Health Systems Strengthening under Ayushman Bharat PM-JAY

Having been part of the scheme since its roll-out 3 years back, I reflect on the progress made by Ayushman Bharat PM-JAY – largest publicly funded health assurance scheme, to strengthen health systems along the building blocks defined by WHO. Happy Weekend Reading!

Background and Summary

One of the key goals of achieving Universal Health Coverage is financial protection i.e., affordable health services at low costs for every individual particularly funded through public sources as recommended by World Health Organisation. This leads to equity in financial contribution and distribution of risk amongst both healthy and sick in society. As per National Health Account 2015-16, it is estimated that out of pocket expenditures (OOPE) comprise over 60% of the total health expenditures in India leading to catastrophic payments and crippling poverty for families seeking hospitalisation. Due to this every year, over 60 million Indians fall below poverty line. Lack of access to good quality tertiary care services has directly affected the sick, elderly and women in families preventing them from seeking timely care. It has forced people to either avoid treatment for years or further aggravated chronic conditions. Ayushman Bharat, under its second component, Pradhan Mantri Jan Arogya Yojana (PM-JAY) was launched in September 2018 as an aim to address some of these challenges and subsuming the earlier scheme of Rashtriya Swasthya Bima Yojana.

Utilization under AB PM-JAY so far

AB PM-JAY, the flagship program of Government of India provides an annual health assurance cover of Rs. 5 lakhs per family for secondary and tertiary care hospitalizations addressing 10.74 Cr total families that form the lowest 40% population in the country. The eligibility criteria is based on the Socio-Economic Caste Census database 2011. Having entered into its fourth year of implementation across 33 States & UTs, the scheme has since created 12.7 Crores Ayushman cards, provided treatment to 2.3 Cr beneficiaries, and empanelled over 27k public and private hospitals. Treatment has been provided under 1570 packages comprising both medical and surgical.

Current Scenario

The above numbers also reflect the progress the scheme has made to create a demand led healthcare pattern and to strengthen health systems within the country along the building blocks defined by WHO. I highlight a few points as below:

1. Financing – While RSBY scheme had a health cover of Rs. 30,000 per family (with maximum capping of 5) based on enrolment criteria, Ayushman Bharat is an entitlement -based scheme providing a cover of Rs 5 lakhs annually per family with no upper capping on family size. This has shown to reduce gender gap and benefitting women where earlier it was observed that large families preferred male members first as beneficiaries.  In 2014 where 6.6 Cr families were covered, there are almost 14 Cr families covered today including the State schemes under PM-JAY.
2. Service Delivery – There are approximately 26,000 hospitals empanelled under PM-JAY (51% Public Hospitals and 48% Private Hospitals) ranging across single speciality and multi-specialty health care providers (HCPs).  The advent of this scheme has also seen a rise in the number of hospitals built in tier-2 and tier-3 cities creating health infrastructure in underserved areas. The Ayushman Bharat fund pool generated in public hospitals is being utilised for improvement in infrastructure, equipment and capacity or strengthening manpower. Many states like Chhattisgarh, Gujarat have implemented the same.  To encourage quality standards of healthcare providers, 9% of hospitals have attained NABH standard through incentivised structure. Additionally, patient centric care is nurtured driven by patient-provider feedback with a 24-hour helpline number (14555) comprising of 100+ call centre team.
3. Health workforce – As a consequence of scheme utilization, considerable employment opportunities have been created across the government sector, private hospitals, insurance companies, third-party vendors etc. AB PM-JAY has also improved institutional capacity by 50% in most State Heath Agencies with skilled team of doctors, auditors, administrators as well as set-up 100+ District Implementation Units (DIUSs). To curb fraud, abuse and malpractices, an anti-fraud unit has been set up both nationally (NAFU) and at state (SAFU) which was a missing component of the earlier schemes resulting in action against 400 hospitals and savings over R. 12 Cr to the beneficiaries. 
4. Health Information System – A robust IT platform forms the backbone of the AB PM-JAY scheme that runs across beneficiary identification (BIS), hospital empanelment (HEM), claims processing (TMS), frauds detection (RADAR, FACTS) as well as scheme monitoring dashboards (INSIGHTS). This has led to a cashless and paperless scheme along with building a strong database in tracking utilization trends, facilitating provider payment mechanisms, disease management etc.
5. Access to essential medicines and treatments – 59% of the treatment amount comprises of tertiary care hospitalizations with the top three services being oncology, cardiovascular and orthopaedic speciality. The 1500+ packages under Ayushman Bharat are very comprehensive and cover 24 specialties. With the introduction of portability, over 2 lakh beneficiaries are able to seek treatment outside home state in national hospitals like AIIMS, Safdarjung, PGIMER etc.

