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(The Gist of Kurukshetra) AYUSHMAN BHARAT: SILVER LINING IN HEALTH CARE [NOVEMBER-2018]


(The Gist of Kurukshetra) AYUSHMAN BHARAT: SILVER LINING IN HEALTH CARE

[NOVEMBER-2018]


AYUSHMAN BHARAT: SILVER LINING IN HEALTH CARE

When the Government of India announced Ayushman Bharat in the Union Budget for 2018-19, it signaled its intent to take health promotion and health care to the centre of the political discourse. However, some critics were skeptical as to whether a programme of such dimensions could be launched within such a short time-span. With the launch of both components: the Health & Wellness Centres (H&WCs) on 14th April and the PM Jan Arogya Yojana (PMJAY) on 23rd September, the Government has amply demonstrated that the budgetary announcements not only has a strong political backing, but also sent out a clear signal that there is growing consensus in the higher echelons of policy making that investing in a good health system is critical to building a prosperous India. ayushman bharat: india’s road to universal health coverage

Interpreted in a literal sense, Ayushman Bharat is a promise for long lives to Indians. In other words, it is about mortality avoidance. But increasing life expectancies cannot be the only goal, if we also simultaneously cannot guarantee well being by minimizing morbidity. Our National Health Policy 2017 aptly articulates out goal as “attaining the highest possible level of health and well-being for all at ages, through preventive and promotive health care orientation in all developmental policies, and universal access to good quality health care services without any financial headship”. Ayushman Bharat, with its two components- Health & Wellness Centres (H&WCs) and PM Jan Arogya Yojana (PMJAY)- is an attempt to move from sectoral and segmented approach of health service delivery to a comprehensive system-based one . It undertakes path breaking interventions to holistically address health; adopting a continuum of care approach-addressing prevention, promotion, primary and ambulatory care; as well as secondary and tertiary care requiring hospitalized treatment.

Present Situation:

In the absence of a strong Government stewardship, the Indian Health System has evolved almost by default. As a consequence, it exhibits extreme fragmentation on multiple dimensions- financing, organization and regulation. This has a major impact on the quality of care as well as overall outcomes of the Health System. For instance, a whopping 67% share of the overall financing of our health system is in the from out of pocket Expenditure by the Households, mostly at the point of care. If we look at the organization of care providers, 95.3% of out private health facilities are small facilities employing less than five workers. Clearly, in a situation where an overwhelming proportion of health seeking occurs directly by the households from very small private providers on paper based prescriptions, it is virtually impossible to monitor or regulate the quality of such care provision. The Government facilities face a different set of challenges in ensuring quality of care: huge patient load, lack of accountability, absenteeism, management gaps and fixed salary based payment incentives.

The current legal framework for regulation of medical service is under the Clinical Establishment Act, 2010, Drugs & Cosmetics Act, 1940 and the various Acts governing the profession such as Medical Council of India and other related professional councils. The weaknesses in out regulatory framework are well documented. For instance, The Clinical are well documented. For instance, The Clinical Establishment Act is yet to be adopted by many of the State Governments. Even where they have been adopted, implementation remains patchy. The MCI has been repeatedly hauled up by the Supreme Court as well as the Parliamentary Standing Committee on health and a legislation to replace MCI by a National Medical Commission.

What is the likely impact of Ayushman Bharat?

The accountability is further enforced through insistence upon compliance to empanelment norms in order to be registered as a provider with the respective NHA/SHA. Since the payers would be carrying out inspections of the health facilities against standardized checklists both at the empanelment stage and also during the operations stage, it would provide the necessary impetus to the provider to plug the gaps between their existing infrastructure, procedures and human resources and what is required of them by the payer. NHA is now in the process of developing Standard Treatment Guidelines (STGs). As and when the adherence to STGs is enforced, facilities will be obliged to follow the standard operating procedures rather than a free for all approach prevalent now. But the process of ensuring strict adherence needs to be gradual, so that the compliance burden on the empaneled providers does not become unmanageable.

