‘Ayushman Bharat’ Program and Universal Health Coverage in India

The limited access, insufficient availability, sub-optimal or unknown quality of health services, and high out-of-pocket expenditure (OOPE) are amongst the key health challenges in India [1]. These challenges exist alongside a global discourse to achieve universal health coverage (UHC) – increasing access to quality healthcare services at affordable cost, by all people; and in times of fast economic growth in India [2]. Though, India’s National health policy-2017 (NHP-2017) is fully aligned with global discourse and has the goal to achieve UHC, outside the policy discourses, health is often not considered high on the priorities by political leadership and is traditionally been underfunded [1,3,4]. The inappropriate mix of inputs (infrastructure, human resources and supplies) results in a failure to deliver the desired health services and public health system is grossly underutilized by people. The elaborate government primary healthcare system in rural India with nearly 185,000 facilities delivers only 8-10% of total health services, availed by people. One-fourth of health facilities in public sector deliver nearly three-fourths of total health services delivered by entire public sector facilities. This means that remaining 75% of health facilities are delivering much lower number of services per facility than these are capable of [5]. People are either compelled to, or prefer to, seek care from private providers, often at a cost beyond their paying capacity. Health expenditure is estimated to contribute to 3.6% and 2.9% of rural and urban poverty, respectively [6]. Annually, an estimated 60 to 80 million people in India either falls into poverty or get deeper into poverty (if already below poverty line) due to health-related expenditures [1,7]. Clearly, the health expenditures undermine poverty alleviation efforts by the union and state governments in India (Box 1) [1,8-17]. India was ranked at 154 of 195 countries on health service delivery index published in mid-2017 in Lancet journal [18]. Though Indian healthcare system has traditionally focused on delivery of maternal and child health (MCH) services, and in spite of making rapid progress, the country continues to have relatively high infant and maternal mortality [19]. Access to even child health services is mostly through private sector. Furthermore, people often have to spend from their pockets for services such as child birth, even when availing services at public health facilities [20,21].

In this background, when Ayushman Bharat Program (ABP) was announced in India’s union budget 2018-19, it received wide and unprecedented media, public and political attention [22-24]. This article reviews and documents the key health sector related announcements in union budget 2018-19, critically analyzes the components of the proposed program, and suggests a few strategies to strengthen implementation and accelerate India’s journey towards UHC.

The Government of India’s union budget, for the financial year 2018-19, was presented to the parliament of India on 1st February 2018 [22]. The Ministry of Health and Family Welfare received an allocation of Rs. 54,800 Crore (approx. US $ 8.4 billion), an increase of nearly 11.5 percent over the budget of last year. Though in nominal terms, the budgetary allocation to health sector has trebled in the last decade (Table I); as proportion of gross domestic product (GDP), it has changed marginally from 1.1% to 1.3% [22-25].

TABLE I	Budget Allocation to Health Sector in India 2008-09 to 2018-19 [22-24]

A key announcement in the union budget 2018-19 has been the Ayushman Bharat Program (ABP). This program has two components: (a) delivering comprehensive primary health care by establishing 150,000 health and wellness centers (HWCs) by year 2022, and (b) Providing financial protection for secondary and tertiary level hospitalization as part of National Health Protection Scheme (NHPS). The ABP with two components intends to provide services with continuum across three levels of care and brings back the attention on delivery of entire range of preventive, promotive, curative, diagnostic, rehabilitative and palliative care services (Fig. 1).

NHPS: National Health protection Scheme; AB-NHPM: Ayushman Bharat- National Health Protection Mission; PM-RSSM: Pradhan Mantri- Rashtriya Swasthya Suraksha Mission; HWCs: Health and Wellness Centres; RMNCHA: reproductive, maternal, neonatal, child health and adolescent; NCDs: Non communicable diseases Fig. 1 Ayushman Bharat Program in India.

One of the two initiatives in ABP is to upgrade 150,000 (of the existing 180,000) Sub health centers (SHCs) and Primary health centers (PHCs) in India, to the HWCs by December 2022. The scope of services from existing SHCs and PHCs is proposed to be broadened from current range of services, and implements the national health programs to a broad package of 12 services. This intends to make comprehensive primary healthcare accessible by community within 30 min of walking distance [1,5,22]. A total of 11,000 and 16,000 HWCs are proposed to be made functional in financial years (FY) 2018-19 and 2019-20, respectively [26]. This includes upgrading all 4,000 primary health centers in urban area to the HWCs by March 2020.