• Universal health Coverage – By extending health coverage to remaining populations beyond PM-JAY, many States like Karnataka, Uttarakahand, Chhattisgarh have expanded beneficiary base and attained universal health coverage.  These States have also reached 90% of families with at least one Ayushman card reflecting greater awareness. As part of beneficiary expansion, NHA has entered partnership with various schemes like Central Government Health Scheme (CGHS), Rashtriya Arogya Nidhi-Health Ministers Discretionary Grant (RAN-HMDG), Building and Construction Workers (BoCW).

Way Forward

Ayushman Bharat recognizes the importance of reaching UHC central to achieving Sustainable Development Goals ensuring good health and well-being for all. Besides financial protection, the other two pillars of UHC are equity i.e. access to health services relative to need and quality i.e. strengthened services such as medical staff, medicines, hospitals etc.

Health systems strengthening forms an integral part of attaining UHC. AB PM-JAY is now looking at these various initiatives to improve the same:

• Expanding beneficiary base – Moving to the National Food Security Act (NFSA) database that would help PM-JAY cover 70% of the poor and vulnerable population who are Ration card holders.  
• Convergence with national schemes – To avoid overlap of families in more than one scheme, uniformity of data, robust IT platform and improved access to services, NHA is moving towards converging with various health schemes catering to different populations or diseases such Janani Suraksha Yojana (JSY), ESIC, BoCW, CGHS and RAN-HMDG.
• Disease management – As the scheme moves into the next phase, it is important to continue to do evaluation studies as to see the impact of the scheme on heath seeking behaviour. With increasing Non-Communicable Diseases burden, studying utilization trends will help in promotive and preventive care.
• Continuum of Care and Health ID– A path-breaking initiative to improve health systems is to connect Health and Wellness Centres to secondary and tertiary care centres through a referral mechanism. This can be done through the Health IDs that is being developed under National Digital Health Mission.

Conclusion

Like the herculean task of building a ship while it’s sailing, Ayushman Bharat has made great strides in improving health systems in India and yet having just scratched the surface with many more milestones to go. The current pandemic has exposed several loopholes in our health system but with continued political will, good governance, and better healthcare expenditures it will not be far-fetched to envision a day when every citizen in India has access to state of the art healthcare providers regardless of need and financial status.

The views expressed are solely mine.

DesiStories 3.0 – Pradhan – The Changemakers of an ODF village

P.S – Like Dumbledore’s pensive in Harry Potter, I thought of penning down my experiences in the rural finally after 2 years out of it. Better late than never. The idea is to share with whoever it interests in the cities where I have invariably grown up, of how the district administration and rural India functions from whatever little I have seen, while for me it was a sea of life experiences.

‘If I want every household in my village to make a twin-pit technology toilet and become Open Defecation Free (ODF) then I myself had to be a front-runner in making a similar model toilet in my house and set an example. Wahi maine aaj iss gaon me kiya hai, ussi me kaafi Vyahwahar Parivartan aaya”. (That’s what I have done here today, that’s what has led to a behaviour change in the village) – Says Shri Kumar, Pradhan of Gram Panchayat (GP) Narwal in Sangipur Block, Pratapgarh as he shows me humbly the toilet he has constructed with the Rs.12000 fund given by the government for an individual household toilet. He is also one of the few Pradhans I met who have endorsed the soak pit technology over the septic tank technology.

Pradhan, ready in pose as for geo-tagging of his own built toilet

As I neared the end of my tenure as a Fellow in district Pratapgarh, Uttar Pradesh, I wanted to write about the changes as seen on ground, to go back feeling happy about this place I was allotted by chance, to feel content to see the rise of this town from 30% ODF Status to 85% ODF as I moved out. I began by visiting some of the Pradhans or Village Heads who led the mission from the front through their innovative ideas to encourage every village household to build a toilet. It was a People’s Movement after all.