It is also quite evident that given the measurement and data challenges that India faces, the ability of the National and the States government to initiate the desired policy changes and to take appropriate action to improve quality of care is severely constrained. This has a serious deleterious effect upon the overall governance and accountability of the Health System. Another potential game changing impact of the Ayushman Bharat would be through the establishment of the Technology Platform and a common IT system to ensure availability of real time data pertaining to health system of course, subject to privacy constraints. Enormous amounts of data would now be instantaneously available for analysis to multiple researchers and enforcement authorities. This would give a serious boost to the quality movement in our health system, further the use of evidence in making policy decision and would enable pushing for behavioral change on the part of the providers.

Conclusion:

Improving the quality of health care at the system level requires a focus on governance issues, improving public-sector management, building and augmenting institutional capacities as well as promoting a culture of data-driven approach. Ayushman Bharat has initiated a number of these steps in the right direction, but they constitute a small subset of a large number of steps that need to be taken to drive the quality process in the Indian health care system. This is just the beginning of a long and an arduous journey

Study Material for UPSC General Studies Pre Cum Mains

(The Gist of Kurukshetra) AYUSHMAN BHARAT: INDIA’S ROAD TO UNIVERSAL HEALTH COVERAGE [NOVEMBER-2018]


(The Gist of Kurukshetra) AYUSHMAN BHARAT: INDIA’S ROAD TO UNIVERSAL HEALTH COVERAGE

[NOVEMBER-2018]


AYUSHMAN BHARAT: INDIA’S ROAD TO UNIVERSAL HEALTH COVERAGE

The Ayushman Bharat scheme, launched by the Honourable Prime Minister in April this year, marks an unprecedented high-level political commitment to Universal Health Coverage (UHC). Ayushman Bharat stems from the policy articulation and budgetary commitment that are derived from experiences and lessons of the past few decades.

Ayushman Bharat comprises two pillars- the first is provision of universal and Comprehensive Primary Health Care (CPHC) delivered in formulation of Health and Wellness Centres (HWCs); which are the transformed first two tiers of the public health system i.e. the Sub Health Centres (SHC) and the Primary Health Centres (PHC). The second component is the Pradhan Mantri Jan Arogya Abhiyaan (PMJAY), for provision of health coverage of up to Rs. 5,00,000/family for nearly for nearly 10.34 crore households to obtain secondary and tertiary in-patient care. The implementation of Ayushman Bharat rests on the health systems strengthening achieved through the National Health Mission (NHM).

In the last decade, the investment in health by both the centre and states has increased. Input related investments in infrastructure and human resources, at most primary and to a limited extent in secondary care, coupled with support for strengthening procurement system, improving governance, establishing referral and transport system, incentives for performance have yielded accelerated positive outcomes for mothers and children, and to an extent, in communicable diseases as well. As per the latest report of the Registrar General of India, Sample Registration System, MMR of India has shown a decline from 167 per 100,000 lives births in the period 2011- 13 to 130 per 100,000 live births in the period 2014-

India has thus, achieved the Millennium Development Goal for Maternal Mortality Ratio. Infant Mortality Rate is 34/1000 live births with rate of decline increasing from 2.5% in 2013-14 to 1% in 2015-16. However, the transformation of HWC requires action on many fronts and coordination of multiple works streams, as demonstrated in Box 1. The impetus on Ayushman Bharat- HWCs is aimed at a paradigm shift in provisioning CPHC to the people:

