Ayushman Bharat (AB) is a major health policy reform, designed to strengthen comprehensive Primary Health Care (PHC) services and to provide financial protection to the poor against impoverishing Hospital-Based Care (HBC). A hundred and fifty thousand Health & Wellness Clinics (HWC) are being planned under the program, by upgrading the existing sub-centers and primary health care centers. The Pradhan Mantri Jan Arogya Yojana (PMJAY) is designed to offer financial protection to nearly 500 million plus, socio-economically disadvantaged beneficiaries towards hospital-based care of notified diseases and procedures. There is also an ongoing effort at bringing convergence between various publicly funded health schemes like the ESIS and CGHS to drive efficiency and the strengthen strategic purchasing lever.
Various state and national level public health insurance programs that preceded PMJAY did not reduce the per capita out of pocket expenses (OOPE) of the beneficiaries as per various studies. However, the incidence of catastrophic and impoverishing health expenses came down, but not as much as intended. A demographic shift towards non-communicable diseases (NCD) across every state is one of the key reasons, as patients with NCDs incur lifelong outpatient expenses for consultations, drugs, and diagnostics. Strengthening publicly funded PHC services through HWCs will mitigate the continuing burden of OOPE.
Beneficiary enrollment and the utilization of services as per their health needs have been lagging in many states implementing PMJAY. Community health workers (ASHA and ANMs) are playing a vital role in various programs under the National Health Mission (NHM). They played an important, albeit less appreciated role during the current Covid pandemic. They work under the aegis of the NHM, but can play an equally important role in the implementation of PMJAY both in terms of the enrollment and education of beneficiaries and ensuring proper utilization of services covered under the scheme. Hence, there is a need for a close relationship between the two implementing authorities, namely the National Health Authority (NHA) and the NHM.
PHCs are important gatekeepers in the appropriate use of hospital-based care. They can triage patients to appropriate empaneled hospitals as per the underlying disease condition. They can use their sound judgement in choosing the right hospital. Since PMJAY is publicly funded, the referral should be, where possible, to an empaneled government hospital. This will be in line with the strategy of selective purchase of services from private providers as stated in the National Health Policy, 2017. As sub centers, PHCs, and the newly formed HWCs are under the purview of the NHM, the need for close collaboration between the NHA and the NHM is reemphasized.
Unlike in the past, most people now suffer from chronic infectious and non-communicable disease that require continuity of care between PHC and HBC. Three proven strategies – robust two-way referral system, interoperable health records, and chronic disease prevention and management programs – are essential in ensuring a continuum of care. The Ayushman Bharat Digital Mission (ABDM) under the domain of NHA is critical in integrating PHC and HBC. ABDM is designed to integrate highly fragmented Indian health systems. Symphony-like coordination is essential between PMJAY, ABDM, and NHM to enable the continuity of care.
Currently we do not witness the interdepartmental coordination needed between NHA and NHM. Hence, the leadership that oversees both these limbs of the public health system should be cognizant of the widening dichotomy and make all-out efforts to bring in this harmony for the Ayushman Bharat mission to succeed.
Dr Krishna Reddy Nallamalla
Regional Director, South Asia, ACCESS Health International
Photo Credits: Iberdrola