Universal Health Coverage In India Research Articles

Utilisation of public healthcare services by an indigenous group: a mixed-method study among Santals of West Bengal, India.

A barrier to meeting the goal of universal health coverage in India is the inequality in utilisation of health services between indigenous and non-indigenous people. This study aimed to explore the determinants of utilisation, or non-utilisation, of public healthcare services among the Santals, an indigenous community living in West Bengal, India. The study holistically explored the utilisation of public healthcare facilities using a framework that conceptualised service coverage to be dependent on a set of determinants - viz. the nature and severity of the ailment, availability, accessibility (geographical and financial), and acceptability of the healthcare options and decision-making around these further depends on background characteristics of the individual or their family/household. This cross-sectional study adopts ethnographic approach for detailed insight into the issue and interviewed 422 adult members of Santals living in both rural (Bankura) and urban (Howrah) areas of West Bengal for demographic, socio-economic characteristics and healthcare utilisation behaviour using pre-tested data collection schedule. The findings revealed that utilisation of the public healthcare facilities was low, especially in urban areas. Residence in urban areas, being female, having higher education, engaging in salaried occupation and having availability of private allopathic and homoeopathic doctors in the locality had higher odds of not utilising public healthcare services. Issues like misbehaviour from the health personnel, unavailability of medicine, poor quality of care, and high patient load were reported as the major reasons for non-utilisation of public health services. The finding highlights the importance of improving the availability and quality of care of healthcare services for marginalised populations because these communities live in geographically isolated places and have low affordability of private healthcare. The health programme needs to address these issues to improve the utilisation and reduce the inequality in healthcare utilisation, which would be beneficial for all segments of Indian population.

Innovations in Critical Care Management and Universal Health Coverage in India

Innovations in Critical Care Management and Universal Health Coverage in India

The Barriers to Universal Health Coverage in India and the Strategies to Address Them: A Key Informant Study.

India has adopted several policies toward improving access to healthcare and has been an enthusiastic signatory to several global health policies to achieve Universal Health Coverage (UHC). However, despite these policy commitments, there has been limited success in realizing these goals. The COVID-19 pandemic has highlighted the urgent need for health system re-design and amplified the calls for such reforms. We seek to understand the views of a diverse group of policy actors in India to address the following research questions: what are the (i) conceptualizations of UHC, (ii) main barriers to realizing UHC, and (iii) policy strategies to address these barriers. We collected data through in-depth interviews with 38 policy actors from diverse backgrounds and analyzed using the Framework Method to develop themes both inductively and deductively using the Control Knob Framework of health systems. There was congruence in the conceptualization of UHC by policy actors. Quality of care, equity, financial risk protection, and a comprehensive set of services were the most commonly cited features. The lack of a comprehensive systems approach to health policies, inadequate and inefficient health financing mechanisms, and fragmentation between public and private sectors were identified as the main barriers to UHC. Contrasting views about specific strategies, health financing, provider payments, organization of the delivery system, and regulation emerged as the key policy interventions to address these barriers. This is the first systematic examination of a diverse set of policy actors' problem analyses and suggestions to advance UHC goals in India. The study underscores the need to recognize the complex and interlinked nature of health system reforms and initiate a departure from path-dependent vertical interventions to bring about transformative change.

Analysis of public health-care facilities in rural India

PurposeThis paper aims to analyze the status of infrastructure, workforce and basic amenities at public health-care facilities in rural India and draw a comparison with its urban counterparts.Design/methodology/approachRural Health Statistics data and National Sample Survey Office Report for the period 2019–10 were used to analyze lower-level public health facilities, namely, subcenters, primary health centers and community health centers (CHCs). Selected tracer indicators under World Health Organization’s (WHO) Service Availability and Readiness Assessment (SARA) mechanism such as health center density, core health workforce density and basic amenities were used to carry out the analysis. The extent of facility coverage was measured using the National Rural Health Mission (NRHM) guidelines and the proportion of facilities satisfying the Indian Public Health Standards (IPHS) was measured to assess the service provision quality in rural public health-care facilities.FindingsResults indicated that the density of public health centers is higher in rural areas than in urban areas. Almost all public health-care facilities lack basic amenities in rural areas. Working positions for health specialists in CHCs barely meet the total requirement. Almost all of the public health facilities functioning in rural areas do not meet the IPHS norms.Originality/valueTo the best of the authors’ knowledge, the present paper is the first initiative to assess the status of rural public health-care facilities on the national level using WHO’s SARA indicators as well as NRHM and IPHS guidelines. The study is significant in terms of policy input for achieving universal health coverage in India.