  • HWC will enable the expansion of package of service that go beyond Maternal & Child Health (MCH), to include care for non-communicable diseases, palliative and rehabilitative care, oral, eye and Ear-Nose-Throat (ENT) care, mental health and first level care for emergencies and trauma.
  • In order to provide these services at the Sub Health Centre (SHC)- HWC, a new cadre of worker- the Mid-Level Health provider (MLHP)-who is either a nurse or an Ayurveda practitioner, trained in competencies of public health and primary health care, clinical management, continuum of care, dispensation of drugs and close follow up for those with chronic illness/patients discharged from health facilities, will lead the team of Multipurpose Workers, and ASHAs.
  • The HWC would follow a well-defined referral chain to ensure continuum of care. PHC-HWC are linked to their SHC-HWC, with the PHC Medical Officer (MO) serving as the team leader for the HWC cluster. Care for all packages is also available at the PHC level, but of a higher order of complexity. For Chronic diseases such as hypertension and diabetes, the PHC MO could initiate the treatment plan. In addition. The MLHP and PHC MO would access specialist care through telemedicine hubs located at the district/medical college levels.
  • These would be a progressive inclusion of diagnostic tests and medicines available at the HWCs so that more condition could be managed at those levels and less referral happens to higher facilities.

The other component of Ayushman Bharat which makes it a programme for ensuring UHC is the Pradhan Mantri Jan Arogya Yojana (PMJAY). Launched on September 23, 2018, it has subsumed the Rashtriya Swasthya Bima Yojana (RSBY) and Senior Citizen Health Insurance Scheme (SCHIS). Poised to be the largest public-funded health insurance scheme in the world, PMJAY will ensure the continuum of care from AB-HWCs and substantial reduction in OOPE on catastrophic healthcare. AB-PMJAY leverages on CPHC through HWcs for preventive, promotive and curative care and will ensure seamless continuum of care. This will avoid overcrowding in tertiary facilities and improve quality of care at secondary and tertiary facilities as well as provide UHC, making services equitable, affordable and accessible.

The AB-PMJAY is being managed by National Health Agency (NHA). The current status of implementation of this schemes is that 33 states/Uts have signed MoUs or agreed to sign MoU with the Centre (remaining being Odisha, Telangana and Delhi) and out of these, 26 States have started the implementation. There are three modes of implementing the scheme i.e. Insurance Mode, Trust Mode and Mixed Mode. The NHA has created robust safeguards to prevent misuse/ fraud/abuse by providers and users, including pre-authorisation being made mandatory for procedures with moral hazard. As on date, one lakh beneficiaries have availed of services under PMJAY, in a period of just about a month.

Footnote

  1. National Health Policy, 2017, Ministry of Health and Family Welfare, Government of India.
  2. Doherty G and Govender R, ‘The cost effectiveness of primary care services in developing countries: A review of international literature’, Working Paper No. 37, Disease Control Priorities Project, World Bank, WHO and Fogarty International Centre of the Us National institutes of Health, 2004, https://www.researchgate.net/publication/24278 3643_The_Cost-Effectiveness_of_Primary_Care_Service_in_Developing_Coutires_A_Review_of_the_International_Literature

AYUSHMAN BHARAT: SILVER LINING IN HEALTH CARE

Who defines quality care as “the extent to which health care services provided to individual and patient populations improve desired health outcomes”. To achieve this, health care must be safe, effective, timely, efficient, equitable and people centred. In a setting, where we are struggling to meet the ever rising demand for access to health services on account of various constraints-financing, availability of skilled human resources, inadequate and unevenly distributed health care infrastructure, under-developed regulatory infrastructure to name just a few- out, the serious challenger ans concerns pointed out, the initiation of Ayushman Bharat provides the proverbial silver lining. For the first time in India, we have witnessed health becoming a part of the mainstream politics. Moreover, what is refreshing is the fact that we are taking a more comprehensive health system approach-addressing all the levers affecting it – rather than tinkering at the margins. In this article, we examine the impact of these new initiatives on the quality of health care in India. Before we delve into this aspect, it would be useful to recapitulate the initiatives under this initiative.

Study Material for UPSC General Studies Pre Cum Mains

(GIST OF YOJANA) Staircase to Swaraj [NOVEMBER-2018]


(GIST OF YOJANA) Staircase to Swaraj

[NOVEMBER-2018]


Staircase to Swaraj

A Young man from central Maharashtra who cleared the ICS preliminary exam met Gandhi at his Sevagram Ashram to seek his blessings. Gandhi asked ‘why do you want to be ICS?’ ‘to serve India’, responded the Young man . ‘Going to village and doing sanitation work is the best service to india,’advised Gandhi. And the ICS aspirant Appa Patwardhan turned out to be one of the finest freedom fighter, specialising in the art of ‘Safai’. In the school of freedom struggle, ‘safai’ and ‘swachata, was the test to graduation. Vinoba bhave, Thakkar Baba, JC Kumarrapora and innumerable youngsters with sparkling brilliance joined the freedom struggle and took the safari and swachata root to independence.

