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Best Practice Document

Gram Arogya Kendra: Village level health unit for universal health coverage
GRAM AROGYA KENDRA
An initiative of Government of Madhya Pradesh
An innovation in health service delivery for universal health coverage
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Contents:

I. Introduction

II. Concept of Anganwari cum Gram Arogya Kendra

(Health for all, universal health coverage and health service guarantee)

III. Objectives of GAK

IV. Provision of Health Services for All at GAK

(Services by ANM & ASHA, VHND, Child health & Seasonal diseases)

V. Implementation of concept and monitoring systems

(Swasth Gram Prahari Dal , ASHA software, CUG sim for ASHA)

VI. What Gram Arogya Kendra does?

(Convergence, Complete village health records)

VII. GAK monitoring checklist

VIII. Potential of GAK

IX. Results and learnings from the experience so far

X. Success Stories of Gram Arogya Kendra

Gram Arogya Kendra: Village level health unit for universal health coverage
An initiative of Government of Madhya Pradesh
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XI. NDEX GRAM AROGYA KENDRA

An innovation in health service delivery for universal health coverage
Introduction

The 12th Five Year Plan for health builds on the achievements of the 11 th Plan and takes
forward the concept of Universal Health Coverage (UHC). The National Health Mission
(with the components of the National Rural Health Mission and the National Urban
Health Mission) seeks to improve the health of every Indian through various programs
and strategies. It also recognizes that outcomes cannot be achieved without system
strengthening measures. These include greater decentralization, strengthened
community participation and ownership, as well as greater convergence of programs at
the village level.

The Dept. of Public Health and Family Welfare of the Government of Madhya Pradesh
implements various components of the NRHM throughout the state. The innovation
brought in has been in actively promoting the convergence of health and ICDS and also
in strengthening community ownership of programs at the village level. This is being
sought to be achieved through the establishment of Anganwadi-cum-Gram Arogya
Kendra (Village Health Centre) in each village.

The Anganwadi-cum-Gram Arogya Kendra

The DoPH&FW along with the DWCD started a new initiative under the “Health for all”
campaign to provide essential health and nutrition services at the village level through
the establishment of “Anganwadi
–cum-Gram Arogya Kendra” in
each village. The main objective
in opening these health centres is
to make the community aware of
their health and environment,
increase community ownership of
village level programs, and
ensure proper delivery of health
and nutrition services through
the involvement of, and
supervision by the community.
Universal Health Coverage & The Anganwadi cum Gram Arogya Kendra at Kankarkheda
Health Service Guarantee: village, Sehore district.
Gram Arogya Kendra as an
establishment re-enforces the commitment of MP government to Universal Health
Coverage. Provision of basic minimum health services at village level ensures that all
who need health care can access it freely and reduces the burden of out of pocket
expenditure on the people of last mile. Moreover through the HEALTH SERVICE

Gram Arogya Kendra: Village level health unit for universal health coverage
An initiative of Government of Madhya Pradesh
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GUARANTEE scheme Gram Arogya Kendras establish first layer of provision of health
services through ASHA and ANM, which is further supervised by the sector supervisors
and sector medical officers (Medical officer of the PHC of the area).
The two main areas of focus of health services at GAK are – treatment of minor ailments
and seasonal diseases and early referral for more serious illness; as well as health
education towards a healthy lifestyle. It is also an initiative to improve convergence
between the health and ICDS services at the village level.

Objectives of the GAK :

a. Provide essential health and nutrition services to the community at the village
level itself.
b. Make the community aware of their health and environment and thus involve
them in taking care of their own health.
c. Strengthen quality of health services through training of the Gram Sabha Swasth
Gram Tadarth Samiti.
d. Improve co-ordination between frontline workers of various departments at the
village level for better provision of services.

Services provision at GAK under Health for all :

Services by ANM Services by ASHA
Conducting the VHND Dispensing medicines for minor ailments and
seasonal diseases
ANC & PNC services
Maintaining village health register- Details of village
health problems, target couples, pregnant mother,
high risk mothers, births, deaths etc
Tests (Hemoglobin, Urine
Pregnancy test, Malaria test Meeting of adolescent girls & health counselling
by RD kit, Urine albumin and
Sugar test) Meetings of Village health & sanitation committee /
Gram Sabha Swasth Gram Tadarth Samiti
Immunization

