Coverage, utilization and impact of Ayushman Bharat Scheme on access to medicines and healthcare in India

 Shafiqa Rasool, Mohammad Ishaq Geer*

Department of Pharmaceutical Sciences, 

University of Kashmir, Hazratbal, Srinagar-190006, J&K

*For Correspondence: Prof. Mohammad Ishaq Geer (migeer@uok.edu.in)

Abstract

Ayushman Bharat (AB) is a government sponsored health insurance scheme that is aimed to cover about 100 million poor and vulnerable people in India. It provides benefit cover of Rs. 5 lakh per family per year with no cap on family size and the services are portable across the country. This scheme was launched by the Govt. of India in the year 2018 as a progressive step towards achieving Universal Health Coverage (UHC). It has two interlinked components, namely Health and Wellness Centres (HWCs) and the Pradhan Mantri Jan Arogya Yojana (PMJAY). The former aims to upgrade sub-centres and primary health centres to deliver comprehensive primary healthcare to the population whereas the latter is a national, publicly-funded health insurance (PFHI) scheme covering secondary and tertiary care hospitalization for the most deprived 40 percent population of the country. Around 1350 medical and surgical packages are covered under this scheme which include about all secondary and most of the tertiary care procedures. As a result of Ayushman Bharat scheme access including availability and affordability of medicines in India has drastically improved.

Introduction

Out-of-pocket expenditure (OOPE) on health in India is 62.6% of total health expenditure which is one of the highest in the world and nearly thrice of global average of 20.5%. More than two-third of this OOPE is paid on consultation fees and medicines followed by diagnostic tests. In India more than 300 million people face catastrophic expenditures and around 50 million people are pushed into poverty every year on account of out-of-pocket expenditures (OOPE) on health. One of the main reasons for this is the limited access to healthcare services in public sector. The average cost per hospitalization is Rs. 20,000 which is more than annual consumer expenditure of nearly half of our population (1). OOP expenditure on medicines alone is high and accounts for 70% of total out-of-pocket expenditure which is more than twice that of consultation fees and diagnostic services (2).

Ayushman Bharat-PMJAY was launched with an aim to protect the population against these very financial hardships and has successfully averted these disastrous consequences for more than 1.3 crore population of India. As per WHO-World Medicines Situation Report of 2004, 65% of Indian population lacked access to medicines at that time (3) but as a result of AB-PMJAY scheme the access to medicines has considerable improved in India.

Coverage and utilization of health services under AB-PMJAY

Ayushman Bharat Mission has been advanced as the prime instrument for achieving Universal Health Coverage (UHC). Unlike previous schemes like Rashtriya Swasthya Bima Yojana (RSBY) and the Senior Citizen Health Insurance Scheme, the AB-PMJAY has no cap on family size and age (4). The identification of the beneficiaries under this scheme is being done on the basis of the Socio-economic and caste census (SECC), 2011. The centre–state financing mode is same as in the National Health Mission. Indian states running similar schemes have been given an option to merge with PMJAY or run it in a parallel manner.

AB-PMJAY covers larger population, provides more comprehensive benefit package and incorporates a wider hospital network for healthcare delivery. The HWCs are committed to provide wider range of preventive, promotive, curative and rehabilitative healthcare services including treatment and services for non-communicable diseases and chronic communicable diseases like tuberculosis. These services were expanded keeping in view India’s high OOP expenditure. Government of India has allocated Rs. 3,200 crore and also envisages contribution of private sector in the form of corporate social responsibility (5,6). As of 21 March 2022, a total of 74,947 AB-HWCs were operational which is set to reach the target of 1.5 lakh by December 2022.

The other component of Ayushman Bharat covers larger number of population. The number of people benefited are double the number benefited from previously launched health schemes. Once fully functional the benefits of HWCs are expected to be available to 100% of population in India. HWCs together with AB-NHPS will be synergistic in providing healthcare needs across all three levels of care and will also help in increasing accessibility, availability and affordability of healthcare and medicines (7).

