Performance of health and wellness centre in providing primary care services in Chhattisgarh, India | BMC Primary Care

Study design

This was a cross-sectional study involving a quantitative assessment of health facilities that included operational HWCs in the state of Chhattisgarh. The health facility survey was conducted from August to October 2023.

Study setting

Chhattisgarh is one of the poorest states in India with a predominantly rural population. The state has a total population of 30 million. Around one-third of the population of Chhattisgarh is a vulnerable social group known as the Scheduled Tribes (STs) [11]. When the state was split off from a larger state in 2000, it took with it a deficient healthcare system and a dire scarcity of medical personnel. When it came to NCDs, there was an acute service shortage in the public health system. The latest data showed that the state has a maternal mortality of 137 per 100,000 live births and infant mortality of 38 per 1000 live births. The state has 31.3% of under-five age children underweight [12]. The state also has a higher prevalence of malaria, tuberculosis, and leprosy. Among the adult age group, 10% had blood sugar levels > 140 mg/dl and 16.3% had hypertension [13, 14].

The state has a three-tier healthcare delivery system named primary, secondary, and tertiary level. It starts from Sub-health Centers which are being upgraded to HWCs covering 3000–5000 population. It has Primary Health Centers (PHCs) for 20,000–30,000 population and Community Health Centers (CHCs) as the first referral units covering 80,000–120,000 population and district hospitals as tertiary healthcare centers [6].

All 5200 SHCs in the state are expected to be upgraded into HWCs. Currently, in state 3350 SHC-HWC are operational with a CHO posted [15].

Sampling

A two-stage sampling was adopted to select the HWCs for the facility survey. In the first stage, more than 50% of districts (18 out of 33) of the state were selected randomly from five administrative divisions of Chhattisgarh. In the second stage, HWCs were chosen through systematic random sampling from a district-wise list of HWCs that had been operating for more than a year with a CHO posted. There were variations in the number of HWCs in each district. To have a fair representation from each district, HWCs were covered in proportion to the total HWCs in each sample district. The required sample size for health facility assessment was 386 HWCs. It was calculated using an absolute precision of 5% and a confidence level of 95%. The study aimed for a 10% additional sample and was able to cover 404 HWCs.

Chhattisgarh is a predominantly tribal state and among 18 selected districts 9 (50%) were tribal districts. Under the National Health Mission, Chhattisgarh is considered a high-priority state and it has five high-priority districts. Among these five districts, we have included three high-priority districts named Bilaspur, Jashpur, and Sarguja.

Data collection

For data collection, a structured health facility survey tool was developed (Supplementary File S1). The facility assessment tool was developed and standardized by following the operational guidelines of Health and Wellness Centers. The data of facility assessment was collected in Google form. Data was collected by district consultants working with the State Health Resource Center, Chhattisgarh. All of them had post-graduate degrees in public health. They spent around 4–6 hour at each HWC for data collection. The information collected through record review, observation, and staff interviews was recorded in a structured survey tool. The tool was pilot-tested before finalization. The facility assessment tool had information in two broad categories − 1. Essential inputs – Human resources, drugs, diagnostics, Infrastructure and capacity buildings, and 2. Service delivery outputs. The list of expected inputs and outputs was based on the operational guidelines for HWCs issued by the Ministry of Health and Family Welfare, Government of India [4].

To collect data related to above mentioned categories tool was divided into four parts as follows:

1. 1.

   The first part covered the profile of sample HWCs in terms of population coverage, remoteness, and years of operationalization. This part also covers the human resources available in HWCs and socio-demographic characteristics of mid-level providers (CHOs) and their training details. This data was collected by interviewing the CHOs.

2. 2.

   The second part covered infrastructure readiness, telemedicine, ambulance services, and biomedical waste management. This data was collected through observation, record review, and interview of the primary care team.

3. 3.

   The third part covered the inputs on the availability of essential medicines and diagnostic services at HWC. For assessment 30 important medicines covering the larger health needs were taken from the recent Essential Medicine List (EML) of the state. This information was gathered through physical verification of supplies and by review of stock registers.

4. 4.

   The fourth part covered the service delivery outputs of HWCs. It captures the range of primary care services delivered. This information was collected from service delivery records available at HWC.

Data analysis

Data were imported into MS Excel and analyzed using SPSS version 20. We have analyzed data descriptively and presented it as mean, confidence interval at 95%, frequency, and percentages. The service delivery outputs for CPHC services were analyzed for five major categories: reproductive and child health (RCH), communicable diseases, NCDs, emergency care, and common acute ailments.

The performance of HWCs was assessed against the expected healthcare needs of the catchment population. The performance of HWCs was measured in terms of a monthly number of out-patient visits and NCD patients. The expected healthcare need for outpatient care and NCD care was calculated from recent studies in Chhattisgarh [13]. The calculation of HWC performance on outpatient care and NCD care (for hypertension and diabetes) was described in Additional File 1. A recent study on measuring UHC in India has used similar indicators [16]. A study on health facility performance in India has also used similar measures [17].