Conducting VHNDs:
Gram Arogya Kendra is a place to conduct village health and nutrition day, which
is held once a month in every village. ANM is the main driver for the VHND along
with ASHA. Organisation of VHND includes ANC checkups, Immunization of
children, Health and nutrition counselling of expectant mothers, distribution of
IFA tablets, Tests for hemoglobin, malaria, Urine sugar & Albumin and treatment
of minor health problems by the ANM. Establishment of Gram Arogya Kendra has
Gram Arogya Kendra: Village level health unit for universal health coverage
An initiative of Government of Madhya Pradesh
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been fruitful for smooth functioning of GAK as the ANM doesn’t have to carry lot
of equipment, drugs and consumables with her to the village as these are already
available at the GAK. Moreover, the problems of privacy for ANC checkup and
waiting area for the beneficiaries have been taken care of.

Health services for children and treatment of seasonal illness:

GAKs are proving to be a very good platform to ensure timely availability of child
health services. Apart from immunization and midday meals being provided at
the Anaganwari to pre-school children, the village ASHA dispenses medicines like
Albendazole to treat worms; demonstrates, prepares and provides ORS and Zinc
to the children with Diarrohoea; helps early identification of pneumonia and
dispenses antibiotics like Cotrimoxazole.
Moreover GAK serves as a center point for the villagers for any referral need
including calling Janani Vehicles and 108, Emergency Ambulance. The ASHA keeps
contact numbers of these vehicles.

The GAK is equipped with the following instruments and medicines to provide the
above mentioned health services:
(Instruments have been procured from the untied fund of Rs. 10,000 which is with the
Gram Sabha Swasth Gram Tadarth Samiti. This relieves the ANM of having to carry
instruments, weighing machines and test kits to each VHND site.)

Instruments / equipment Medicines / articles

Table and chair, bench Paracetamol tablet 500 mg
ANC examination table, step for climbing ORS packets
BP machine and stethoscope Chloroquine tablets, 150 mg base
Infant weight machine IFA tablets (adult, pediatric)
Child weighing machine (Salter, 25 kg) Co-trimoxazole tablets
Adult weighing machine Gentian violet solution
Thermometer Zinc sulphate dispersible tablets
Fetoscope Albendazole tablets 400 mg
Slides, lancets , Test tubes Dicyclomine HCl tablets 10 mg
Rapid Diagnostic Kit- Malaria, Pregnancy Povidone iodine solution
test kit, Urine sugar & Albumin test strips
Hub cutter
Torch
Almirah Cotton bandage
Gram Arogya Kendra: Village level health unit for universal health coverage
An initiative of Government of Madhya Pradesh
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Stationery Absorbent cotton

Waste bin All vaccines with diluents (during VHND)
Drinking water container, tumblers, long
handled mug

Gram Arogya Kendra: Village level health unit for universal health coverage
An initiative of Government of Madhya Pradesh
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Implementation of concept and monitoring system for GAKs

The Swasth Gram Prahari Dal :

A strong monitoring and supportive supervision mechanism is necessary to ensure
effective delivery of village level health services. A special supervisory cadre, The
“GRAM SWASTH PRAHARI DAL” is formed to ensure that the health services at the
village level are delivered smoothly, effectively and in a quality manner through the
Gram Arogya Kendras. This has enable the state to create “HEALTH SERVICE
GUARANTEE” scheme.

Composition of Swasth Gram Prahari Dal:

1. Sector Medical Officer: Convener
2. Male multipurpose health Supervisor: Member
3. LHV: Member
4. MPW: Member
5. ANM: Member

Administrative structure:

The Gram Swasth Prahari Dal is being established as first unit of monitoring in the health
system of the state. The Prahari Dal is mandated to visit the villages in its sector for at
least 08 days every month. For this the sector medical officer can hire a vehicle. This is
the responsibility of BMO to ensure vehicle availability with the sector MO for sector
visits.

Roles and Responsibilities:

Gram Swasth Prahari Dal (GSPD) discusses and supervises the implementation of regular
agenda of the GAK. It plays an important role in functionality of GAK for accessibility and
monitoring of community based health services. Also it supports in preparing village
level health plan. It guides the utilization of untied fund to VHSCs and SHCs, awareness
among the community to prevent from seasonal diseases and focus on cleanliness.
Sector MO and GSPD ensure coordination for providing quality health services. In
association with BMO, the team identifies the SAM children and ensures health services
in problematic areas.
GSPD is also responsible for selection of program themes, monitoring of IEC/ BCC
activities and performance of local cultural hired groups. IEC activities are conducted on
GSPD visit day. The team also organizes, implements and monitors community based
training. VHSC reviews the work performance of ASHA, AWW and AWHs at GAK. GSPD
checks and ensures the record keeping in village health register.

