MLHP Incentive indicators guidelines

 

Health & Wellness Centres

Primary Health Centre

Health & Wellness Centres are envisaged to provide a comprehensive set of 12 services:

 

1.      Comprehensive Maternal Health care services to be provided in those sites equipped to services as “deliverypoint”.

2.      Comprehensive neonatal and infant health careservices.

3.      Comprehensive childhood and adolescent health careservices

4.      Comprehensive contraceptiveservices.

5.      Comprehensive reproductive healthservices.

6.      Comprehensive management of communicablediseases.

7.      Screeningand  Comprehensivemanagementof non communicable diseases.

8.      Basic ophthalmic careservices

9.      Basic ENT careservice

10.  Screening and basic management of mental healthailments.

11.  Basic dental healthcare.

12.  Basic geriatric health careservices.

 

ExistingStaffpattern    MPHA(F) +MPHA(M) HWC      MLP     : Midlevel Provider

Mid Level Provider (B.Sc. Nursing), to lead the Primary Health Care Team at Subcentre  MPHA (F) and (M)) and ASHAs

             Job responsibility of MLP

Ø  MLHP would be responsible for ---

Ø  Implementation of National Health Programmes

Ø  Administration and management at Health and Wellness Centers

Ø  Provision of preventive, promotive and curative care

Ø  Identification of danger signs and referral after pre-referral stabilization

Ø  Ensuring quality protocols are adhered to— including implementationof Biomedical waste disposal and Infection Control guidelines.

Ø  Provision of on the job mentioning to health workers

Ø  Ensuringmaintenanceof          inventory of drugs, consumables, diagnostic and otherequipment

Ø  Ensuring maintenance of records, and undertaking monthly reviews of key indicators and provide feedback to the team

Ø  Participation in monthly outreach and community level meetings including engaging with representatives of Local Government institutions/VHSNC

 

Any other job assigned by the Medical Officer of the PHC.

 

 

Institutionalizing Performance Linked Payments (PLP) for Mid- Level Health Providers (MLHP)

Background:  The Operational Guidelines for Ayushman Bharat: Comprehensive Primary Health Care through Health and Wellness Centres identify Performance Linked Payments as a strategy to improve motivation levels, strengthen quality of services, enhance accountability for population health outcomes and serve as a mechanism to identify performance and skill gaps, at the Health and Wellness Centers at sub center level.The PLP are provided for the Mid-Level Health Providers who willplay a key role in enabling continuum of care.

This guidance note is expected to enable the states to roll out Performance Linked Payments for the primary care team at the HWC-SHC - A Mid-Level Health Provider (Team leader), in the catchment population of the HWC-SHC.

These payments are to be made on a monthly basis. Individual performance will be assessed on the basis of data obtained from existing information systems. However, states also have the flexibility to undertake independent monitoring, to validate the information systems.   This could be done through partnerships with research organizations, NGOs, State Health System Resource Centres and medical colleges or through training the existing staff at district and block level to undertake population- linked surveys to monitor progress on outcomes on a periodic basis.

The key features and suggested indicators to guide performance linked paymentmechanism at HWC-SHC is explained below-

1.      Level of Incentive Distribution: Sub-Centre-Health and Wellness Centers

2.      HWC-SHC - Mid-Level Health Provider as per the population of the HWC-service area.

3.      Periodicity: Every Month

4.      Indicators for performance measurement and source of verification:The performance will be assessed on indicators that will be amix of service utilization and coverage of population for essential services.  (Table 1).

Key criteria for selection of indicators is that they cover essential activities related to the first seven service packages of CPHC that have been rolled out.  Thus, outpatient services for acute simple illnesses, provision of ANC, Immunization, services, screening and management for NCDs and TB, and management of Vector borne diseases have been included. In addition, other public health and management functions of HWC-SHC teams such as community level meetings for health promotion and prevention, and monthly meetings at HWC-SHCs have also been included.

The selected indicators are those that are reported in the RCH portal, CPHC-NCD Application, and Nikshay. Monthly performance will be assessed on a set of 15 indicators. That have been specified in Table 1. Additional indicators if required may be included by each State/UT linked on their specific context.For example states having a high burden of vector borne diseases may include indicators pertaining to same. However, the total amount linked with performance incentive for HWC would remain the same. (Refer Point 5)

The list of indicators will be updated periodically linked on the- experience gained from the implementation of performance linked payments, progress on outcomes and roll out of new service packages.  

5.      Distribution of Incentive Amount for each HWC- The monthly incentive could follow the distribution listed below:

·        The maximum amount of incentive for Rs 15,000/ MLHP/month as per the work performance.

