health Technology Assessment.
7.2.2. Hub and Spoke Model
With regards to the diagnostic services at the HWC, the primary objective is to minimize the movement of
the patient and improve the timeliness of reporting. This can be achieved by following the hub and spoke
model by creating the hub (Central Diagnostic Unit) at CHC or block level PHC for 20-30 HWCs, depending
on the distance and population served. State will need to define context specific protocols for peripheral
collection of samples from HWCs.
At the level of PHC- HWC, availability of diagnostics and medicine would be ensured as per the existing IPHS
and Essential Medicine List PHC. A suggestive list of diagnostics to be available at HWC and CDU is attached
in Annexure 3.
7.3. Rational Use of Diagnostics and Medicines
Medicines and diagnostics at the HWC should be made available as per the specified clinical pathways and
standard treatment guidelines for all services. Clear treatment protocols ensure the correct and efficacious
use of medicines and diagnostics. Monthly review meetings at sector PHC/ CHC will be a platform for
dissemination of updated standard treatment protocols to the primary health care team. Service providers-
MLHPs, MPWs and PHC staff will need to be trained to undertake counselling for rational use of medicines and
appropriate consumptions based on treatment plan. States/Districts should plan for periodic prescription
audits, robust quality checks on quality of medicines, use of IT system for ensuring rational use of medicines
and diagnostics through periodic training of members from primary care team.
7.4. Equipment and Supplies at HWC
Equipment as well as consumables will be added at the HWC level in accordance with the expanded range
of services. Similar to medicines, certain consumables will be indented by MLHP as per requirement from
PHC/ referral centre. E.g. for home based palliative care of a patient in area catered by SHC-HWC, a kit will
be maintained by MLHP at HWC and required consumables will be indented. Indicative list of items for
Equipment and Supplies is attached in Annexure 4. The list of equipment is exhaustive and can be made
available in incremental manner as range of services expand and budget provision increases.
7.5. Streamlining Supply Chain Logistics
In order to provide the assured set of services detailed in the previous section, availability of essential
medicines and developing basic diagnostic facilities at the HWC is a priority. Issue of poor outcomes related
to supply side deficiencies need to be addressed for this. Assured medicine availability closer to the homes of
patients would support in treatment compliance for long term illnesses where patients generally discontinue
the treatment due to the challenges of medicine refills. It would also have an impact on the levels of out of
pocket expenditures and establish the credibility of public health care delivery system.
The first step would be to make all medicines as per the SHC- EML and consumables, equipment for
diagnostics listed as per the SHC- Indian Public Health Standards available at the HWC. Subsequently,
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additional medicines and equipment as well as consumables for diagnostics will be added at the HWC level
in accordance with the expanded range of services.
The Essential Medicine List will guide the procurement and supply of medicines. The DVDMS system needs
to be extended to the PHC level in those states where it is operational and be enabled on a priority basis
where it is yet to be implemented. In future, efforts will be made to incorporate demographics of patients in
e-Aushadhi software- and enable linkage with patient wise consumption data to estimate real time need.
In order to ensure free medicines and diagnostics, the state will have to ensure a state level robust system for
procurement, involving real time utilization based indenting, well timed tendering, finalization of technical
and financial bids, measures of rate contracting etc. A streamlined distribution, logistics and quality assurance
is required that allows supply chain management to be responsive to changing and diverse patterns of
consumption of consumables across facilities.
7.6. Planning Equipment and Supplies
SPMU/DPMUs could plan to provide equipment and supplies under the following categories to enable
delivery of quality Comprehensive Primary Health Care services:
zz Medicines and Vaccines
zz Clinical Tools, material and equipment
zz Linens and Consumables
zz Furniture and Fixtures
zz Laboratory and Diagnostic Materials
Most of these equipment and materials indicated in annexure would be available in the existing Health
Sub health Centres. An efficient utilization of resources would demand a sub-centre wise gap analysis of
available materials to avoid duplication and plan procurement only for those items, which are either not
available, not functional or required in additional quantity.
* In case of creating HWCs at the PHCs, additional provision can be made for equipment at Wellness Room, which would involve-basic physiotherapy
equipment, tools for exercise, mats etc. for arranging yoga sessions. In addition, a spirometer needs to be available at PHCs linked to HWCs, for confirmation
of COPD.
AYUSHMAN BHARAT: Comprehensive Primary Health Care through Health and Wellness Centers