Gram Arogya Kendra: Village level health unit for universal health coverage
An initiative of Government of Madhya Pradesh
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Display of PROTOCOLS at one

GAK, Dindori District

Software based monitoring:

A website has been developed by the state which tracks various activities being done at
Gram Arogya Kendra along wih community monitoring and work of ASHA. The software
is a web based application and known as “Community Action” website.

Link to the website: http://www.communityactionmp.com/

The website tracks and displays all activities related to ASHA, Village health & sanitation
committee (VHNSC)/ GSSGTS and Gram Arogya Kendra (GAK). A few of these are listed
below:

1. State directives and guidelines related to ASHA, USHA , VHNSC/GSSGTS and

Gram Arogya Kendra
2. Data base of AHSH and GAK
3. Training details related to ASHA
4. Incentive details to ASHA
5. Gram Arogya Kendra Status/grading and status of essential commodities (district
wise and block wise details)

Gram Arogya Kendra: Village level health unit for universal health coverage
An initiative of Government of Madhya Pradesh
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6. Various announcements/vacancies/orders from state about community

monitoring / ASHA and Gram Arogya Kendra

Snapshot of Community Action Website

Provision of CUG sim for all ASHAs in the state:

The state govt. has provided mobile numbers through CUG sim cards to all the ASHAs in
the state. This initiative has been taken for regular, smooth and two way communication
with the ASHAs working in all the villages. SMS based IEC and reminders are being sent
to ASHAs for their routine work, periodic reports, celebrating various important days and
following up with the action plans provided by their supervisors.

Gram Arogya Kendra: Village level health unit for universal health coverage
An initiative of Government of Madhya Pradesh
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What Gram Aarogya Kendra does?

At present there are over 55,000 GAKs in the state. The functioning of the GAK is
monitored by the health supervisors during field visits, and also by the sector medical
officer. The functioning of ASHA and reporting of GAK functional status based on a
standardized checklist is further supervised by Block community mobilizers (BCMs).
The centres are currently graded according to the presence or absence of records,
infrastructure and drugs available, on 57 parameters and are being graded into
categories A, B & C for implementation & monitoring purposes. Details of assessment
are entered into ASHA software from BCMs at respective blocks and analysis is done at
state level.

Gram Arogya Kendra: Village level health unit for universal health coverage
An initiative of Government of Madhya Pradesh
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GAK has high acceptability among the villagers, with women appreciating the fact that there is a place where
pregnant women can be examined properly and in privacy and other health problems also can be solved.

“I have been there several times. Once to get medicine for fever for myself, once to get “ghol packet”
(ORS) for my daughter who had diarrhoea, and once when my older son had a cough. We always get better
with the medicines. I don’t have to go to the ASHA’s house which is far away”.
-Malati Bai, resident, Kankarkheda village, Sehore

ASHA and ANM at the AWC-cum-GAK with

medicines, BP instrument, uristix etc

When women come for their antenatal checkup during VHND, they see all the things that are happening in
the AWC also. They have started sending children to the centre to learn. Women also get the THR in the
same place as the checkup. There is a lot of activity here now and it is nice.
- AWW, Kankarkheda village.

Gram Arogya Kendra: Village level health unit for universal health coverage
An initiative of Government of Madhya Pradesh
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The GAK Supervision Checklist:

Parameter 1 (yes)
SN or 0(No)
Infrastructure & Basic amenities
Basic information about the village is available (Village map, area,
1 population)
2 Village health plan is available
Contact information of DC, CMHO, DPM, BMO, CDPO, Janani express
3 etc is available
4 Birth, Death & Marriage registration details available
5 Details of Self Help Group, Mothers Help Committee available
6 Details of mid day meal scheme group
Information about married & target couples, pregnant women,
newborns, under five children, malnourished children, children
7 registered in AWC available
Details and lists of immunization, TB, Leprosy, Diarrhea, Malaria
8 patients available
9 List of temporary methods of family planning
Details of the information of health services provided by ANM & MPW
10 and their visits available?
Names and services provided by ASHA, AWW and Sahayika are
11 available
12 Information about the village health committee available
The VHC has details of the information about the funds received from
health department, women & child development department and its
13 expenditure
Instruments/Furniture availability
14 Chair
15 Table
16 Bench
17 ANC table
18 Foot step/stool for ANC table
19 Weighing machine for baby
20 Infantometer for newborn
21 Weight machine for children
22 Weight machine for adults
23 Haemoglobinometer
24 Stethoscope
25 Curtains