Development Prerequisite

Development has been a faithful companion of human civilisation. . From a prehistoric hunter-gatherer to the sophisticated urbane human, we have improvised life a great deal. Development is seen as a betterment that innovation brings about in any facet of life. The notion of human development incorporates all aspects of individuals’ well-being’: food security, clean and fresh air, safe drinking water, health and sanitation, access to wherewithal and to ensure all these, quality education and freedom of choice.

Much of these components of development can be classified as physiological need fulfilment, as Abraham Maslow would put it. As a developing community, we have taken great pains to build mechanism to take care of one side of the physiological need, the supply side, to the utter neglect of another side, the disposal has scarcely been in the scheme of the development agenda.

Truth Realisation

For Gandhi, sanitation was not just a biological requirement; it was a way of life, an integral part of Truth realisation. His understanding of cleanliness stems from his realisation of the universal oneness of Truth. Gandhi who worshipped Truth as God, saw the Absolute, the all encompassing truth as Pure and hence equated cleanliness with godliness. He accorded ‘sanitation’ the status of an essential step to freedom incorporating it into the list of eighteen Constructive Programmes.

The seeker after Truth, saw life as the closest manifestation of Truth, therefore, he equated life with Truth or God. All the processes that are part of life and its conduct are also part of the Truth realisation. In this sense, Gandhi believed, sanitation cleanliness of inner and outer self are means of God realisation. “We can no more gain God’s blessing with an unclean mind. A clean body cannot reside in an unclean city.”

Swaraj

Gandhi’s holistic perspective about freedom of Indian led him to understand the unique place of sanitation in India’s pursuit of swaraj.

Demanding the right of Indian Home Rule, Bal Gangadhar Tilak roared, ‘Swaraj’ was more profound in its implication. He started in young India, “ swaraj is a sacred word, a vedic word, meaning self-rule, self-restraint and not freedom from all restraints which ‘independence’ often means.’Self restraint from all indulgence, not to mention, from littering, not to mention, from littering public places. He went on further, “Swaraj of my dream is the poor man’s swaraj”, and the self-restraint needs to sleep up to the the last man. Addressing the grand audience on the occasion of the inauguration of banaras hindu university, he referred to the filth that smothered the hole city. “No amount of speeches will ever make us fit for self-government (freedom). It is only our conduct that will fit us for it” Cleanliness has been a ‘swaraj Yojana’ for him.

This ‘self-restraint’ he evoked i individual conduct of personnel and public life, both physical and attitudinal facets of living. Talking on the disposal mechanism Gandhi stated, ‘Swaraj is not poorna Swaraj, until all the ordinary amenities of life are guaranteed to every human under it.’

Staircase to Swaraj

Spearheading the freedom struggle, he explained the dimensions of freedom and highlighted the importance of and highlighted the importance of ‘clean behaviour’ . In this context he stated “before we think of self-government, we shall have to do necessary plodding”. From the standpoint of health, gandhi temed the condition of villages as deplorable. “ One of the chief causes of our poverty is the non-availability of this essential knowledge of hygiene. In this sense he stated, Swaraj is not ‘freeing India merely from the English yoke… but from any yoke whatsoever.’ On another occasion he stated, swaraj will be a fruit of incessant labour and intelligent appreciation of the environment.