Of the 17 blocks that comprised my allotted district, Sangipur block I visited is about 20 kms away from the heart of the city which was home for 15 months. Yes, home and just not a place of stay. Having been given permanent transport facilities thankfully to the Centre and State Administration commuting with a vehicle and a driver to the far-off blocks was convenient by road.

As the last visit to this block, I reached Sangipur Block Office on a cloudy day in the month of September from where the Block Coordinator, Satish accompanied me to GP Narwal. The Swachh Bharat Mission besides many administrative hands has at least 2 block coordinators (BC) positioned in each block as one of the frontline forces along with the sanitation workers called Swachhagrahis. Satish Ojha was a sharp, dedicated coordinator in his thirties, who spoke less and actioned more, a rare feature in itself to witness in the hinterlands where politics and credits played a bigger role. The Block Office of Sangipur is one of the most well-maintained and developed blocks of the district, primarily led by a good leadership.

Since Satish interacts with the village heads regularly and online real time data also suggested a good progress of the of the village I was to visit, I set off to Narwal where, the Village Head, also known as Pradhan was awaiting to greet me at his abode. Over the months I had visited many houses of Pradhans. They varied from a thatched roof house to a cemented house made of bricks with a garden or to even a palatial house overlooking the lush green fields. There was range of all.

As we arrived, the Pradhan’s welcomed me at his courtyard accompanied by the Secretary of the GP, Shri Mishra and two of his male relatives who are usually his accomplices in village work. Village Heads always had their immediate advisor running in the family reins I had noticed. Dressed in a light-coloured shirt along with shorts, Pradhan Shri Kumar (name changed) was a soft-spoken person with no airs about his credibility. Offering me a cup of tea and snacks as a usual gesture of the households that I couldn’t deny, he began by sharing some details about his village.

The Pradhan in conversation at his courtyard along with the Secretary

GP Narwal comprises of two revenue villages Narwal and Balipur Bedua. As per the Baseline Survey of 2012, Narwal has 185 registered individual households. “Funds have been released for 122 households. Of which 107 have been made over the last three years, geo-tagging i.e. photos uploading of 15 are pending”. The funds in SBM are released based on the total number of households mentioned in Baseline Survey, 2012. The district transfers the funds to the Pradhan’s village account who then does a direct cash transfer to the village household.

He goes on to say that in year 2015, 25 households built it when the first tranche of Rs. 3200 was given while 50 other households made it in 2016-17. Of which, 42 households made it themselves while the rest had to be motivated through awareness campaigns.

Pradhan along with his accomplice

In the village where social norms outweighed the importance of a public health, to bring about behaviour change, awareness campaigns were in the form of Triggering in schools, Nigrani Samitis and Swachhata Raths to which he credits for the success . “Jab triggering kiya gaya tha, tab paisa nahi mila tha”. (When triggering was done, the funds had not been released). “While 10-12 households had made earlier”, he continues to say, “20-25 made it only after the Swachhata Rath (Sanitation Van) came to their village which was an effective tool. Swachhagrahis like Satish and few others had initiated morning follow-ups and Watch Groups to alert about people who defecated in the open.

Besides that, the Pradhan said that awareness campaigns had to be conducted not only for informing the villagers the importance of making an individual toilet, but also to educate them about constructing the right twin-pit toilet model also known as ‘do gaddhe wala shauchalya’.  It was cheaper, more ecofriendly and long lasting than the sewage tank technology, widely preferred due to myths prevailing and lack of awareness. It was also about breaking the notion that the bigger the tank the longer it lasts.

Beneficiary in village Narwal proud of his prized possesion

BC Satish and Pradhan showing me the twin pits behind the toilet

Although my conversation with the Pradhan continues to be engaging, I steer it towards an end having to visit the next village. He concludes it by saying about one of the major issues, being the coverage, “The village houses over 350 families, while only half of them are enlisted in the 2012 database. Exclusion of Above Poverty Line (APL) families and inclusion of eligible families would be beneficial”. This indeed was one of the major challenges of the mission.

As I listen to his descriptions, I could get strongly relate it with my own experiences while visiting villages. Of trying to motivate people to change their behaviour about hygiene and health or of the concerns faced by Pradhans as elected by people to ensure every household is pleased and none left out. While I was just a facilitator to monitor the progress out here, the Pradhan is the real change-maker in a village. He held the key to daily monitoring and leave a long-lasting impact of behaviour change and a progressive Gram Panchayat in the country.

