AYUSHMAN BHARAT

Junior Resident: Dr Tanveer Rehman

Faculty Moderator: Dr Jayalakshmy

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 CONTENTS

1. Background

2. Rashtriya Swasthya Bima Yojana

3. Ayushman Bharat Program

4. Pradhan Mantri Jan Arogya Yojana

5. Comprehensive Healthcare: Health and Wellness Centres

6. Expected Outcome

7. SWOT Analysis

8. Summary

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 BACKGROUND

a) 3/4th of total public sector health services delivered by 1/4th of public health facilities1

b) 70% of all OPD & hospitalization: Private sector2

c) At a cost beyond their capacity to pay: 4% of all poverty2

d) Ranked at 154 of 195 countries on health service delivery index: Lancet, 2017

e) 156,231 SC - 25,650 PHC - 5,624 CHCs: Only 15% meet IPHS3

1
Government of India. Report of the Task force on Primary Health Care in India, 2017
2
National Sample Survey Organization. Report of 71st round of National Sample Survey 2014
3
Government of India. Rural Health Statistics 2017
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 RASHTRIYA SWASTHYA BIMA YOJANA (RSBY)

a) Cashless health insurance scheme

b) 2008 - Ministry of Labour and Employment

c) Hospitalization expenses coverage of Rs. 30,000/- per annum

d) Transportation coverage: Rs. 1,000/- with Rs. 100/- per visit

e) 5 members - Below Poverty Line (BPL) or 11 other defined designated categories - districts

f) Rs. 30/- every year & enrolment based

g) Sharing pattern: Central Government & State Government - 75%: 25%

h) 2015 - Ministry of Health and Family Welfare

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 SENIOR CITIZEN HEALTH INSURANCE SCHEME (SCHIS)

1. Launched on 01.04.2016 - top up scheme of RSBY

2. Age > 60 years

3. BPL and 11 other defined designated categories

4. Rs. 30,000/–per annum per senior citizen - over and above RSBY entitlement

5. Ministry of Social Justice and Empowerment

6. 8 States: Assam, Gujarat, Karnataka, Kerala, Meghalaya, Nagaland, Tripura and Uttar
Pradesh

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 SHORTCOMINGS

1. Low awareness:
2017: 3.63 crore families covered (enrolment of 61%) – 23 states

2. Hospitalization cost: increased >10% between 2004 - 2014, benefits unchanged

3. Target beneficiary: 6 crore families

4. Denial of services: > 1 year to distribute cards

5. 23% increase in OPD costs in the RSBY households

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 EXPENDITURE DISTRIBUTION

1. Public health expenditure: 2016-17: 1.15% of Gross Domestic Product (GDP)

2. Of the Government Health Expenditure, Union Government share is 37% and

State Government share is 63%.

3. Government expenditure on Primary Care is 51.3%, Secondary Care is 21.9%

and Tertiary Care is 14 %

4. Private expenditure on Primary Care is 43.1%, Secondary Care is 39.9% and

Tertiary Care is 16.1%.

*National Health Accounts 2014-15

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 AYUSHMAN BHARAT
PROGRAM (ABP)

PRADHAN MANTRI JAN HEALTH AND

AROGYA YOJANA WELLNESS
(PMJAY) CENTERS (HWCs)
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 BENEFITS
1. Benefit cover of Rs. 5 lakh per
family per year
2. More than 10 crore families
(nearly 40% of the population)
belonging to poor and vulnerable
population
3. No cap on family size and age
4. Secondary and Tertiary care
procedures
5. Pre-existing conditions
6. Transport allowance
7. Public/private/ESI hospitals
across the country
8. Technologically driven cashless,
paper less transaction
9. Subsume the on-going centrally
sponsored schemes – RSBY &
SCHIS
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 AUTOMATICALLY INCLUDED

Based on fulfilling any of the 5 parameters of inclusion

1. Households without shelter

2. Destitute, living on alms

3. Manual scavenger families

4. Primitive tribal groups

5. Legally released bonded labour

*Additionally, families with an active RSBY cards as of 28 February 2018

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 MARKERS OF DEPRIVATION

1. Households with one or less room, kuccha walls and kuccha roof

2. No adult member in household between age 18 and 59 years

3. Household headed by female and no working age male member

4. Household with differently able members and no able bodied adult

5. Household with no literate over 25 years

6. Landless households deriving a major part of their income from manual

labour

7. SC/ST households.
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BENEFICIARIES
 CORE PRINCIPLES

1. Entitlement based enrolment

2. Risk and resource pooling are almost non-existent - fully subsidised

3. Co-operative federalism and flexibility to states

4. Mode of implementation

5. Institutional structure

6. Comprehensive media and IT platform

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 CORE PRINCIPLES

1. Entitlement based enrolment

2. Risk and resource pooling are almost non-existent - fully subsidised

3. Co-operative federalism and flexibility to states

4. Mode of implementation

5. Institutional structure

6. Comprehensive media and IT platform

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 MODE OF IMPLEMENTATION

TRUST/ SOCIETY MODEL INSURANCE MODEL

1. Not-for-profit orientation 1. Experience

2. Awareness and sensitisation: government 2. In-house capacity & structure

administrative machinery 3. Scale up of scheme
3. Weak in-house capacity 4. Cost-escalation overtime
4. Weak governance structure

