Actualising Universal Health Care: India’s journey of Ayushman Bharat

By Preeti Sudan

Preeti Sudan, Former Union Health Secretary, Government of Indiaia

In 2017, the Government of India announced the National Health Policy 2017. Crafted through an extensive consultative process, it envisioned the provision of comprehensive health care with integration of preventive and curative services at all administrative levels, development of primary health care in stages and creating a system of medical education to include preventive and social medicine.

Within a year, in 2018, we saw the operational manifestation of the policy with announcement of Ayushman Bharat (AB) with its two pillars of Pradhan Mantri Jan Arogya Yojana (PMJAY) and Ayushman Bharat- Health and Wellness Centers (AB-HWCs).

PMJAY, the world’s largest health assurance scheme provides the neediest with a protection from catastrophic expenditure as the government becomes a payer of hospital expenses up to Rs 5 lakhs per family for about 50 crore population.

The AB-HWCs were set up to deliver universal comprehensive primary health care and have multiple components that are rooted in two fundamental premises –

The first is to introduce wellness as a key aspect of service delivery and to ensure that the spectrum of preventive, promotive, rehabilitative and palliative care receives as much attention as curative care. This in fact, changes the concept of Health from merely being an absence of ill health or sickness and focuses on well-being.

The second is to expand the range of services to include non-communicable diseases, mental health, ENT, ophthalmology, oral health, geriatric and palliative care and trauma care apart from the ongoing focus on maternal, newborn child care and identified communicable diseases.

It is with these two fundamental premises as the focus that on April 14th 2018, India embarked upon the journey of comprehensive, preventive and promotional health care with Hon’ble Prime Minister inaugurating the first Ayushman Bharat Health and Wellness Center (AB-HWC) in remote Jangla of Bijapur district in Chattisgarh. It is with pride that we note that the country has not only reached the set target of 1.1 lakh AB-HWCs by 31st March 2022 but also over-achieved to have 1,17,440 AB-HWCs already operational.

The transformation of SHCs, PHCs and UPHCs to AB-HWCs is a 9-point reform spanning all aspects of the healthcare systems such as expanded package of services, human resources with the introduction of a new cadre of mid-level health care providers viz. Community Health Officers, financing, access to an expanded range of essential medicines and diagnostics, creating IT systems to facilitate continuum of care and paradigm shift in services delivery, community participation, ownership and governance.

Why are AB-HWCs important and different from the present sub centers and primary health care centers? The four pillars of Primary Health Care, including community participation, appropriate technology, equitable distribution and inter-sectoral coordination are being anchored in and around AB-HWCs to allow every citizen of India access to quality healthcare, free of cost near to their homes. AB-HWCs is a major transformation of primary health care from disease-centric to a whole-of-society approach.

The thrust of primary health care till recently has been on maternal & child healthcare needs. The HWCs that are operational are now providing services not only for pregnant women, mothers, new-borns and children, but also for communicable and non-communicable diseases, mental health, geriatric and palliative care and for acute simple illnesses. Screening for primary prevention of chronic diseases such as hypertension, diabetes and common cancers, also show an encouraging trend. With more than 85.87 crore footfalls in the HWCs at the end of March 2022, 17.95 crore have been screened for hypertension, 14.87 for diabetes and 17.75 crores for three cancers: oral, breast and cervical cancer. The increase in the number of women accessing the HWCs for non-communicable disease services is particularly heartening as hitherto these services were not easily accessible to them.

Availability of free essential drugs especially for chronic diseases in the HWCs not only reduces patients’ sufferings but also has the potential to decrease out of pocket expenditure and prevent secondary complications, thus ensuring wellness and healthy lives for many.

Yoga and wellness are an integral part of India’s culture, so integrating it as a part of healthcare service delivery framework has been long overdue. In September 2019, at the first ever high level meeting on Universal Health Coverage in the United Nations, Hon’ble Prime Minister called preventive health care as the first pillar. Through HWCs, the Government of India has mainstreamed India’s rich tradition of the indigenous health system and Yoga into the healthcare delivery system. Yoga and wellness sessions are being organized at AB-HWCs and as of 14th April 2022, a total of 1.05 crore wellness sessions have been organized at AB-HWCs across the country. Health and Wellness Centers are also becoming the locus for other physical activity, (such as regular yoga sessions, organizing cyclathons and marathons) meditation, laughter clubs, talks on Eat Right campaign and Fit India movement, cessation of Tobacco and drugs and a place for exchange of best practices amongst the community. Through an Annual Health Calendar, planned activities at these centers for a range of lifestyle modifications are resulting in increased public awareness and preventive measures for fitness. In addition, school teachers are being trained as Ayushman Ambassadors or Health and Wellness Ambassadors to enable integration of lifestyle changes in the formative years, which has the potential of preventing or delaying the onset of chronic diseases in adulthood.

The sustainability and impact of AB-HWCs largely hinges on the community ownership of the facilities and people’s trust in the services. Jan Arogya Samitis (JAS) at AB-HWCs are being established to enhance people’s ownership of the public health facilities and the health care team’s accountability to the citizens. Each JAS has nearly 20 members with the local government elected representative being its chair. This provides the citizens with an opportunity to reap benefits of the public health resources that they rightfully own. These JAS should work in tandem with community based platforms like Village Health and Sanitation Committees (VHSNCs) in rural and Mahila Arogya Samitis (MAS) in urban areas, to enhance action on social and environmental determinants of health and enable village health planning at the local level. Social Audit through self-help groups will enhance both local accountability of the centers and sense of ownership of the community. The Swachh Bharat Abhiyan and the Jal Jeevan Mission are the interventions that are bound to contribute positively to India’s journey to wellness. The enhancement of the untied fund to Rs.50,000 for the Sub-Health Center Health and Wellness Center is a welcome move in this direction.

The celebrations of the 4th anniversary of AB-HWCs began on 16th April 2022. Nationwide congratulations are being conducted under the theme “eSanjeevani HWC- ​​Health and Wellness through teleconsultation”. The theme echoes the vision laid down in the early years of Ayushman Bharat Scheme – reaching the unreached by leveraging technology. It is amazing to know that more than 2.47 crore tele-consultations have been conducted across 94,049 AB-HWCs as on 12th April 2022 and are increasing by the hour.

Today, after four fruitful years, with the meticulous effort put together by the Government, the healthcare workers and the community, we have been able to tackle the anticipated challenges in improving primary health care. Personally, for me, it is fulfilling to see this vision now in mission mode. Even though the journey has been long, the 4th anniversary of AB-HWCs is an opportunity to honor India’s march towards Universal Health Coverage acknowledging and celebrating the health warriors who have been working relentlessly to “reach out to the unreached”, committing to a healthier and happier India.

(The author is Former Union Health Secretary, Government of India. Views expressed are personal and do not reflect the official position or policy of Financial Express Online. Reproducing this content without permission is prohibited).


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