 

#DesiStories Blog 1.1 – The Rustic kickstart

Top right clockwise – The poster on my tiny room, Vikas Bhavan from below, Vikas Bhavan view from top, a political meet in the building, and neta present arrives with his bandwagon

Disclaimer: These observations are a first person narration of what I saw being on ground woven together to tell a story and does not uphold any read between the lines agenda 🙂

When I took up a rental place in the town, I was asked to what caste I belonged, a question that I had never encountered when I grew up in a city. On my first day at work, I was asked by a colleague as to how much salary did, I draw. In the corporate it was a choice to answer. These questions stayed with me during my tenure asked by anyone and all. So much so that, had I not grown up elsewhere I was close to getting influenced by it. This is rural hinterlands.  This is how class talks perhaps stems in Bharat, from daily conversations.

Getting down to work, Monday morning first day at work, I was expecting to see a worn-out building located somewhere in the corner of the Pratapgarh city. However, unlike my thoughts, the District Administration building known as Vikas Bhavan by all, was a colossal building standing grand right in the middle of the town. Unlike my thoughts it formed one of the essential landmarks too. Vikas Bhavan is a busy place from where the entire district functions. Did you know that? Well, I didn’t.

On a hot May Day in Uttar Pradesh, the sun had made it very difficult for me to survive since the first minute I landed itself. The guest house where I was staying was beautiful as a government accommodation could be, but it was no breather to the heat. I used to get ready for work only to be drowned in sweat once again.

I made my way to the first floor for a brief meeting with my reporting officer, here known as District Panchayat Raj Officer, DPRO. He welcomed me with a kulhad chai and an introduction to all the block officers seated in room that “Madam Delhi se hai”. I just did a calculation in my mind, Madam means respect and Delhi means where the final buck stops. I was then brisked to the top floor by, now my fellow colleagues to our department. I was still beating the heat wiping my face off profusely. As I enter, it’s a tiny room ironically inside an empty giant room. The tiny room filled was buzzing with young lads and computer screens while the giant room lay there peacefully empty just with a chair covered in white and table laid out with stationary and the buzzer. It signified authority, it awaited The District Magistrate its true owner to grace its presence.

My fellow colleague who I mentioned earlier, a nice old fellow with a white cap and kurta pyjama and chaste Urdu introduced me to the rest of the young male lads, made me comfortable amongst them by placing just one more table and desktop in the already crowded room. Talks of a cooler in the room for me I overheard. The heat! The young male lads were District Coordinators, Block Coordinators and Computer Operators for this scheme. I will describe the role of each as we move forward.

With my entry, I thus made a balance to the skewed gender representation in the room. My fellow colleague made a balance to the skewed creed representation in Vikas Bhawan while all the rest made a balance to the different castes in the state. With this ironic diversity, I thus began my wonderful fast paced journey in the government scheme – Swachh Bharat Mission India as a Zilla Swachh Bharat Prerak in collaboration with the Ministry of Drinking Water & Sanitation and Tata Trusts.

The story of open defecation in India, Swachh Bharat awaits my next blog, hold on.

Blog 1.0 – The Sarkari Swag, desi UP Style

My first kulhad chai, my first baati chokha meal, my first village program and my first political meeting view

With a train missed for the first time from a new city (read The Capital) to my posting place in a rural North India district (happens to be home to a gangster) changing 3 buses interim and crossing by 3 districts (one of them being of The Political Family) and a full delay of 8 hours I arrive scarred, worried in district of Pratapgarh, Uttar Pradesh (UP). To give you a perception, it’s near Allahabad nee Prayagraj.

Just when I reminded myself that you have to fend for your own keep expectations none, I am received by a few government officials at the bus stop who also drive me to the guest house, with a large-hearted meal in between at the best restaurant to boast. Talk about first impressions! All this mayhem, just to experience working for the government, with the government and for a scheme by the government. My adventure for Swachh Bharat Mission hence begins in Uttar Pradesh.

How did I land in Pratapgarh? I will spare the story for the next time because here I want to begin with my first impression of Uttar Pradesh.