Gram Arogya Kendra: Village level health unit for universal health coverage
An initiative of Government of Madhya Pradesh
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26 Foetoscope
27 Spirit lamp
28 Functional BP instrument
29 Hub cutter
30 Thermometer
31 Test tubes
32 Slides
33 Torch
34 Almirah
35 Box
36 Water tank
37 Glass
Availability of medicines & consumables:
38 All vaccines with diluents
39 ORS
40 IFA tablets - small & large
41 Cotrimoxazole tablets
42 Gention violet
43 Zinc sulphate dispersible tablets
44 Paracetamol tablet (500 mg)
45 Methyl ergomentrine tablets
46 Albendazole tablets (400 mg)
47 Dicyclomine tablets (10 mg)
48 Povidon Iodine ointment
49 Cotton bandage
50 Absorbant cotton
Deetails of additional information
51 Village health register
52 Death related information
53 Register for village health committee meetings
54 Register for other activities being done at the Gram arogya kendra
Details of information displayed at the GAK
55 Sign board for AWC & GAK
56 Notice board for displaying information outside the center
57 Description of village health plan displayed outside
Total Score (Out of 57)
0
Grade A (above 80%)= Green, B (61-80 %)= Yellow, C(<61%)= Red

Gram Arogya Kendra: Village level health unit for universal health coverage
An initiative of Government of Madhya Pradesh
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A point place for convergence

The Deendayal Mobile Hospital, Janani

Express and 108 Sanjeevani service - All
these services have been linked to the
AWC-cum-GAK. The mobile clinic uses the
GAK to provide health services in the
village on a fixed day each month
including examination, lab tests and
medication. The Janani Express and 108
service are also summoned by the ASHA
who is based at the GAK.

All the centres falling within one health

sector (roughly 10-12 villages) are Children being weighed during VHND at the
supervised and supported by the sector AWC
medical officer.

Serving as a single unit for all village health records

In addition to the basic health services provision, all health related records including
population, list of eligible couples, pregnant and lactating women and under-five
children, list of children for immunization, vital statistics, as well as the tour programme
of the ANM – are available at the centre. A folder of health education material is also
available at the centre for the ASHA and ANM to use during meetings and interactions
with the community. Lists of patients on treatment for chronic diseases are also
available at the centre. The names of the members of the SHG providing the meals to
the AWC children; names of the GSSGTS members; minutes of the meetings of the
GSSGTS; as well as names of health and ICDS functionaries of the village are available.
The contact details of the CDMO, the Collector, District Programme Officer, District
Executive Officer are displayed on the wall of the health centre.

Gram Arogya Kendra: Village level health unit for universal health coverage
An initiative of Government of Madhya Pradesh
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Adolescent girls’ counseling

Gram Arogya Kendra: Village level health unit for universal health coverage
An initiative of Government of Madhya Pradesh
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What is the potential of the GAK?

The Gram Arogya Kendra is a unique concept to promote village based health and
nutrition activities, and for involving the community in their own health. By co-locating
the AWC and GAK, all women and child-related services will be available in one place,
and the community can more easily understand the links between health and its
determinants like nutrition, water and sanitation. It is also in line with the 12th Plan
priorities for system strengthening through decentralization, community involvement,
and by improving interdepartmental co-ordination.

The GAK has the potential to be the hub of health related preventive, promotive and
curative activities in the village. It also enhances interaction between the AWW and the
ANM and ASHA since all activities related to women and children (which fall under the
mandate of both the ICDS and health departments) can now take place at one location.
Antenatals and lactating women can come to the same centre for their checkups and to
collect the THR. There is a place to keep an examination table for pregnant women, a
table for records and for keeping vaccines for immunization. The profile of the AWC as a
place where health services are also provided, is enhanced. The community also knows
that the ASHA is available for treatment of minor ailments at a particular place at a fixed
time on specific days of the week.

The visibility and access of the ASHA worker as a village contact person for treatment of
common ailments has also improved since she now has a place to sit and keep the
medicines properly. This is particularly so when her home is in one corner of the village
and the AWC is more centrally located.

The centre can develop as a place for health education to all sections of the community
– to mothers during VHND, to pre-schoolers in the AWC, to community members
through the Gram Sabha Gram Tadarth Samiti and be the focal point for positive
community action for health.

