(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.

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Courtesy: Kurukshetra