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Interventions towards Universal Health
Coverage in India
Dr T R Dilip
International Institute for Population Sciences
Course E1.1: Health care systems and policies
25th November 2021
Contents: Recent Health System Response
• Universal Health Coverage- India Situation
• Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY)
• Ayushman Bharat - Health and Wellness Centre (AB-HWC)
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Universal Health Coverage (UHC)
• UHC means that all individuals and communities receive the health services they
need without suffering financial hardship.
• It includes the full spectrum of essential, quality health services, from health
promotion to prevention, treatment, rehabilitation, and palliative care across the
life course.
• The delivery of these services require adequate and competent health and care
workers with optimal skills mix at facility, outreach and community level, and who
are equitably distributed, adequately supported and enjoy decent work
• Protecting people from the financial consequences of paying for health services
out of their own pockets reduces the risk that people will be pushed into poverty
because unexpected illness requires them to use up their life savings, sell assets,
or borrow – destroying their futures and often those of their children.
Universal Health Coverage (UHC) effective coverage, India
Source: IHME http://www.healthdata.org/india
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Universal Health Coverage (UHC) Index- Components
• How well essential services are distributed in India
Source: https://www.thelancet.com/action/showPdf?pii=S0140-6736%2820%2930750-9
Major bottlenecks for Universal Health Coverage (UHC) in India
• Limitations in Infrastructure & trained manpower
• Uneven distribution existing of health care facilities & manpower
• Low level of government funding for health care
• High out of pocket expenditure
• No risk pooling mechanism
• Health regulations poor implemented & sector unregulated
• General lack of priority for health sector by governments (changed during
Covid)
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WHY AB-PMJAY in India?
• Poor health security and hence high out of pocket expenditure
Need to protect poor and deprived households from catastrophic health expenditure and related poverty
Source: National Statistical Office. Health in India (July 2017–June 2018) Report No 588 (75/25.0).
AB-PMJAY-Reduce Out of pocket expenditure in poor households?
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Core Features of AB PM-JAY
A cover of INR 5 lakh per family per year
Over 10 crore poor and vulnerable families eligible
States given flexibility to decide on mode of
implementation
Benefits will be portable across the country
Entitlement based scheme
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Largest fully subsidized health protection scheme in the world covering 40 % of India’s population
Feature of AB PM-JAY (contd.)
• Annual Benefit Cover of INR 5,00,000/- Per Family Per Year for
Secondary and Tertiary Treatment on Cashless and Paperless basis
• No Limit on Family Size
• Release of Grant-in-Aid through Escrow Account
• Implementation through Insurance and/or Trust and/or Mixed Mode
• Convergence with Central as well as State Health Insurance Schemes
• Alliance with State Scheme
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Target Beneficiary Families :
About 11 crore families, or 49 crore individuals – identified as deprived in the Socio-
Economic Caste Census 2011 – for fully subsidized health insurance cover
Rural Urban RSBY Leftout
Families
Total
Families in
Deprivation
Criteria D1, D2,
D3, D4, D5 &
D7
Automatically
Included
Families
Families belong
to 11
Occupational
Criteria
Mainly in States of
Karnataka, Himachal,
Kerala, Chhattisgarh
etc.
In line with budget
announcement
8.03 cr 16 lakh 2.33 cr 22 lakh 10.74 cr
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Target Group for Rural
Total deprived Households targeted for AB PM-JAY who belong to one of the six
deprivation criteria amongst D1, D2, D3, D4, D5 and D7:
• D1: Only one room with kucha walls and kucha roof
• D2: No adult member between age 16 to 59
• D3: Female headed households with no adult male member between age 16 to 59
• D4: Disabled member and no able-bodied adult member (D4)
• D5: SC/ST households (D5)
• D7: Landless households deriving major part of their income from manual casual labour
Automatically included-
• Households without shelter
• Destitute/ living on alms
• Manual scavenger families
• Primitive tribal groups
• Legally released bonded labour
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Target Group for Urban
Occupational Categories of Workers
1. Rag picker
2. Beggar
3. Domestic worker
4. Street vendor/ Cobbler/hawker / Other service provider working on streets
5. Construction worker/ Plumber/ Mason/ Labour/ Painter/ Welder/ Security guard/ Coolie and another