The second initiative in ABP is NHPS (also known as AB-NHPM or PM-RSSM), which has been referred as ‘the world’s largest government-funded healthcare (insurance) program’ [22]. The NPHS aims to provide a coverage of up to Indian Rs. 500,000 (or US$ 7,700) per family per year for expenses related to secondary- and tertiary-level hospitalization. The AB-NHPM, after the launch would subsume Rashtriya Swasthya Bima Yojana (RSBY), and the Senior Citizen Health Insurance Scheme (SCHIS) [27-29]. The RSBY was providing insurance coverage of Rs. 30,000 (US$ 470) for up to 5 members of a family per annum, for a target beneficiary base of 60 million families. The target beneficiary in AB-NHPM has increased to 107.4 million families, and estimated 535 million people, equivalent to ~40% of Indian population [22,27]. The key health sector specific announcements in the union budget 2018-19 are listed in Box 2. The key components and implementation design of both HWCs and AB-NHPM/PM-RSSM are publically available and summarized in Web Table I and Web Fig. 1-3 [5,22,26,27]. The additional details on team at HWCs and on the design structure of AB-NHPM/PM-RSSM are summarized in Web Appendix 1 and 2, respectively [1,5, 22,26,27].

The union budget 2018-19 of India can be credited as one of the most explicit political acknowledgement of linkage between ‘good health’ and ‘economic growth’. The Union Finance Minister in his budget speech said: "Only ‘Swasth Bharat’ can be ‘Samridha Bharat’. India cannot realize its demographic dividends without its citizen being healthy.’ and ‘Ayushman Bharat Program will build a New India 2022 and ensure enhanced productivity, well-being and avert wage loss and impoverishment. These Schemes will also generate lakhs of jobs, particularly for women" [22]. Soon after union budget, the health needs of the people of India occupied center stage of discussion, by political leaders, media and people, and terms such as ‘universal health coverage’ and ‘Ayushman Bharat Program’ were introduced in the functional dictionary of general public [25,30,31] – something, which has a potential to place health higher in future public and political discourses in India.

In a shift, AB-NHPM has the beneficiaries beyond traditional approach of targeting ‘below poverty line’ (BPL) population. Inclusion of ‘vulnerable and deprived population’ identified through Socioeconomic and Caste Census (SECC) will nearly double the number of people to be benefited [22,27,32]. The benefits of HWCs, when fully functional, would be available to 100% of population of the country.

This was the first union budget of India since the release of NHP-2017 in March 2017. This budget follows upon a few strategies proposed in the NHP-2017, including suggestions to invest two-third or more of government funding on the health on primary healthcare, establishing health and wellness centers and introducing ‘strategic purchasing’ in healthcare, among other [1,22].

The ABP combines two initiatives, announced in past as a single program. The NHPS was first announced in union budget of 2016-17, though with a coverage of Rs. 100,000 (US$ 1550) per family per annum [23,24] and the HWCs were proposed by the task force on strengthening primary healthcare in India in 2016 and first announced in the union budget 2017-18 [5,23]. The ABP has strengths and limitations (Table II), and potential to address select but key health challenges in the country. Two initiatives in ABP together will meet the range of healthcare needs across primary, secondary and tertiary care, appears synergistic, and may help in increasing accessibility, availability, appropriate care and affordability. This can help India progress towards UHC.

The ABP as a program could be termed bold and ambitious for both the initiatives. The financial coverage in AB-NHPM is around 17-times more generous than RSBY, and two- to four-times more generous when compared with the other states’ government-funded health insurance schemes in India. NHPS/PM-RSSM targets almost twice the target beneficiaries and thrice of actual numbers enrolled under RSBY in year 2016-17. Understandably, NHPS has received a lot of attention in India and across the developing part of the world. However, arguably, the proposal to set up 150,000 HWCs by 2022 is even bigger and potentially more impactful initiative for the reasons listed here. One, the comprehensive primary healthcare delivered through HWCs would benefit entire 1.3 billion people of India across rural and urban setting. Second, it would strengthen government primary healthcare system, which caters to only 10% health needs of the people at present while a well-functioning primary healthcare system has potential to cater up to 80-90% of health needs [33,34]. Third, strengthening primary healthcare through HWCs can bring efficiency in health services through increased access, gate keeping and a functional two-way referral system. Fourth and importantly, the extended services in HWCs would cover a number of non-communicable diseases (NCDs), and can tackle the epidemiological transition. In 2016, the NCDs contributed to nearly two-third of all mortality and 56% of preventable mortality in India [17].