An act of Sublime Joy

Gandhi, who saw non-violent living as the best means to worship God and truth, saw every act that serves life as a way to God, He deemed cleaning as an act of purification and drew immense joy from it. Pyarelal, Gandhi’s secretary , gives an interesting anecdote on this, from Noakhali where Gandhi was walking the length and breadth to build harmony between Hindus and Muslims. He writes, “Even for Noakhali, it had been an expectation dewy night, and the narrow footpath by which Gandhiji wa sto proceed had been rendered extremely slippery when on the morning of January 19, 1947, he left Bagalkot for Atakara. Twice col. Jiwan singh accustomed to difficult marches, lost his walking stick to pull himself up the slippery slope.

The footpath was narrow so that the party could walk on it only in single file. All Of a sudden the column came to a dead stop. Gandhi was removing excreta from the footpath with the help of some dry leaves. The footpath had again been dirtied by some communal urchins . ‘Why did you not let me do it ? Why do you put us to shame like this?” Manu asked. Gandhi laughed: “ You little know the joy it gives me to do such things.”

Gram-Rajya

Village, the centre of all primary produce and sustenance, is the heart of India. I the life of villages rests the life of India, Gandhi believed. Hence, he equated hind-Swaraj-Indian Home Rule, with ‘Grama-rajya. Visualising villages of free India, Gandhi stated, That village may be regarded as reformed, which has every kind of village industries to produce each of her requirements in which nobody is illiterate, where the roads nobody is illiterate, where the roads are clean, there is a fixed place for evacuation, the wells are clean..” Gandhi proposed ‘An ideal Indian village will be so constructed as to lend itself to perfect sanitation . It will have cottages with sufficient light and ventilation built of a material obtainable within a radius of five males of it’. Lamenting over the present despicable state of villages, he wrote,”If sanitation in villages can be improved, lakhs of rupees will easily be saved and the condition of people improved to that extent. A sick peasant can never work as hard as a healthy one.”

UPSC Pre General Studies Study Material

(GIST OF YOJANA) Sanitation Revolution : Cleaning urban India [NOVEMBER-2018]


(GIST OF YOJANA) Sanitation Revolution : Cleaning urban India

[NOVEMBER-2018]


Sanitation Revolution : Cleaning urban India

A multi-pronged approach comprising regulatory and policy level changes, sustainable infrastructure creation and focussing on attitudinal and behaviour change among people through large scale citizen engagement has been the hallmark of the Government’s initiatives on the journey towards a “swachh bharat”.

The Cost of Poor Sanitation

The Sustainable Development Goals (SDGs) place significant emphasis on sanitation, cleanliness and hygiene. There is significant evidence globally that better sanitation, hygiene and cleanliness helps in effective control of various vector borne disease, parasite infections and nutritional deficiencies. There have been studies linking cleanliness and hygiene with reduction in respiratory disorders, gastrointestinal diseases (especially diarrhea) , psychologist issues and allergic conditions . As per a UNICEF report (2011), almost 90 percent of child deaths from diarrheal disease are directly linked to contaminated water, lack of sanitation or inadequate hygiene. In addition to the impact on communicable diseases, better sanitation, hygiene and waste disposal lead to reduction in occurences of low birth weight in occurrences of low birth weight babies, spontaneous abortions and occurrences of birth defects. Various studies have established that the problem of solid waste management has been compounded due to high population concentration in urban areas. Waste that is not properly managed, especially excreta and other liquid and solid waste from households and the community, are a serious health hazard and lead to the spread of infectious diseases.

The launch of Swachh Bharat Mission

Decades ago, Mahatma Gandhi said that ‘sanitation is more important than political freedom’. The launch of Swachh Bharat Mission on 2nd October 2014 by the Prime Minister to address this burgeoning health crisis was a historic moment for India-not merely for placing the issue of sanitation at the centre of the Government’s development agenda, but also for the resounding agenda that was sent out from the ramparts of the Red Fort: “ Na Gandagi Karenga Denge” ( I shall not make my environment diry, nor will I allow others to do so), there by making every citizen an equal partners in India’s journey towards ‘swachhata’. The Swachhata Bharat Mission (urban ) (refer Figure being implemented by the Ministry of Housing and Urban Affairs (MoHUA) is aimed at transforming Urban India into a garbage- free and open defecation free tribute to Gandhi ji’s memory on his 150th birth anniversary.