Impact of AB PMJAY on access to health services

Various studies on AB-PMJAY have reported mixed responses on financial risk protection. High value of greater than Rs. 30,000 and very high value claim of greater than Rs. 1,00,000 make up 32% and 9% of PMJAY claim payouts respectively. This is indicative of the fact that this scheme has enabled access to services that would otherwise be OOP or catastrophic to the individual. However, PMJAY does not cover out-patient services that account for around 60% to 70% of the total OOPE in India (8).

In a retrospective study conducted among 160 patients registered at Ayushman Bharat cell of a Srinagar-based tertiary care hospital namely SKIMS between 26th December, 2020 and 20th February, 2021, every patient was found to have received the benefits of the scheme as a result which they had to pay nothing for their hospitalization and there was no need for them to sell their assets or borrow money for treatment thus bringing the prevalence of distress financing to zero level. This was found to be quite contrary to studies conducted by the same authors at the same centre before the launch of the scheme wherein prevalence of distress financing among cancer and chronic kidney disease patients was found to be more than 70% (9,10,11).

Discussion

India, the sixth largest economy and largest democracy of the world has been improving its health-care facilities slowly since last few decades. India has made considerable progress in reducing maternal and child mortality under the national health mission. Ten to fifteen years ago communicable diseases alongwith maternal and nutritional disorders contributed to the major disease burden. Doubling the life expectancy from 31 years in 1947, when India got its independence from the British rule to 68.3 years in 2017, the Indian government has been doing a fairly good job; however, it is still quite less as compared to the western world. In terms of health-care access and quality India still stands at 145th position among 195 countries, lagging way behind than most of the countries like its neighbour Bangladesh which stands at 133rd position (12).

Conclusion

As India moves towards the path of UHC, the focus should be on reduction of burden due to non-hospitalization care. High OOP spending on medicine needs to be addressed. Use of medicines should be rationalized and rational prescribing encouraged. To significantly reduce OOPE, the provision for free medicines should be increased (The Indian Express, 2021). The utilization of manpower under Ayushman Bharat has been proved to be successful by way of engagement and potential usage of nearly 1 million ASHA workers under the National Health Mission (NHM). The programme provides an innovative initiative of building a highly impactful health model with low cost alongwith the utilization of skilled workforce. All these facts prove that Ayushman Bharat is a boon for the country (13).

References

1.Bhardwaj S. A study of Ayushman Bharat PM-JAY as an enabler of social upliftment. International Journal of Research in Humanities, Arts and Literature 2019: 7(3); 559-564.
2.  The long road to Universal health coverage. The Indian Express dated April 24, 2022. (Available at: https://indianexpress.com/article/opinion/the-long-road-to-universal-health-coverage/) (Accessed on 24.04.2022).
3.    World Health Organization. (‎2004)‎. The world medicines situation, 2nd ed. World Health Organization. WHO/EDM/PAR/2004.5. Available at: https://apps.who.int/iris/bitstream/handle/10665/68735/WHO_EDM_PAR_2004.5.pdf?sequence=1&isAllowed=y (Accessed on 24.04.2022).
4.   Indrani Gupta, Samik Chowdhury, Abhijit Roy, Ramandeep. Ayushman Bharat: Costs and Finances of the Prime Minister’s Jan Arogya Yojana. Economics and Political Weekly 2020 (4): 36; 56-64.
5. Bajpai N, Wadhwa M. Health and wellness centers: expanding access to comprehensive primary healthcare in India, ICT Indian Working Paper No. 13 dated July, 2019. (Available at: https://csd.columbia.edu/sites/default/files/content/docs/ICT%20India/Papers/ICT_India_Working_Paper_13.pdf) (Accessed on 24.04.2022).
6. Vitsupakorn S, Bharali I, Kumar P, Yamey G, Mao W. Early experiences of PM-JAY in India: A narrative review. Duke Global Working Paper: 30 march 2021. (Available at: https://centerforpolicyimpact.org/wp-content/uploads/sites/18/2021/02/PMJAY_FINAL.pdf) (Accessed on 24.04.2022)
7. Lahariya C. ‘Ayushman Bharat’ Program and Universal Health Coverage in India. Indian Pediatrics 2018:55;495-506.
8. Garg S, Bebarta KK, Tripathi N. Performance of India’s national publicly funded health insurance scheme, Pradhan Mantri Jan Arogaya Yojana (PMJAY), in improving access and financial protection for hospital care: findings from household surveys in Chhattisgarh state. BMC Public Health (2020) 20:949 (https://doi.org/10.1186/s12889-020-09107-4).
9. Abas Khan, Farooq Jan, Haroon Rashid. Prevalence of distress financing and catastrophic health expenditure among end stage renal disease patients attending a tertiary care teaching hospital of north India. Biomedical Journal of Scientific & Technical Research 2020: 32(4); 25133-35.
10. Abas Khan, Farooq A Jan, Haroon Rashid, Arshad Manzoor Najmi, Imtiyaz Ahmed Wani. Prevalence of distress financing and catastrophic health expenditure in cancer patients: a study from India. European Journal of Pharmaceutical and Medical Research 2020;7(12); 384-386.
11. Abas Khan, Yatoo, G. H., Mohd Sarwar Mir. Impact of Ayushman Bharat scheme on the prevalence of distress financing and catastrophic health expenditure among patients attending a tertiary care teaching hospital. Rivista Medicine 2021:1;11-15.
12. Mehta V. Ayushman Bharat Initiative: India’s answer to provide Universal Health Care. Journal of Medical Research and Innovation 2019;3(1):e000148
13. Venkatesh U, Mogan KA, Mukesh Kumar, Preety Doley, Jugal Kishore. Ayushman Bharat is a boon for the country. Motion International Journal of Preventive, Curative & Community Medicine 2019:5(3);31-35.

