Mainstreaming of AYUSH at Andhra Pradesh

Commissioner of Family Welfare
Government of Andhra Pradesh (India)
DM&HS Campus, Sultan Bazar, Hyderabad – 500 095
Phone No. +91 40 24650365, Fax No. +91 40 24652267

Inter-Sectoral Convergence
Under Inter-sectoral convergence scheme will reflect proposed actions for better synergisation of activities at operational levels in conjunction with the departments of Women Development & Child Welfare, Rural Development, Indira Karanthi Patham (IKP) Department Panchayat Raj Department, AYUSH, Education Department and also with other externally funded in the State and with State and National NGOs working in the State in health areas. It has to be appreciated that the funds for different programmes shall continue to flow under the existing institutional mechanism of different department. However, NRHM State PIP is intended to reflect an overarching framework, availability of funds for the Health Sector (including for the determinants of Health) ad optimum utilization of funds after identifying hospital for convergent action.

Convergence Efforts under RCH-II
Many of the RCH-II project components have been designed with the clear understanding that they will be implemented in close convergence and coordination with other departments and agencies within the State Government and outside that are working in the same area.  Important examples of such components include: (i) identification, training, setting up, and monitoring of performance of Women Health Volunteers in the 67,505 habitations of the state with the support and participation of the ICDS project and the AP Eradication of Rural Poverty project (APERP), i.e. Velugu Project; (ii) implementation of the supplemental nutrition component through the Women Development and Child Welfare department; (iii) Behavioural Change Communication programmes in coordination with the other major wings of the health department under the State Government and the AP Eradication of Rural Poverty project, etc.

Convergence with Other Externally Funded Projects in the State
Under the Andhra Pradesh Eradication of Rural Poverty Project, (Velugu project) a separate health component intervention is being implemented in the program districts in close convergence with the Health and Family Welfare department and the Women Development and Child Welfare departments. In the ICDS projects, nutrition for pregnant and lactating women and children is being provided, besides addressing the health needs of the adolescent girls. Adolescent girls are being sensitized and health awareness created on family health issues, age at marriage, nutrition, prevention of anemia, etc., through attachment to the Anganwadi workers in the villages.

Under the RCH-II, all these departments are involved in developing District Action Plan and their implementation. 

Convergence with National and International NGOs working in the State in Health Area:
Active convergence is being achieved with the international NGO CARE India, which is providing support for improving the nutrition of pregnant women and children in nine districts of the state. Similarly, another NGO Naandi, working with the support of Non-Resident Indians settled in the USA, is implementing an intervention for reduction of Neo-natal Mortality in the backward district of Mahabubnagar in the state, under the European Commission Sector Investment Project of the Family Welfare department.

Convergence & Staff, Activities, and Budget of Externally Funded Projects
It is not proposed to merge the activities, staff and budget of other externally funded projects with the RCH-II, since under those projects, specific MOUs have been entered into with the project sanctioning and monitoring teams for achievement of specific outcomes/benchmarks, etc. Further, release of funds under these projects is closely linked to achievement of such benchmarks. However, it is proposed to take into account the relevant program components under these projects in designing and finalizing the RCH-II project.

Further, close convergence with other externally funded projects with in the Family Welfare department, such as the APERP Health Component will be easily achieved through the Commissioner of Family Welfare being the Project Director for both the APERP Health Component and the RCH-II Project. As described earlier, convergence with other projects that are located in other departments of the government, such as the APERP (Velugu Project) which is under the Rural Development department, ICDS Project which is under the Women Development and Child Welfare department, will be achieved through sharing of project proposals at the design stage among these departments, having frequent meetings between the state level to the field level functionaries, etc. on all common program areas and interventions.

Institutional Arrangements for Convergence at the District Level:
Convergence in program implementation at the district level has by and large been already achieved in Andhra Pradesh. The District Collector is the chairperson of the district level committees that are entrusted with the project implementation, monitoring and review, for projects implemented by most social and developmental departments at the district level. Further, in these committees, officers of other related departments are most often co-opted as members as per the existing instructions of the government. This helps in achieving the required convergence in program implementation at the district level.