head-load worker
6. Sweeper/ Sanitation worker / Mali
7. Home-based worker/ Artisan/ Handicrafts worker / Tailor
8. Transport worker/ Driver/ Conductor/ Helper to drivers and conductors/ Cart puller/ Rickshaw puller
9. Shop worker/ Assistant/ Peon in small establishment/ Helper/Delivery assistant / Attendant/ Waiter
10. Electrician/ Mechanic/ Assembler/ Repair worker
11. Washer-man/ Chowkidar
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AB-PMJAY Coverage (including State Schemes)
Source: PMJAY Website: https://pmjay.gov.in/states/states-glance accessed on 24-11-2021
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Coverage of AB_PMJAY + State Social Insurance Schemes in India (November 2021)
Item Number
Total Number of Households in India 22,65,93,557
" Eligible Families as per SECC/RSBY database 8,93,92,413
"Additional Families (Covered by State upto 5 Lakh)" 5,11,96,288
Number of Eligible Families under PM-JAY 14,05,88,701
Non PM-JAY Families (Covered under the State Scheme beyond 5 Lakhs) 2,81,15,398
Total number of Government Hospitals Empaneled (NABH Accredited) 11,839(92)
Total number of Private Hospitals Empaneled (NABH Accredited) 9,979(813)
Total number of Hospitals Empaneled (NABH Accredited) 21,818(905)
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Eg of Name of the schemes and agency implementing the scheme
Source: PMJAY Website: https://pmjay.gov.in/states/states-glance accessed on 24-11-2021
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State/UT Name Name of Scheme in the State/UT Name of the State Health Agency
Andhra Pradesh Ayushman Bharat-Dr. YSR Arogyasri Dr. YSR Arogyashri Healthcare Trust (Dr YSRAHCT)
Karnataka AB-ArK (Ayushman Bharat-ArogyaKarnataka) Suvarna Arogya Suraksha Trust (SAST)
Kerala
Pradhan Mantri Jan Arogya Yojana - Karunya Arogya Suraksha
Paddhati (PMJAY-KASP) State Health Agency, Kerala
Tamil Nadu
Pradhan Mantri Jan Arogya Yojana-Chief Minister's
Comprehensive Health Insurance Scheme (PMJAY-CMCHIS) Tamil Nadu Health System Project (TNHSP)
Telangana Ayushman Bharat PM-JAY Aarogyasri Aarogyasri Heath Care Trust
Madhya Pradesh Ayushman Bharat-Madhya Pradesh ‘Niramayam’ Yojana Deen Dayal Swasthya Suraksha Parishad
Maharashtra Ayushman Bharat State Health Assurance Agency
Population outside risk pooling in India
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Challenges so far
• Only cover inpatient care. Out of pocket expenses from outpatient
care remains
• Some of the real vulnerable households not covered or leftout
• A sizeable share of enrolled beneficiaries not benefitting from this
health security scheme at the time of hospitalization due to various
factors
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Why Health and Wellness Centers ?
• Changes in health needs of the population due to decline in fertility
and mortality induced changes in age composition & disease burden
• Rise in share of non-communicable diseases
• Need to focus on health and wellness promotion activities, for overall
improvement of health status
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Recent trends in selected RMNCH Indicators in India
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NFHS Indicator
NFHS 4
(2015-16)
NFHS 5
(2019-21)
Neonatal mortality rate (NNMR) per 1000 live births 29.5 24.9
Under-five mortality rate (U5MR) per 1000 live births 49.7 41.9
Total Fertility rate 2.2 2.0
Current use of any modern method (%) 47.8 56.5
Total unmet need for family planning (%) 12.9 9.4
% of child births in institutions 78.9 88.6
% birth attended by skilled personnel 81.4 88.4
% of Children age 12-23 months fully vaccinated 62.0 74.6
Source: IIPS, Mumbai The National Family Health Survey 2019-21 (NFHS-5)- India Fact Sheet
Changes in causes of deaths in India
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Source: IHME http://www.healthdata.org/india
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Ayushaman Bharat – Health and Wellness Centres
–
a Platform to integrate service delivery – provide comprehensive care
RMNCHA+N
Communicable
Diseases
Non
Communicable
Diseases
Preventive
and
Promotive
Comprehensive
Primary
Health
Care
–
Oral,
Mental,
Geriatric
etc
.
Moving towards
Universal Health
Coverage
PRIMARY
SECONDARY
TERTIARY
CHC/ SDH/District
Hospitals / PMJAY
empanelled Pvt.
facilities
Preventive, Promotive,
Curative, Rehabilitative &
Palliative Care
Unmet need:
NCDs/other
Chronic Diseases
Existing
services:
RMNCH+A
Referral/Gatekeeping
CPHC
through
HWCs
AYUSHMAN BHARAT – HEALTH AND WELLNESS CENTRES
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Rmncha+n : the unfinished agenda
• Strengthen the existing RMNCHA+N services and build on quality of
services being provided
• Role of Primary Health Care Team led by Community Health officer (CHO)
• Immunization and ANC – not just ANM and ASHA
• Defined role of CHOs for FP services, ANC / PNC care , immunization etc. –
linking with performance linked payment of the AB-HWC team
AB-HWCs - What has CHANGED ?