Preparing Institutional Development Plan (IDP): First step towards implementation of National Education Policy-2020

IDP is a documentary framework through which higher educational institutions can develop their own indicators, fix their achievable targets, prioritize their actions, assess their financial needs and overcome their constraints towards implementation of NEP-2020

It has been almost two years since National Education Policy 2020 (NEP-2020) was launched by the Govt. of India on July 29, 2020, outlining the renewed vision of India's new education system and strengthening its five pillars of Affordability, Accessibility, Quality, Equity and Accountability. Innumerable seminars, symposia, workshops and conferences have since been held all across India with a view to fully understand the provisions, goals and objectives of the new policy. Now it is time for all higher education institutions (HEIs) across India to devise their strategic action plan for the implementation of the policy in letter and spirit. Formulation of Institutional Development Plan (IDP) is one of the first steps towards practical implementation of this policy that has been necessitated for all HEIs in the policy document itself. IDP lays down the roadmap for implementation of various provisions of NEP-2020 in a time-bound manner outlining the needs, constraints, targets and timelines for a particular HEI. IDP seeks to identify achievable targets of a HEI in terms of curricular reforms, infrastructural development, pedagogical innovation, augmentation of human resource, administrative reforms, effective institutional governance, evaluation and examination reforms, research innovation, skill development, community outreach programmes, student exchange programmes, stakeholder involvement, partnering with skill hubs, industry-academia interaction, innovation and start-up incubation, promotion of open learning and workflow automation. While NEP-2020 remains same for all HEIs, IDPS will be customized to their individual needs and specific requirements based on their existing status and future goals.

For optimum results a bottom-up approach is suggested for the compilation of IDPs in consultation with various departments, centres and schools of a university or a college. Individual departments can furnish the requisite information on a prescribed format covering all aspects of NEP-2020 after convening their departmental committee meetings, that in turn can be used to consolidate and finalize an IDP for the whole university or college. Bottom-up approach is preferred because faculty of a particular department is the best judge of its needs, aspirations and future programmes. Therefore, brainstorming at the departmental level can be followed by discussions at the level of schools under the stewardship of deans and subsequently by final deliberations at the central level under the chairmanship of institutional heads in order to arrive at the final IDPs. Viewpoints of scholars, students and administrative staff too need to be factored in while projecting departmental needs for preparing IDPs, based on which they can develop initiatives and monitor their progress in achieving the goals set therein. This way most essential and pressing needs and demands of each department and centre could be duly addressed in the IDPs making it inclusive and all-encompassing in nature ensuring wider participation of all stakeholders of the HEI. This way IDPs can be used to suitably assess their human resource requirements such as faculty shortages, ICT related technology requirements, physical infrastructure for teaching-learning, continuous professional development, student support as well as to address the issues related to contractual teachers, tenure track and guest faculty, promotion besides facilitating lateral transfer of HEIs from autonomous to teaching to research universities. The IDP has to be initially prepared for a period of five years and shall also contain a description of measures for sustainability beyond this period. Therefore, the goals need to be categorised as short, mid- and long-term goals. 