The genesis ofthe PM-JAY health insurance scheme inIndia: technical andpolitical elements influencing a national reform towards universal health coverage.

Many countries are using health insurance to advance progress towards universal health coverage (UHC). India launched the Pradhan Mantri Jan Arogya Yojana (PM-JAY) health insurance scheme in 2018. We examine the political economy context around PM-JAY policy formulation, by examining the perspectives of policy stakeholders shaping decisions around the reform. More specifically, we focus on early policy design at the central (national) level. We use a framework on the politics of UHC reform proposed by Fox and Reich (The politics of universal health coverage in low- and middle-income countries: A framework for evaluation and action. J. Health Polit. Policy Law 2015;40:1023-1060), to categorize the reform into phases and examine the interactions between actors, institutions, interests, ideas and ideology which shaped reform decisions. We interviewed 15 respondents in Delhi between February and April 2019, who were either closely associated with the reform process or subject experts. The ruling centre-right government introduced PM-JAY shortly before national elections, drawing upon policy legacies from prior and state insurance schemes. Empowered policy entrepreneurs within the government focused discourse around ideas of UHC and strategic purchasing, and engaged in institution building leading to the creation of the National Health Authority and State Health Agencies through policy directives, thereby expanding state infrastructural and institutional power for insurance implementation. Indian state inputs were incorporated in scheme design features like mode of implementation, benefit package and provider network, while features like the coverage amount, portability of benefits and branding strategy were more centrally driven. These balanced negotiations opened up political space for a cohesive, central narrative of the reform and facilitated adoption. Our analysis shows that the PM-JAY reform focused on bureaucratic rather than ideological elements and that technical compromises and adjustments accommodating the interests of states enabled the political success of policy formulation. Appreciating these politics, power and structural issues shaping PM-JAY institutional design will be important to understand how PM-JAY is implemented and how it advances UHC in India.

Universal health coverage in India and health technology assessment: current status and the way forward.

In India, there is a renewed emphasis on Universal Health Coverage (UHC). Alongside this, Health Technology Assessment (HTA) is an important tool for advancing UHC. The development and application of HTA in India, including capacity building and establishing institutional mechanisms. We emphasized using the HTA approach within two components of the Ayushman Bharat programme, and the section concludes with lessons learned and the next steps. The UHC has increased the importance of selecting and implementing effective technologies and interventions within national health systems, particularly in the context of limited resources. To maximize the use of limited resources and produce reliable scientific assessments, developing and enhancing national capacity must be based on established best practices, information exchange between different sectors, and collaborative approaches. A more potent mechanism and capacity for HTA in India would accelerate the country's progress toward UHC.

Contemporary Universal Health Coverage in India - The Case of Federal State of Odisha (Orissa).

The present study assessed the awareness of the public about Biju Swasthya Kalyan Yojana (BSKY), which is a flagship public-funded health insurance scheme of the Government of Odisha. The study also identified its determinants and examined utilisation of the scheme among households in Khordha district of Odisha. Primary data were collected from randomly chosen 150 households using a pretested structured questionnaire from Balipatana block of Khordha district, Odisha. Descriptive statistics and binomial logistic regression were used to substantiate the objectives. The study found that even though 56.70% of the sample households had heard about BSKY, procedure-specific awareness was low. State government organised BSKY health insurance camp was found to be a major source of knowledge among the sample. The regression model had an R2 of 0.414. The Chi2 value showed that the model with predictor variables was a good fit. Caste, gender, economic category, health insurance, and awareness about insurance were significant determinants of BSKY awareness. A majority (79.30%) of the sample had the scheme card with them. However, only 12.60% of the cardholders used the card and only 10.67% received benefits. Mean out-of-pocket expenditure (OOPE) faced by the beneficiaries is Rs. 15743.59. Among the beneficiaries, 53.80% financed the OOPE from their savings, 38.50% by borrowing, and 7.70% financed the OOPE by both means. The study found that even though majority of people had heard about BSKY, they were not aware of its nature, features, and operational procedures. The trend of low benefit received and higher OOPE among the scheme beneficiaries hampers the economic health of the poor. Finally, the study highlighted the need to increase the magnitudeof scheme coverage and administrative efficiency.

Evolution of Government-funded health insurance for universal health coverage in India.