Gram Arogya Kendra: Village level health unit for universal health coverage
An initiative of Government of Madhya Pradesh
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Results and Learnings from the experience so far

Gram Arogya Kendra as a village level health unit which integrates the nutrition, health,
education, water, sanitation, hygiene and panchayati raj activities at a single place
involves villagers for their betterment through a formal institution. While, it has shown
to be successful as a concept, it has also shown promising results at operational level.
The idea to convert existing Anganwaris to Anganwari cum Arogya Kendra has been well
taken by the community and field authorities. Establishing supply chain for essential
commodities including furniture, equipment and drug/consumables served as an
operational challenge initially, which has been overcome in due course with continuous
monitoring from state, district and filed level supervisors.

It is learnt that ASHA can be trained for correct dispensing of essential medicines with
trainings and regular supportive supervision efforts. However, the concern of ASHA
staying at GAK and not doing house hold visits for discharging her regular activities
creates a conflicting situation to her time management. This has been further tried to be
corrected by helping ASHA in reinforcing the need of home visits on a planned schedule
and spend remaining time at the AWC-GAK. A strong supervisory cadre, Swasth Gram
Prahri Dal led by the sector medical officer helps ASHA improving her management.

Gram Arogya Kendra: Village level health unit for universal health coverage
An initiative of Government of Madhya Pradesh
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Success Stories

1. Sansari Bai, Rajnagar Village, Chatarpur District

Sansari Bai, 25 years a resident of Rajnagar village in Chhatarpur district visited Gram
Arogya Kendra with her 2 years old daughter. Her daughter was suffering from fever and
she had not been eating well. She consulted ASHA at the GAK for this. ASHA examined
the baby and found that the baby was having fever which came with chills. She gave the
mother Fever tablets (Paracetamol) and informed ANM about the case. Next day on
VHND, the ANM made slides for malaria test and she gave the baby anti-malarial tablets
(Chloroquine).
Her blood test was reported negative for malaria parasite after two days but fever was
not coming now. Sansari Bai, followed the instructions and completed the course of
malaria tablets.

She quoted to the district supervisory team that “Availability of medicines at Gram
Arogya Kendra and ASHAs response saved her from going to a PHC which was 15
kilometers from her house and possible consequences of fever”.

Children at AWC cum GAK

Gram Arogya Kendra: Village level health unit for universal health coverage
An initiative of Government of Madhya Pradesh
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2. Kusumwati, Khairi village, Chatarpur District

Kusumwati, 22 years was pregnant for second time. Her first baby, a girl was only 13
months old. She was told by village ASHA to come to gram Arogya Kendra for
counselling and check up. ASHA found that she was very weak and pale looking. ASHA
counselled her for better nutrition and provided her Iron and Folic acid tablets. She was
then followed up for ANC checkups on VHNDs by ANM along with ASHA. After
continuous follow up, counselling, 3 ANC check ups and IFA consumption her
hemoglobin remained 8 gm % during 7th month of pregnancy. She was then referred to
the CHC for IV Iron sucrose therapy to improve her Hemoglobin levels before delivery.

At CHC she received three IV Iron sucrose infusions before her delivery and by the time
she was full term, her hemoglobin had crossed 9.5 gm %. She finally had a normal
delivery. As she was also counselled for post partum family planning by the ASHA and
ANM earlier she adopted PPIUCD.

Antenatal check up and counseling at

VHND at a GAK by ANM

Gram Arogya Kendra: Village level health unit for universal health coverage
An initiative of Government of Madhya Pradesh
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3. Sunita , Todha Gautamia village, Sagar District

At Sagar district , Sunita, a 25 year old lady, got benefitted from the Gram Arogya
Kendra. Her 3 year old son was having diarrohea and fever, for which she visited the
GAK in Todha Gautamia village. The ASHA in that village provided her with ORS packet
and Zinc tablets. The ASHA also demonstrated how to make ORS solution and how to
give it to the boy. ASHA also gave her co-trimoxazole tablets as the boy was having fever
also suspecting signs of some infection. Son of Sunita was fine after 3 days and Sunita
was thankful to the ASHA of the village and government to have set up gram Arogya
Kendra in her village.

Sunita was approached by supportive supervision team and she mentioned – “if these
medicines were not available at the village GAK, she would have gone to see the
private doctor to nearby village which would have costed her at least Rs. 200-300”.

ORS and Zinc Distribution at

GAK

Gram Arogya Kendra: Village level health unit for universal health coverage
An initiative of Government of Madhya Pradesh