6.      Incentive Amount to be allocated for the indicators-   For ease of implementation in the early stages, all indicators are weighted equally, and the MLHP would receive Rs. 1000 per indicator, up to a maximum of Rs. 15,000.  

7.      Service Delivery Output for incentive payment- The service delivery outputs as included in Table 1 have been graded at two levels of achievement: 75% and 100% for 8 out 15 indicators. Performance linkedpayment that is to be disbursed for each indicator will correspond the level of achievement.

8.      Illustration for Calculation of incentives-*

	Assessment Indicator	Definition	Source of Verification/ Reporting	Service Delivery Output to receive 75% of Incentive Payment	Service Delivery Output to receive 100% of Incentive Payment	Maximum incentive allocation for each personnel (Rs) at 75% achievement	Maximum incentive allocation for each personnel (Rs) at 100% achievement
1	Number of OPD cases in the month	No. of OPD cases including new and old cases	NCD application	Min. 300 OP/Month	400 OP/month	MLHP=750	MLHP=1000

Based on standard assumption that there fifteen indicators and monthly incentive allocated

9.      Key principles to assess performance:

Ø  Indicators for performance measurement of the primary care should be easily verifiable. The selection of indicators is such that report for these indicators can be verified from the existing information systems such as- RCH Portal/Registers, NCD Application of the CPHC IT system, NIKSHAY, IDSP reports, meeting records submitted to PHC Medical Officer.

Ø  Ensuring that data is fed accurately and regularly in the information system at each level is a collective and individual responsibility of the HWC.

 

10.  Process-

Ø  The PHC Medical Officer under whose jurisdiction the HWC-SHC is assigned or (any other suitable representative as decided by the state) will be responsible for assessing the performance of the HWC-SHC . He/ She will-

a.      Ensure that MLHPs/MPWs are trained in using the CPHC IT system for online auto compilation and transmission of performance data for HWC-SHC team.  However, till the time such a system is in place, MLHPs will use the data entered in the respective information system to submit performance reports on service delivery outputs for the particular month in a standard format developed by the state.

b.      Ensure release of performance- linkedincentives within one month of submission of performance report by MLHPs. 

c.       Use the performance monitoring mechanism to identify the areas of improvement for the primary care team at the HWC-SHCand provide the necessary handholding and support to improving the performance and overall service delivery at HWCs.

d.      Undertake monthly visits to every HWC for field level monitoring visits and use these visits to handhold and mentor HWC-SHC team.

 

11.  Mode of Validation-

a.      Local-PHC-MO will assess and validate the records submitted by MLHPs with the reports from information systems- RCH Portal/Registers, NCD Application of the CPHC IT system, NIKSHAY, IDSP reports, meeting records submitted for performance- linked payment.

 

External- (i) Existing mechanisms of 104 Call Centre etc. can also be used to validate team performance data reported by MLHPs. (ii) States can also opt to assess service use and satisfaction by random surveys of service users through telephone surveys, (iii) States may also opt for nominating an independent committee comprising of officials and civil society representative to validate the quantity and quality of service delivered by HWCs. This committee can evaluate the performance quarterly or bi annually to ensure that no conflict of interest arises, during the process of performance- linked payment.

 

12.  Ensuring timely payments

Though external validation is essential to check fraudulent reporting; in any given circumstance monthly payment of incentives to MLHPs and frontline functionaries should not await call centre linked validations. 

13.  Possible Action for False reporting by MLHPs:

MLHP as team leader would be accountable for submitting performance reports of HWC-SHC team. He/she should be given one warning if an instance of false reporting of performance indicators is identified from the call-linkedvalidation of performance reports.  Any repeat of falsification could result in deducting the amount from their salaries, and a third instance could lead to termination of service contracts of MLHPs if continuous false reporting is observed despite warning. 

 

 

Table 1 Suggestive List of Indicators to Assess Monthly Performance of HWC-SHC  for Service Utilization

 