Star Rating For Garbage Cities

The Ministry has introduced a new innovative for evaluating the Garbage Free status of Cities and awarding the “Garbage Free City Stars” to the city. The Star Rating initiative , which is a rating protocol based on twelve protocol based on twelve (12) parameters, follows a SMART framework - Single metric, Measurable, Achievable, Rigorous verification mechanism and Targeted towards outcomes- and has been devised in a holistic manner covering all aspects of Solid Waste Management viz. Public Cleanliness, Door to Door collection, source segregation, processing, cleanliness of drains and water bodies, plastic waste management, managing construction and demolition waste etc. which are critical drivers for achieving garbage free cities. In fact, as more and more cities get certified as ‘stars’ and ’citizens, aspirations grow around cleanliness and higher standards of liveability,it may well emerge as a key differentiator in the administrative/ political fabric of the country, where number of stars for their city can be one of the parameters for evaluating effectiveness of administration and elected representatives in achieving Swachhata.

Some Inspiring Stories of Citizens Participation A doctor couple from Challapalli district have been undertaking cleanliness drives in their surroundings every day of the year.

Monks of Ramakrishna Mission in Karnataka hold regular cleaning drives alongwith citizen volunteers to keep roads had localities clean. Wing Commander PAramvir Singh, along with three swimmers and six raft-men, undertook a Ganga Avahan’ , swimming a length of 2,800 km along River Ganga from Devprayag (Uttarakhand ) to Ganga Sagar (West Bengal) to spread awareness be out the Swachh Bharat Mission.

Three enterprising ladies from Maharashtra-Suvarna Lokhande from Sinnar-Nasik district, Sangeeta Awale from Saikheda- Washim district, and Chaitali Rathod from Mozar- district Yavatmal had taken the their families’ self-esteem.

While Suvarna took a loan from “Bachat Gat” (Self-help Group) for building the toilet, Sangeeta sold her mangalsutra to fund the toilet, and Chaitali asked for a toilet at her in-laws’ place instead of any other items from her parents during her marriage. Agra-based organisation India Rising carries out weekly cleaning drives with citizens volunteers across multiple locations in the city. Social and Economic Impacts of Swachh Bharat Mission: A Few Examples

A recent study by the Indore Municipal Corporation (jagran 2017) has found that vector-borne disease have reduced by 70 percent due to the sanitation interventions under Swachh Bharat Mission . in fact, the number of patients affected by jaundice, cholera, vomiting, diarrhoea, hepatitis and malaria in Indore have reduced from 1,00,000 between june to August 2016 to 35,000 during the same period in 0217. As a result, the sale of medicines across Indore has dropped by INR 20 crores, which has contributed i controlling healthcare related costs in the city. State of Chhattisgarh has reported a dramatic reduction in contamination and incidences of diseases such as diarrhea, typhoid etc,. In the last two years.

Success Story

Plastic Free Sitamarhi

Sitamarhi, the first district in Bihar to become open defecation free (ODF), on 17 july 2018 is now heading towards a much-talked about plastic ban that will be carried out in a phased manner. This initiative comes under Swachh Bharat Mission-Gramin/ Lohiya Swachh Yojana, the vision being Swachh Sitamarhi (clean Sitamarhi), Sunder Sitamarhi (Beautiful Sitamarhi).

Under this, all kinds of plastic bags ( both with and without a handle), all plastic or thermocol cutlery such as spoons and plates, non-woven polypropylene bags, food containers, plastic packaging, and PET and PETE bottles are included.

Until now as many as 10 lakh cotton bags which have been made by rural women entrepreneurs from various Self Help Groups (SHG) of project JEEVIKA have been procured by the district for distribution. Plastic free Sitamarhi campaign will not only reduce the micro-plastic contents in the food cycle but will also give a boost to the rural women entrepreneurship program of JEEVIKA and will act as a catalyst for women empowerment towards a social cause

UPSC Pre General Studies Study Material

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