Ethics declaration

The study was conducted in accordance with the National Ethical Guidelines for Biomedical and Health Research Involving Human Participants Issued by the Indian Council of Medical Research. The study was approved by the Institute Ethics Committee of the State Health Resource Center (SHRC), Chhattisgarh, India (L. No./1469/SHRC/21.09.2022). Informed consent was taken from HWC staff before data collection including interviews and their confidentiality was maintained. Results.

General profile of HWCs

The profile of HWCs included in this study is shown in Table 1. On average, an HWC covered four revenue villages and a population of 5083. An HWC’s average distance from the state and district headquarters was 229 km and 40 km, respectively. An HWC was located on average 11 km away from the closest PHC and 19 km away from the nearest CHC. Around two-thirds of the HWCs were located more than five kilometers away from any PHC.

Infrastructure readiness of health and wellness centers

Around three-fourth (72%) of HWCs have displayed the clinic timings and external branding and appropriate signage were done in 91% of facilities. Most of the HWCs (85%) had running water supply, around 90% had at least one functional toilet, and all most all (98%) had electricity. Around 91% have functional labour rooms, more than half (54%) had functional baby warmers, and three-fourths (76%) have refrigerators. Most of them (96%) had colour-coded bio-medical waste collection bins, hub and needle cutters and half of them had deep and sharp pits constructed. Around 45% of the HWCs had utilized ambulance services at least once during a month. Information on the infrastructural readiness of HWCs is shown in Table 2.

Human resources readiness of health and wellness centers

All the HWCs had a CHO posted. Majority of HWCs (96%) had an additional paramedical staff posted and of that around half of the HWCs (51%) have two paramedical workers posted. More than half of the CHOs (55%) had done the 6-month Community Health Certificate (CHC) bridge course after their bachelor’s degree in nursing and the rest had undergone an integrated course where CHC curricula were part of their nursing degree. Almost all the CHOs had had received multiple rounds training on standard treatment protocols and most of the paramedical staff (ANM & MPW) have received training for common ailments. The characteristics of human resources working at HWC are shown in Table 3.

A majority of CHOs (83%) were below age of 30 years and around 90% were female. Almost 72% of the CHOs were posted in a HWC located in their respective native districts. Around half (45%) stayed in the same village where they were posted and around 23% had residential facilities in the HWC. HWCs have a provision for the formation of Jan Arogya Samiti (JAS). 99.2% of the HWCs had formed JAS and doing monthly meetings. JAS serves as an institutional platform for community participation. (Table 3).

Availability of drugs and diagnostics at health and wellness centers

The mean availability and stock-out of important essential drugs at HWCs are given in Table 4. Almost all the HWCs have a fair availability of various class of essential medicines. However, the medicines used in the treatment of mental illnesses were stocked out in the majority of the HWCs.

The availability of essential drugs at HWCs is shown in Table 4.

The availability of essential diagnostics kits at HWC is shown in Table 5. The majority of the centers have the availability of rapid kit-based diagnostic tests for pregnancy, malaria, urine (albumin/sugar), and sickle cell disease. The majority of HWCs were providing sputum collection services for tuberculosis.

Comprehensive range of primary care services provided by health and wellness centers

On an average 358 OPD patients including 128 NCD patients were treated monthly at HWCs. Among NCD patients, 93 received monthly medicines from HWCs while others received screening and follow-up care. More than half (58%) of the HWCs conducted more than 20 digital teleconsultations per month, whereas 22% of HWCs had done none.

The profile of curative services provided at HWC is shown in Fig. 1. Acute illnesses had the largest share in the volume of services provided at HWC, followed by care for NCDs, communicable diseases, RCH services, and emergency care (3%).

Share of clinical services provided by health and wellness centers

Among acute illnesses, the major conditions treated at HWC were pain, common cold and fever. Along with the communicable diseases under national disease control programmes, HWCs also provided care for skin infections, eye and ear infections and reproductive tract infections. In addition to the numbers reported here, there were services provided by the HWC primary care team as a part of outreach services, especially the RCH services (antenatal care, immunization, home visits for RCH services). Care related to pregnancy and childbirth was also provided at HWCs and on average 2 (2–3) deliveries were conducted monthly. Almost 75% of the HWCs conducted at least one delivery per month. HWCs provided primary care for minor injuries and burns. The disease-specific volume of primary care services is shown in Table 6.

Major value addition in HWC services was screening, ensuring diagnosis, dispensing medicines, and follow-up care for NCD services, especially for hypertension and diabetes.

Performance of Health and wellness centers in coverage of population health need

The performance of HWCs in coverage of population health needs for out-patient and for NCD care is shown in Table 7. HWCs were able to cover the one- third (31%) of the total population’s health need for out-patient care. In terms of care for NCDs, HWCs were able to cover around one-fourth (26%) of the total population need for hypertension care and around one-fifth (21%) in case of diabetes.

Since Chhattisgarh is a predominantly tribal-populated state, we calculated the performance of HWCs for tribal and non-tribal (rural) districts. The monthly outpatient performance of HWCs in tribal and non-tribal districts was 36% (34–38) and 34% (32–36) respectively. Also, the performance of HWCs in hypertension and diabetes care in tribal areas was 29% (27–32) and 22% (21–24) as compared to performance in rural areas i.e., 29% (27–32) and 24% (22–26) respectively.