	Assessment Indicator	Definition	Source of Verification/ Reporting	Service Delivery Output to receive 75% of Incentive Payment	Service Delivery Output to receive 100% of Incentive Payment
1	Number of OPD cases in the month	No. of OPD cases including new and old cases	NCD application	Min. 300 OP/Month	400 OP/month
2	Proportion of estimated pregnancies registered	Numerator: Number of pregnant women registered for ANC Denominator – Total no. of estimated pregnancies	RCH Portal/ Sub Centre register	60% of the estimated pregnancies registered	80% of the estimated pregnancies registered
3	Proportion of Pregnant Women registered who received ANC	Numerator - No. of pregnant women who received ANC services (as per schedule) in a month Denominator - Total no. of registered pregnant women whose ANC is due that month	RCH portal/Sub Centre RCH register	80% of the pregnant women received ANC as per schedule	100% of the pregnant women received ANC as per schedule
4	Proportion of Children up to 2 years of age who received immunization	Numerator - No. of children who received immunization (as per schedule) in a month Denominator - Total no. of registered children whose immunization was due that month	RCH portal/Sub Centre RCH register	90% of the children received immunization as per schedule	100% of the children received immunization as per schedule
5	Proportion of High- risk pregnant women who received follow-up care	Numerator - No. of high-risk pregnant women who received follow up care (as per schedule) in a month Denominator - Total no. of high- risk pregnant women identified	RCH portal/Sub Centre RCH register	100% of high-risk pregnant women who received follow up care
6	Proportion of Newborns who received HBNC visits	Numerator - No.of newborns who received visits (as per schedule) as per HBNC schedule Denominator - Total no.of newborns	RCH portal/Sub Centre RCH register	80% of newborn received HBNC visits	100% of newborn received HBNC visits
7.	Proportion of above 30 years individuals screened for Hypertension*	Numerator - No. of individuals screened for Hypertension     Denominator-Total population above 30 years of age	NCD application	Cumulative monthly 8% increment(SCREENING) of above 30 individuals screened for HTN and to be repeated every year.
8.	Proportion of above 30 years individuals screened for Diabetes*	Numerator - No. of individuals screened for Diabetes     Denominator-Total population above 30 years of age	NCD application	Cumulative monthly 8% increment (SCREENING)of above 30 individuals screened for Diabetes and to be repeated every year
9	Proportion of Patient of HTN on treatment	Numerator - No. of HTN patients who received follow up care Denominator - Total no. of HTN/ patients	NCD application	30% of patients who received treatment	50% of patients who received treatment
10	Proportion of Patient of DM on treatment	Numerator - No. of DM patients who received follow up care Denominator - Total no. of DM/ patients	NCD application	30% of patients who received treatment	50% of patients who received treatment
11	Proportion of cases referred for TB screening	Numerator-Number of suspected TB cases referred for diagnosis/ Denominator- Total number of patients attended in OPD	Nikshay/HWC records	Minimum 3% cases identified from OPD should have referred for screening of TB
12	Notified TB patients who received treatment as per protocols	Numerator - No.of TB patients who are on regular treatment as per protocol Denominator - Total no.of TB patients	Nikshay/TB treatment card	100% of patients on treatment
13	VHND held against planned	Numerator - No.of VHND attended Denominator - Total no.of VHND held	Self- reported in CPHC-NCDapplication	MLHP should monitor at least two VHNDs in a month for performance- linked incentive
14	Village meetings (VHSNCs)/MASheld	Numerator - No.of VHSNC / Village meetings attended as per plan Denominator - Total no.of VHSNC/ Village meetings held		MLHP should monitor at least two VHNSC meeting in a month for performance- linked incentive
15	Monthly meetings held at SHC- HWCs	Organized monthly meeting with Primary Care Team at Sub centers HWCs to monitor the following- 1. Review of work plan for current month. 2. Updating work plan for the next month.  3. At least one technical session held for capacity building of the primary health care team.		One meeting held at the SHC- HWC and should be attended by MPWs and all ASHAs

 

Bridge Course undergone by the MLHP

·        6 month course — byIGNOU

·        Course Outline —

·        Theory classes and hands-on Practicum training atProgramme Study Centers and  Health  Centers   (District   Hospitals,  CHCs, PHCs, Sub-centers, etc.) identified and accredited IGNOU.

·        In addition, community visits would also be conducted for field- based assignments and research projects.

Site	Activities
District Hospital & CHC	Case management, Understand Functionality, HR pattern, lab services, records & reports, M&E, etc.
Orientation visit to Primary Health Centre	Case management of general medical conditions, ambulatory, Infrastructure &equipment, functioning of PHCs
Orientation Community visit to Sub Centers and Community	Antenatal, postnatal, camps, management & referrals, Health education, observe VHNDs and functions of ASHA in field.
Visit to DPMU, BPMU, PRIs, centers where the programs are being implemented	Understanding the system of Health planning & Management: Village Health Action Plan –Role of PRIs, VHSNCs, Observation of activities undertaken under the National Health & Family Welfare programs

 

Mid level health providers are posted in the sub-centers in the initial phase.

All the sub centers except headquarters sub-centers will be converted into e-sub-centers by March 2019.

The PHC Medical Officer is overall incharge of MLHP and MLHP should report to Medical Officer for any queries.