The IDP is sought to be a living document, evolving as the strategic planning capacity of the institution increases and shall become the basis for further public funding as evidenced from the policy statements. Various steps involved in developing IDPs are as under: 

1. Clearly define the vision and mission of the department/centre/school.
2. In light of their vision and mission, carry out a needs assessment based on wide consultations with all its faculty members to identify the goals, priorities and commitments of the department/centre/school.
3. Quantify the department’s goals using tailored indicators and time-bound targets on the basis of short, mid and long-term goals.
4. Based on their goals and priorities identify capacity (human, infrastructural and financial capacity and needs) and organizational gaps and steps to bridge these gaps.
5. Develop annual activity plans that result, sequentially, in achieving the goals of the department/centre/school. These activity plans will also serve as a tool for monitoring the implementation of the IDP (Ref.NEP-2020). 

IDPs will describe the department’s vision and expectations for its future, embodying where the department wants to be in consonance with the provisions of National Education Policy-2020 over the next one, three, five and ten years. One of the first steps towards developing IDPs includes conducting “Needs Assessment” of the department/centre/school concerned that mainly includes financial assessment of some of the goals enumerated above. Apart from conducting “Needs Assessment” every department/centre/school has to conduct “Constraints Assessment” for achieving their goals besides conducting their “Gap Analysis” and “SWOC analysis” that includes an assessment of their individual strengths, weaknesses, opportunities and challenges. 

In the light of NEP-2020 the departments/centres/schools of colleges and universities can strategize their actions for arriving at a comprehensive and robust framework in the form of IDPs in order to ensure that they have the necessary state-of-art academic infrastructure, including technology-enabled learning ecosystem that is required for effective execution of teaching-learning activities and other objectives of NEP. Accordingly, all departments/centres/schools need to furnish details about their goals, targets, indicators and plans for the accomplishment of following:

 

—  Multidisciplinary Educational Research University (MERU)

—  Contribution towards increasing the GER to 50% by 2035

—  Transformation into research intensive university

—  Instituting Academic Credit Bank

—  Offering 4-year multidisciplinary Bachelor's and/or integrated Master’s degree programmes

—  Establishing start-up/innovation incubation centre

—  Provide exposure to vocational education

—  Establishing smart classrooms and fully automated libraries

—  Providing residential/hostel facilities to staff and students

—  Internationalization (attracting foreign students) of education 

As such, all departments/centres/schools of a university or a college need to take following necessary measures for evolving their departmental IDPs:

 

1. Carry out a situation analysis to identify gaps, barriers, prospects, challenges of the department/centre/school at present.
2. Clearly stipulate short, mid and long-term goals to be achieved over the next one, three and five years respectively.
3. Draw and define a roadmap for action during the next one, three and five years by prioritizing areas and fixing definite timelines for accomplishment of various goals and targets.
4. Identify areas, devise plans and formulate blueprints for human resources development
5. Identify areas and formulate blueprints for curriculum development
6. Chalk out a plan of action for institutional capacity building and infrastructure development over the next 5 to 10 years.
7. Devise objectives, plans and timelines for attainment of goals towards creating state-of-art facilities.
8. Assign roles and responsibilities to faculty members and stakeholders.
9. Monitor progress and evaluate actions at the end of each year.
10. Revise the action plan based on the results and feedback obtained. 