As I enter office of my reporting officer, his Ardali (read Personal Guard) with long moustache as if to suit his role, bows down to me with a Salaam and stays on there as if until I return his goodwill. I walk ahead and the likes just stand up in respect. Just out of the corporate sector seeing this I am perplexed. I was expecting complete resent and not be welcomed on my arrival, I was prepared but events didn’t turn out as expected. Good happened. What do I owe this to? Someone asks, “Madam, aap Delhi se hai?” “Kya ye gaadi aapko di gayi hai?” that’s the final stamp I learn.  I come with this  label that I am from the Centre with a car and a driver allotted to me. Welcome to UP, this what I call is The Sarkari Swag the entire bonhomie of a government job in this hinterland of UP. My observations herewith after spending more than a year.

Being completely unawares to a public administration environment a government job is a gold mine for a resident here. And respect doubles if you have a vehicle assigned to you. I had least expected any of the features provided. The first evening saw me visit the Chief Development Office (CDO) to introduce my arrival. Unawares of his ranking, I introduced myself, again expecting resent but instead found him very friendly and the first feeling in the district of speaking to one your own kind. Comes next day I see the same officer get down from a SUV, leading a troupe of personal men behind him including a personal guard, a stenographer and an Ardali, and walk into his cabin. I aghast. There he is awaited by a string of district officials, some villagers with complains or just people like us waiting to present him some work. He my friend happens to be the Lead – in charge of Vikas Bhawan the district administration building itself and is an IAS Officer recently posted. As I spent some more time in his cabin observing the entire persona surrounding him, I am left gasping which quite did not leave for days. They have the power and they are treated likewise. Everything at beck and call. They can bring about a change or roll it back too.

With a kulhad chai in one hand in a room full of men, baati chokha as my first meal in the sweltering heat top floor room with a creaking fan and watching from the window a political neta with his gunmen enter the building casually, I feel I had arrived in UP. My adventure begins in the next chapter.

Do you hear my cause?

In conversation: Dr. Neelam Vaid, Brett Lee & Debashree Lokhande

If asking my mind to catalog small things around me is called observing, then my commutes around make sure I get my daily quench.

That one day, it was rush hour and my mind compelled my fingers to speed and zigzag past all the roads. Just then, my eyes meet a man on a scooter making quick sign actions to his pillion rider like in conversation. The response by the lady was even quicker. It was a sight of overwhelm to watch them laugh in glory and crackle along in conversation. On a closer glance, I soon realized they were hearing and speech impaired. For a few seconds, the noise around me seized to exist and I watched their happiness in silence.

That day in time, created a strong memory reason enough to write in context today. Last week, I felt glad to attend a connect program by Cochlear™ India to raise awareness on hearing loss and be enlightened to the staggering statistics of it globally. Cochlear™ is a global company that, for over 30 years has provided Cochlear™ Implant systems to about 2,60,000 recipients. Speaking in action was Bret Lee, their Global Hearing Ambassador who shared his association with this cause through the campaign ‘Sounds Of Cricket’. His words resonated on saying that cricket is a sport that binds 3 billion people and through exactly this language of cricket he wishes to expose more people to implantable hearing technologies.

Did I know that 32 million children under the age of 15 years suffer from disabling hearing loss? Did I know that a hearing aid can be put on a child as early as 6 months old? I sat intrigued listening to these and many other facts shared by speaker Dr. Neelam Vaid MS (ENT), the Associate Professor and Consultant at ENT Department KEM Hospital. She spoke of how it as an extremely invisible disability and that spread genetically. “It is important to spread the word to every parent and ask for their child to be tested for hearing loss as early as birth”, she put forth.

As I sat there listening to the facts and figures, my curiosity was met by a real life recipient of an implant system, Debashree Lokhande an architect by profession and a bilateral Cochlear™ Nucleus® 6 implantee. Not often do we hear such brave stories where she lost her hearing due to TB in 2014 and now after a Cochlear™ implant surgery, proudly enjoys her life again. With Dr Neelam Vaid, it was interesting to know her journey from silence to the first magical sound after 2 years.

Cochlear™ implants have been implanted in children for almost 15 years now with fabulous outcomes. What’s important is to make sure this message reaches the rural India too, where many cases go unnoticed. Brett Lee with the campaign Sounds of Cricket wishes to do just that. “Cricket is one game that has a mass appeal – urban and rural. With this in mind I wish to spread this word far and wide”, he signs off.