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 CORE PRINCIPLES

1. Entitlement based enrolment

2. Risk and resource pooling are almost non-existent - fully subsidised

3. Co-operative federalism and flexibility to states

4. Mode of implementation

5. Institutional structure

6. Comprehensive media and IT platform

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 INSTITUTIONAL STRUCTURE

National Health ABNHPM Governing

ABNHPM Agency
Protection Mission Board State Health Agency
(NHPM) Council
• Decision-making • CEO-Secretary/
• State: insurance
• Policy guidance • MoHFW & NITI Additional
company or
• MoHFW & NITI Secretary to GoI
Aayog through a trust
Aayog • Operational level in
• Financial Advisor
• Health ministers of the form of a
(MoHFW), Mission
all States Society
Director and Joint
Secretary
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ABNHPM
 CORE PRINCIPLES

1. Entitlement based enrolment

2. Risk and resource pooling are almost non-existent - fully subsidised

3. Co-operative federalism and flexibility to states

4. Mode of implementation

5. Institutional structure

6. Comprehensive media and IT platform

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 OUTCOME

1. Standardised treatment guidelines (STGs)

2. Standardised package rates

3. Updating ROHINI (Registry of Hospitals in Network of Insurance)

4. Enrichment of National Health Resource Repository (NHRR)

5. IT integration and data generation

6. Employment generation

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 ANALYSIS OF PMJAY

1. Health sector budget allocated: only 2.4% higher over the last year

2. Rs 2,000 crore compared to RSBY Rs 1,000 crore last year

3. NITI Aayog annual estimate: Rs 10,000 crores

4. Check the movement of patients from rural areas & OOPE

5. Moral hazards

6. All the different states agree: ‘game changer’

7. Social determinants of health

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 HEALTH AND WELLNESS CENTRES (HWCs)

a. Subcentres: 1/5th without regular water supply – 1/4th without electricity – 1 in 10 without
all weather road, and over 6,000 without single ANM1

b. Creation of 150,000 health and wellness centres – by December 2022

c. “Assuring availability of free, comprehensive primary health care services” by community

within 30 min of walking distance

d. Upgrading all 4,000 primary health centres in urban area to the HWCs by March 2020

e. 11,000 and 16,000 HWCs are proposed to be made functional in financial years 2018-19
and 2019-20

Central Bureau of Health Intelligence. National Health Profile 2017

1

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 ORGANIZATION OF HWCs

Primary care provider team:

1. Mid-Level Healthcare Provider (MLHP): Community Health Officer (CHO)

BSc/-General Nurse Midwifery or B.Sc. Community Health or AYUSH doctor
trained in 6 months Certificate Programme in Community Health

2. Multi-Purpose Worker (MPW) Female- 2

3. Multi-Purpose Worker (MPW) Male – 1

4. 5 Accredited Social Health Activist (ASHA)s as outreach team

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 ORGANIZATION OF HWCs

1. Central Diagnostic Unit (CDU): every 20 HWCs

2. Diagnostic runners

3. Electronic health records (EHR)

4. Training: Learner support centres

5. Infrastructure

6. Team incentives

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 PROPOSED SERVICES THROUGH HWCs

Family planning,
Childhood and Contraceptive
Care in pregnancy Neonatal and infant
adolescent health services and Other
and child-birth health care services
care services Reproductive Health
Care services

Management of General Out-patient Screening and Screening and

Communicable care for acute Management of Basic management
Diseases: National simple illnesses and Non-Communicable of Mental health
Health Programs minor ailments diseases ailments

Trauma Care (that

Care for Common Geriatric and can be managed at
Basic Dental health
Ophthalmic & ENT palliative health care this level) and
care
problems services Emergency Medical
services
 ANALYSIS OF HWCs

1. Rs 1,200 Crore has been allotted; rest from state

2. ‘Rate limiting factor’ - MLHPs or CHO, ANM with training

3. Underserve their primary objectives (promotive and preventive)

4. Upgrading SCs to HWCs without matching referral setup can be

counterproductive

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 SWOT ANALYSIS

AYUSHMAN BHARAT PROGRAM

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 STRENGTHS

1. Apparent shift from ‘disease specific’ and ‘Reproductive and child health’

2. From ‘poor only’ to expanded approach of vulnerable and deprived population

3. Seemingly high level of political commitment

4. Acknowledgement of linkage between better health and economic growth of India

5. Well-functioning primary healthcare system - potential to cater 80-90% of health needs

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 WEAKNESSES

1. HWCs: only part of primary healthcare system

2. Private sector & insurance: limited to financial viability

3. Out-patient department visits: not part of PM-JAY

4. Moral hazards

5. Impersonation

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 OPPORTUNITIES

1. Alignment with NHP 2017 and NITI Aayog’s three year Action Agenda 2017-20.

2. Media attention - can bring desired public accountability to expedite implementation

3. Progressive universalization: UHC is about everyone, everywhere!

4. Global and national level focus on universal health coverage (UHC)

5. Upcoming general elections and assembly elections in a number of states

6. Potential - innovative models and strategies for strengthening entire healthcare system

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 THREATS

1. Change in the political leadership or the priorities of the elected governments

2. Limited buy-in and interest by the Indian states: state’s own schemes

3. Challenge in availability of mid-level care providers

4. Focus on these components only and the other broader health system needs ignored

5. Disproportionate focus on one of two initiatives in ABP

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40
 SUMMARY

PM-JAY
TERTIARY

SECONDARY
Unmet Needs: NCD/ HWCs
Other Chronic Existing
Diseases services:
RMNCHA
PRIMARY 28/09/2018 41
SUMMARY

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STATES IMPLEMENTATION STATUS

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THANK YOU

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