There is sufficient evidence available that strengthening of primary healthcare is the most appropriate approach to achieve UHC. Investment on comprehensive primary healthcare system is a practical and affordable solution for India [1]. Health services are human resource intensive, and India has plenty of potentially trainable human resources available at a low cost. The successful engagement of nearly 1 million Accredited Social Health Activists (ASHA) under National Health Mission (NHM) in India is a proof of the potential and effectiveness of community health workers [35,36]. More of appropriately skilled workforce such as mid-level healthcare providers (MLHP) as part of HWCs would be affordable, efficient and effective. In the process, India might end up building a low cost, high impact model of primary healthcare, for rest of the world. Many countries such as Chile, Costa Rica and Thailand have succeeded through their own context-specific model for primary healthcare at low cost, and achieved comparable health outcomes as to high-income countries.

The global evidence on effectiveness of government funded and social health insurance (SHI) in reducing OOPE is limited, either side [37,38]. However, there is enough evidence to conclude that if implemented well and at-scale, insurance schemes increase access to health services, can save lives, and improve financial affordability. It is this emerging evidence and intention to make health services affordable to poor people, that many state governments in India launched publically funded health insurance schemes, mostly in the last decade (Table III). There is evidence that such schemes can prove an effective tool to improved quality of health services through differentiated rates and incentives if providers meet certain quality standards, and have accreditation; increased adherence to Standard Treatment Guidelines (STGs), and provider’s willingness to accept slightly higher regulation, amongst other approaches [39-41].

TABLE III Evolution of Health Insurance Schemes at National and State Levels in India

The insurance schemes in India have had low population coverage (against the target beneficiaries) and limited impact on OOPE. The coverage with insurance schemes in surveys have ranged from 11-12% families in India [42] or that at least one member in around 28% of Indian families [43]. Considering most of the insurance schemes cover a narrow range of secondary- and tertiary-care procedures, and exclude outpatient services; there seems to be a long way in reducing OOPE in India. The cost of consultations in outpatient department, along with cost of medicines and diagnostics are the major contributor to the OOPE in India, which were not covered in either RSBY earlier or PM-RSSM now. Understandably, health insurance schemes, focused only on secondary and tertiary level hospitalization, do not always lead to reduced OOPE. Rather in some cases, OOPE increases as the awareness about schemes can lead to utilization of health services (by the people who were not accessing services) and people have to pay for additional services not covered [38,39,44]. The budgetary allocation to RSBY during the years of implementation was less than one percent of total annual government spending on health in India. Clearly, the impact on OOPE could not have been much different. In the similar vein, considering that total OOPE in India in 2014-15 was Rs 302,425 Crore (Approx. US$ 46.5 billion) and a scheme such as PM-RSSM with an annual budget of around Rs 12,000 Crore (or US$ 1.8 billion), even with full scale implementation would have only marginal impact on reducing OOPE. Though, it may prevent catastrophic health expenditures for the families covered.

For health insurance schemes being effective and efficient, a common and bigger pool, administered through a single agency is considered the best approach. India has multiple schemes with their independent and almost parallel administration, management and beneficiaries. Even within a state, there are multiple scheme running parallel, targeted at different beneficiaries. If PM-RSSM can initiate the process of merger of multiple schemes in a single pool over period of time and where non-poor join by paying the premium, that would make it truly a ‘game changer’. In this context, the initiative by the government of Karnataka to combine 7 ongoing and existing schemes in a single pool, to be administered by a common agency, could be studied for probable learnings [45]. At national level, a few schemes for financial assistance to patients have been harmonized by union government by the abolition of autonomous bodies and transfer to Ministry of Health & Family Welfare [46]. Alongside, a road-map for the extension of benefit of PM-RSSM to additional population, with graded subsidy, should be actively considered and strategy outlined.

Many countries have included health as a basic right in their constitution [47]. Evidence indicates that inclusion of health as basic right help in increasing access to services and holding the governments accountable. While India has adopted a number of right based initiatives, including the ‘right to education’ legislation, the health has not been mentioned as a right in the constitution of India, though often interpreted in context of Article 21 on right to life [48]. India’s NHP-2017 takes a stride and proposes ‘progressively incremental assurance’ towards health, though it falls short of ‘right to health’ [1]. The sustainability of select SHI in India over other schemes has partially been attributed to legislative provisions [49]. A scheme of magnitude of PM-RSSM might benefit from legislative backing as has been case with Employee State Health Insurance Scheme (ESIS) and Central Government Health Schemes (CGHS) [50, 51].

The National Health Services (NHS) of United Kingdom is said have emerged from political commitment in aftermath of post-World War II [52]. With ABP in India, there appears a political will and commitment. The community and civil society plays a crucial role in ensuring that political promises and commitments sustained in changing political environment [52,53]. An institutional and legally backed-up mechanism to engage communities and civil societies, such as national health assembly in Thailand [54] may help India as well, though the modus operandi could be home-grown.