Convergence in Program Designing and Implementation between Different Wings of the Health Department:
In the Health department in Andhra Pradesh, the following are the main wings that render services to the public: (i) Director of Health, who coordinates the functioning of all PHCs, and some FRUs in the state, besides being the cadre controlling authority for all the medical and paramedical personnel in the state; (ii) Commissioner of Family Welfare, who coordinates the functioning of all Rural and Urban Health Sub-Centers in the state, supervises the implementation of all the centrally sponsored schemes under the family welfare program and the RCH project, besides other externally funded projects in these areas; (iii) Commissioner of APVVP, which is a semi-autonomous agency that coordinates the functioning of most of the First Referral Unit Hospitals in the state (with more than 230 FRUs under its management); (iv) Director of Medical Education, who coordinates the functioning of medical colleges and teaching hospitals in the state; and (v) Commissioner, AYUSH (Ayurveda, Unani, Siddha, and Homeopathy) who coordinates the functioning of the hospitals under Alternative Indian systems of medicine.

Convergence between these wings in program implementation is currently being achieved through frequent meetings and interaction depending upon the program needs. Under the RCH-II, since there is overwhelming focus on improving emergency obstetric service delivery to pregnant women through institutional deliveries, as well as neonatal care and infant/child emergency health care, it is considered very necessary to have more formal coordination arrangements in place, particularly between the wings that control the functioning of the FRUs in the districts, and the Family Welfare department. At present, there is a state level FRU committee with representation from concerned heads of wings of the health department. However, this committee generally addresses the issues relating to the referral cases in the FRUs.  In order to achieve better coordination with all wings in the health department on the RCH issues, it is proposed to request the Government to constitute a State Level Coordination Committee for Strengthening of RCH Services and their Improved Accessing and Utilization by the Urban and Rural Poor , with the Project Director RCH as the convener, and heads of other important wings in the health department as members. Multi-wing issues that have an impact on RCH services will be taken up in this committee.

MAINSTREAMING OF AYUSH : Keeping in view the guidelines relating to road map for mainstreaming of Ayush in the health delivery system, following proposals are submitted for inclusion in the NRHM.

Creation of Ayush facilities in Primary Health Centres
As the Ayush covers many systems of medicine, keeping in view the local acceptivity of different systems, it is proposed to provide 50% of the 1570 PHCs with Ayurveda facilities, 30% with Homeopathy, 10% with Unani and 10% with Naturopathy systems of medicine. 

Creation of Ayush facilities in Community Health Centres
There are (167) Community Health Centres in the state. Out of these Ayush facilities have already been created in (39) CHCs by way of re-location of Ayush Dispensaries. Thus, (128) CHCs have to be now covered under NRHM for creation of AYUSH facilities.

As in case of PHCS, it is proposed to create Ayush facilities in these remaining (128)  CHCs over a period of (3) years. Thus, every year it is planned to have (42) CHCs for extension of Ayush facilities. 

Ayush related training programmes for ANMs and Women Health Volunteers
There are 25,000 ANMs and 55,400 Women health volunteers in the state. These 80,400 functionaries are proposed to be given 2-day training in home remedies and use of medicines provided in the home remedy kit. It is estimated that this training will cost Rs.125/- per person per day inclusive of boarding, lodging and information material. 

Training of Ayush doctors in National Health programmes
As on now (1039) dispensary Medical Officers in the Department of AVUSH. These Medical Officers need to be given a suitable training in implementation of National programmes. The re-orientation programme will be for a duration of one week  and also preparation and distribution of IEC material on Avush, supply of Ayush home remedies kits, provision of minimum equipment for existing Dispensaries in Rural Areas, equipment to Ayush Hospitals etc.

Preventive medicine, public health lab & food health:
As per the latest Water Safety Plans (WSPs) Five Key Components have been identified by WHO to deliver safe drinking water.

• The establishment of health based targets for microbial and chemical quality of water
• A system assessment to determine whether the water supply chain from catchments to consumer can deliver safe drinking water at the point of consumption.
• Monitoring of identified control measures with in the water supply chain that provides assurance of safety.
• Management plans documenting the system assessment and monitoring – which describes the actions to be taken during normal operations and incident conditions to secure water safety.
• Independent public health surveillance of water safety. 