• Improved infrastructure
• Human Resources at AB-HWCs – ideally as per IPHS norms ;
• Community Health Officer (SHC),
• 1 MO, 1 LT, 1 Pharmacist (PHC/UPHC)
• ANM and ASHA (as per population norms)
• Strengthening of existing services – RMNCHA+N
• Availability of essential medicines
• Availability of essential diagnostic services
• Population Based Screening for 30+ (NCD , 3 Common Cancers)
• Emergence of IT – AB-HWC portal and NCD Application
• Wellness activity – YOGA and others
• Contribution to Covid 19 preventive activities well recognized
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Institutional Mechanisms for leveraging people’s participation
State level - State Health
Society
District level- District Health Society
Facility level :
CHC/DH-Rogi Kalyan Samiti
AB-HWC
at PHC& SHC level
– Jan Arogya Samiti (JAS)
Village level (Rural)-VHSNC
Slum level(Urban)- MAS
Untied Fund at SHC-
HWC increased
From Rs.20,000 to
Rs.50,000
Functions
of JAS
1. Serve as
Institutional
platform of
SHC/PHC
HWC for
community
participation
2. Support
Health
Promotion
and Action on
Social and
Environmental
Determinants
of Health
3.Provide
mentorship to
VHSNCs
(SHC level)
4. Support and
facilitate the
conduct of
Social Audit at
HWC level
5.Act as
Grievance
Redressal
platform
6.Bring
Accountability
for use of
untied funds
at SHC
7. Mobilize
resources,
both
monetary and
non-monetary
8. Support
Gram
Panchayats in
undertaking
health
planning.
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Structure & Composition of JAS
Service
providers/
System
functionaries
JAS SHC- 10
JAS PHC- 9
Elected
Represe
ntatives
JAS SHC-5
JAS PHC-7
Civil Society
JAS SHC-3
JAS PHC- 3
Service
recipien
t
JAS SHC-2
JAS PHC- 0
Composition of
JAS
At least 50%
representation of
women to be
ensured
At least 33%
representation from
Vulnerable and
marginalized
populations
AB-HWCs National Statistical Report for the Week as on Date - 01-11-2021
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Source: https://ab-hwc.nhp.gov.in/home/Consolidated_Weekly_Report?pmo_date=2021-11-01&state=0
accessed on 25-11-2021
Beneficiaries/indicator Number
Total Functional-HWCs in India 79,715
Total Footfalls-Males 31,98,88,766
Total Footfalls- Females 36,68,47,304
Total Footfalls-Others 17,79,329
Total Footfalls- Total 68,85,15,399
No of Wellness sessions including Yoga conducted 85,54,884
Total Screenings For Hypertension 13,87,39,334
Total Screenings For Diabetes 11,40,13,082
Total Screenings For Oral Cancer 7,32,76,608
Total Screenings For Breast Cancer 3,67,65,111
Total Screenings For Cervical Cancer 2,50,46,892
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AB-HWCs Challenges
• Crossed 50 % of targeted number of HWCs
• Rebranding or upgrading of existing facilities only. Rebranding
completed but infrastructure upgradation is due/ underway in many
of the HWC’s
• Shortage of space for additional staff under HWC for new staff and to
conduct of their activities as part of HWCs
• Large interstate variation in level of implementation. Staff training or
reorientation to be completed
• Shortage of EML-drugs, medical equipment and supplies continues
• Constrains in maintenance of equipment's at facility level
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Thank You
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Reading/ Resource list
• Official Website Ayushman Bharat - Health and Wellness Centre https://ab-hwc.nhp.gov.in/home/aboutus
• Kieny, M.P., Bekedam, H., Dovlo, D., Fitzgerald, J., Habicht, J., Harrison, G., Kluge, H., Lin, V., Menabde, N., Mirza, Z. and Siddiqi, S.,
2017. Strengthening health systems for universal health coverage and sustainable development. Bulletin of the World Health
Organization, 95(7), p.537. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5487973/pdf/BLT.16.187476.pdf
• Kumar A, and Sarwal R. 2021. “Health Insurance for India’s Missing Middle” https://www.niti.gov.in/sites/default/files/2021-
11/HealthInsuranceforIndia%E2%80%99sMissingMiddle_01-11-2021_digital%20pub.pdf
• Ministry of Health and Family Welfare. Ayushman Bharat Health and Wellness Centres. New Delhi: Ministry of Health and Family
Welfare, Government of India.2021.
https://static.pib.gov.in/WriteReadData/specificdocs/documents/2021/sep/doc202192010.pdf
• National Health Authority. Ayushman Bharat.- Pradhan Manthri Jan Arogya Yojana-Capacity Building Guidelines. New Delhi:
MOHFW, Government of India. 2019. https://www.pmjay.gov.in/sites/default/files/2019-
02/Capacity%20Building%20Document%2C%2022.01.2019_Approved.pdf
• NHM Presentation on HWC’s
https://nhm.gov.in/New_Updates_2018/Presentation/Goa_19th_20th_August_2019/2ND_REGIONAL_WORKSHOP_V2_20_8_201
9.pptx
• Official PMJAY Website: https://pmjay.gov.in/states/states-glance
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