In implementation of HWCs, caution has to be exercised and an overzealous attempt to expand package of services should not results in reduced attention on maternal and child health (MCH) services. Rather, the MCH service platform should be used to build upon expanded package of services. In addition, HWCs and financial affordability offered through PM-RSSM would further increase accessibility, affordability to all populations including mothers and children and bring hitherto uncovered populations to the public health system. HWCs can help in addressing different types of inequities in health services, as identified by multiple surveys. There is evidence that when geographical and financial access to services is increased, it is poor and women who are more commonly benefited.

The people have to be at the center of health services and in scale-up and reform of health services, attention should not be on supply-side interventions only; people’s perspective should get due consideration. Mechanisms for satisfaction survey and feedback assessment should be strengthened, and the data used for regular actions and initiatives.

Finally, there is a strong economic case for accelerated implementation of ABP in India. Healthier population means enhanced overall productivity, reduced wage loss and less impoverishment. In Germany, domestic health economy contributes to 12% of gross value added and 8% of Germany’s export [55]. The rapid implementation of ABP in India has potential to generate employment through recruitment of additional workforce such as MLHPs.

The initiative under ABP can be called ambitious and bold; however, would be operationally challenging for a health system, not known to deliver. The sub-optimal implementation and partial scale-up has been the case with a number of initiatives in the past [27,56-60]. This includes initiatives started a few years ago (i.e., a number of free treatment and diagnostics schemes by union and state governments) as well as NHPS announced in 2016 and the proposed universalization of maternity benefit scheme, announced in December 2016 [61,62]. Clearly, in health sector, more need to be done for translating policies and intentions into practice.

Health sector is a specialized field where successful outcome requires getting both design and implementation right. In setting up HWCs, a ‘rate limiting factor’ could be recruiting MLHPs or Community Health Officer (CHO), one each would be required for 150,000 HWCs. This is an opportunity to innovate and explore solutions for recruitment of additional cadre of providers on priority basis. Alongside, the quality of services delivered through these facilities needs to be assured by achieving Indian Public Health Standards (IPHS).

There is limited capacity amongst Indian states in identification and enrolment of beneficiaries, designing the benefit package, fixing the package rate, empanelment of facilities, monitoring and regulation and fraud detection. Many of these are ‘sine qua non’ for success of a health insurance scheme. The insurance schemes require a state level authority with sufficiently trained staff, and a well-functioning Information technology (IT) system to implement the program. In India, the capacity of the states to run insurance schemes is lowest where these are needed most. The success of PM-RSSM would also be dependent upon how the supply-deficient Indian states such as Uttar Pradesh, Bihar and the North-eastern states take up and implement the scheme. A well-functioning IT platform would be essential to meet diverse needs of different stakeholders including patients, service providers and program managers [26,27]. The significance of IT platform cannot be over-emphasized and it would be very crucial in strategic purchase of services, provider payments, fraud detection and monitoring of the scheme. India to utilize the opportunity provided by PM-RSSM to build a strong IT platform not only for this scheme but also to develop an integrated health information platform to bring multiple IT systems on a single platform. The implementation would benefit from generating real time data and then use of data for action. As a first step, the data generated from RSBY should be analyzed and learnings used for designing and scaling-up of PM-RSSM.

The ABP success on advancing health and achieving UHC in India would be dependent upon the response and leadership of Indian state. The states may require different model and design to address both supply deficiency and capacity. A few additional suggestions to improve implementation effectiveness of ABP are provided in Box 3.

As health seems to have received priority in India, the opportunity should be used as a catalyst for decisive and broader health system re-designing and strengthening. A few steps can contribute to the implementation effectiveness:

India has committed to achieve UHC as a signatory to the globally agreed Sustainable Development Goals as well as through the NHP 2017. For countries aiming to march towards UHC, there is no ‘one size fit all’ solution, and the strategies have to be locally developed and implemented. Every strategy/program would have to build upon strengths and attempt to minimize limitations. Ayushman Bharat Program appears to be a balanced approach, which combines provision of comprehensive primary healthcare (through HWCs) and secondary and tertiary care hospitalization (through PM-RSSM). While ABP would help India make progress towards UHC, this program alone would not be enough and needs to be supplemented by rapid scale-up and convergence of ongoing schemes and programs, and taking a few additional measures. The ABP can prove an initiative bigger than simply delivering health services and rather a platform to prepare India for making health coverage universal.

69. Press Information Bureau. Gram Swaraj Abhiyan on Ambedkar Jayanti. Government of India. 6 April 2018; New Delhi. Available from: http://pib.nic.in/newsite/PrintRelease.aspx?relid=178495. Accessed February 12, 2018.