The steps 2 to 4 constitute Water Safety Plan (WSP). It is usually the responsibility of the water supplier to prepare, implement and evaluate the WSP .The establishment of health based targets and surveillance are more typically the responsibility of the Health sector.  IPM Water Analysis laboratories participate as independent Public Health Surveillance of water safety (The 5^th key component identified by WHO) .Our laboratories are recognized as external water quality surveillance laboratories and the central laboratory as a state referral Laboratory on water and health issues for the last fifty years We conducted workshops on Fluorosis, water treatment and quality monitoring and surveillance procedures for the catchments, sources, treatment plants and distribution to evaluate their maintenance and the final quality of water at the consumer end.  For the last 50 years it has contributed large volume of data on Fluoride affected habitations and other drinking water related diseases and their prevention by offering trainings, conducting workshops and presenting valuable papers on surveillance, disinfection and monitoring procedures.

As per the latest WSPs pesticides and toxic metals from all the drinking water sources of the protected water supply schemes in the state should be tested once in six months to establish their safety. It is also proposed to start a research and quality control cell for the control and prevention of water borne diseases by identifying the causative agents and conducting workshops/trainings to the Medical officers and Paramedical staff of Directorate of Health and Municipal Administration.

The central laboratory as the state reference Laboratory for drinking water analysis and quality monitoring [as per Water Safety Plans as envisaged in WHOGuidelines for drinking water Quality -2004, volume-3] and also to be an accredited Laboratory at state level on water and health issues it should be developed into a state of art Laboratory  by constructing laboratory building with latest design as per — USEPA  norms and equipping it with latest equipment for estimation of toxic metals, pesticides and effluent analysis.

Child heart diseases programme:
The Govt. of Andhra Pradesh has spontaneously responded to the suffering of the children with heart disease immediately after the rally which was conducted on 7^th August, 2004.  Govt. vide reference above cited, is providing free treatment and surgery to the children suffering with heart diseases below 12 years of age.

The Director of Medical Education in consultation with Director of Health and Commissioner of A.P. Vidya Vidhana Parishad is conducting screening camps in various districts of the Andhra Pradesh at regular intervals to identify children suffering with Heart diseases.  The 1^st phase of screening camps were held in the month of August, 2004 and total number of 7553 children were screened and 6308 children have been identified to be suffering from cardiac disease.  Amongst them about 5500 require surgery.  And the 2nd phase of screening camps were held in the month of September & October, 2006 and total number of 6,210 children suffering with heart diseases were identified.

The Director of Medical Education has identified 43 hospitals in Andhra Pradesh both in Government & Corporate hospitals and also other premier institutes outside the state like Bangalore & Chennai.  The Corporate Hospitals have been identified for performing surgeries after the inspection by an expert committee deputed from the Director of Medical Education.  Different surgical procedures are grouped under 10 categories and the range of payment varies from Rs.2,800/- to 1,00,400/- and the cost of the permanent pacemaker implantation in category X.  These rates were derived from the existing tariff of  Nizams Institute of Medical Sciences.    During negotiations with corporate hospitals the above rates were agreed upon by all the parties involved.  Surgeries are being done regularly in these hospitals.

This is an unique programme which has been initiated by the Government of Andhra Pradesh the first of its kind in India to alleviate the sufferings of children with heart diseases.  This schemes objective is to predominantly help Children of BPL families. Timely intervention for these children would result in providing near normal life. Since this scheme incurs huge expenditure a matching grant may be sanctioned to this scheme under National Rural Health Mission (NRHM) for effective implementation as this is an on going programme.

The State Government is allocating Rs.8.00 crores per annum in the state plan budget  towards reimbursement of medical expenses of surgeries to children with heart diseases. As on 31-01-2007 the total number of beneficiary children are 4618 surgeries and interventions  are sanctioned  and Rs.12.97 crores has been reimbursed to the various hospitals.

As on today a total no. of 6734 children suffering from Heart Diseases have been identified and are awaiting for Surgery.