Focus of each department/centre/school has to be on following key objectives while preparing their IDPs:

 

v Revisiting its vision and mission statements in tune with NEP20

v Re-examining and rethinking its future goals, objectives and plans of action

v Redesigning and remodelling its course curriculum in consonance with various provisions of NEP-2020

v Re-assessing its academic and research infrastructure needs

v Restructuring and re-orienting its human resource

v Revamping the organizational structure in tune with NEP-2020

v Reviving and re-energizing its faculty improvement programmes and student welfare measures and practices

v Refurbishing its student and teacher amenities and other facilities

v Re-aligning and repositioning its march towards growth, progress and development

v Contributing towards redeeming and restoring our glorious past in education 

In the Union Territory of Jammu and Kashmir there are 154 government degree colleges, 208 private colleges and 25 professional colleges affiliated to various universities functioning in J&K and 100 new colleges are being established soon to enrol an additional 1.5 lakh students. We have 8 government universities, 3 semi-government universities besides, NIT, IIM, IIT, SKIMS, NIFT, IIMC, 7 autonomous institutions of national importance in J&K. Besides, two cluster universities have been constituted by pooling the resources of 10 prestigious colleges of J&K. Kashmir University is one of the top 50 universities on NIRF ranking while Jammu University ranks 52 and SMVDU 83rd in engineering discipline. Both the state universities are A⁺⁺ while IUST and SMVDU have B⁺⁺ NAAC ranking whereas 48 colleges are NAAC accredited. Under RUSA, Rs.500 crore have been made available for two more cluster universities, two professional colleges, five degree colleges and for the upgradation of infrastructure in 42 colleges. Sarva Shiksha Abyan (SSA) and Rashtriya Madhyamik Shiksha Abyan (RMSA) are two major programmes launched by the government to lay a strong foundation for primary and secondary education. However, in the sphere of higher education, RUSA aims at improving access, equity and quality education. Jammu University is in the process of establishing research clusters as Centres of Excellence in Data Science and Artificial Intelligence, Centre for Bio-Technology, Centre for Nanotechnology and Material Science, Centre for Climate Change and Sustainable Development and Centre for Global Corporate Governance whereas Kashmir University is establishing Centre for Advanced Instrumentation for Research and Centre for Interdisciplinary Research and Innovation (CIRI). An amount of Rs.30 crores is being spent on starting vocational courses in colleges affiliated to both the universities so as to foster employability, innovation and entrepreneurship. Besides, IIM Jammu has been taken as a partner in this area for mentoring and hand-holding for linkages with industries and corporate sectors. So far 40 girl hostels have been established to accommodate 7000 students for equitable participation from hilly and remote regions where girls drop out ratio is significant. Besides, 3.50 lakh students have been enrolled for higher education. GER in J&K is 30.6% which is above the national average of 26% with the distinct feature that girls outnumber boys. Under Technical Education Quality Initiatives (TEQIP), Rs. 40 crores have been provided for professional universities (BGBSU, IUST, SMVDU and GCETs) with an increase of 54 M.Tech. seats in computer, mechanical, electronics and communication engineering for the session 20-21. 

In spite of such landmark progress and developments in the field of higher education there is a lot more that needs to be done. Many newly established degree college in rural areas are still complaining of acute shortage of teaching and non-teaching staff, lack of well-equipped laboratories and libraries, paucity of hostel and transportation facilities besides lack of funds for developmental activities. Such colleges too can project their needs and prepare their IDPs in tune with their shortcomings and requirements and submit the same to higher education department of J&K so that they can be considered for adequate funding with a view to align them to the goals and objectives of new education policy. Once strategic Institutional Development Plans are formulated and submitted by the HEIs to the higher education department and UGC, it will become easier for them to secure substantial financial support and execute the same in a time bound manner. Since public funding to HEIs has been made subservient to the submission of IDPs there is no choice for HEIs but to prepare and submit the same as early as possible. Nevertheless, once submitted IDPs will not be full and final for all times to come. They can be periodically reviewed, revised and resubmitted in tune with continually evolving needs and emerging challenges of the HEIs. However, it is important to take lead and initiate the process of their compilation in compliance with guidelines issued by the University Grants Commission for their preparation. It goes without saying that IDP is the key towards successful implementation of NEP-2020 by HEIs.

 

(With inputs from NEP-2020 document. Author teaches at the Dept. of Pharmaceutical Sciences and holds the additional charge of Director, CCPC, University of Kashmir)