India has run multiple Government-Funded Health Insurance schemes (GFHIS) over the past decades to ensure affordable healthcare. We assessed GFHIS evolution with a special focus on two national schemes - Rashtriya Swasthya Bima Yojana (RSBY) and Pradhan Mantri Jan Arogya Yojana (PMJAY). RSBY suffered from a static financial coverage cap, low enrollment, inequitable service supply, utilization, etc. PMJAY expanded coverage and mitigated some of RSBY's drawbacks. Investigating equity in PMJAY's supply and utilization across geography, sex, age, social groups, and healthcare sectors depicts several systemic skews. Kerala and Himachal Pradesh with low poverty and disease burden use more services. Males are more likely to seek care under PMJAY than females. Mid-age population (19-50 years) is a common group availing services. Scheduled Caste and Scheduled Tribe people have low service utilization. Most hospitals providing services are private. Such inequities can lead the most vulnerable populations further into deprivation due to healthcare inaccessibility.

The Right to Health and Universal Health Coverage in India

The Right to Health and Universal Health Coverage in India

A theory of change roadmap for universal health coverage in India.

The Theory of Change (ToC) approach is one of the methodologies that the Lancet Citizens' Commission has chosen to build a roadmap to achieving Universal Healthcare (UHC) in India in the next 10 years. The work of the Citizens' Commission is organized around five workstreams: Finance, Human Resources for Health (HRH), Citizens' Engagement, Governance, and Technology. Five ToC workshops were conducted, one for each workstream. Individual workshop outputs were then brought together in two cross-workstream workshops where a sectoral Theory of Change for UHC was derived. Seventy-four participants, drawn from the Commission or invited for their expertise, and representing diverse stakeholders and sectors concerned with UHC, contributed to these workshops. A reimagined healthcare system achieves (1) enhanced transparency, accountability, and responsiveness; (2) improved quality of health services; (3) accessible, comprehensive, connected, and affordable care for all; (4) equitable, people-centered and safe health services; and (5) trust in the health system. For a mixed system like India's, achieving these high ideals will require all actors, public, private and civil society, to collaborate and bring about this transformation. During the consultation, paradigm shifts emerged, which were structural or systemic assumptions that were deemed necessary for the realization of all interventions. Critical points of consensus also emerged from the workshops, such as the need for citizen-centricity, greater efficiency in the use of public finances for health care, shifting to team-based managed care, empowerment of frontline health workers, the appropriate use of technology across all phases of patient care, and moving toward an articulation of positive health and wellbeing. Critical areas of contention that remained related to the role of the private sector, especially around financing and service delivery. Few issues for further consultation and research were noted, such as payment for performance across both public and private sectors, the use of accountability metrics across both public and private sectors, and the strategies for addressing structural barriers to realizing the proposed paradigm shifts. As the ToCs were developed in expert groups, citizens' consultations and consultations with administrative leaders were recommended to refine and ground the ToC, and therefore the roadmap to realize UHC, in people's lived reality.

A historic opportunity for universal health coverage in India

The milestone of India's 75th anniversary of independence on Aug 15, 2022, offers an opportunity to reassert the country's commitment to realising universal health coverage (UHC). The first such effort predates independence, with the 1946 Bhore Committee report.1 India's colonial ruler, the UK Government, had simultaneously commissioned the Beveridge Report (1942), which led to the birth of the UK National Health Service in 1948. The Bhore Committee recommended a similar national health-care system for India with guiding principles that have stood the test of time (panel).

Burns in India: a call for health policy action

Burns in India: a call for health policy action

Gagandeep Kang: helping to shape a healthier India

Having worked in enteric disease research for the past three decades, Gagandeep Kang has a broad perspective on many of the health challenges confronting her native India. Kang, who is Professor of Microbiology in the Department of Gastrointestinal Sciences at the Christian Medical College (CMC) in Vellore, southern India, also directs CMC's Wellcome Trust Research Laboratory. There, rotavirus vaccine work—which has been a central part of her career—remains a priority. “We are currently collaborating with a network of 25 hospitals across India to enable us to better understand how much disease is alleviated and why the key prevention tool of rotavirus vaccines does not generally work as well as they do in high-income countries”, she says. Reimagining India's health system: a Lancet Citizens’ CommissionThe COVID-19 pandemic and response are having profound impacts on India's people, leading to myriad health-care challenges, a looming economic recession, and humanitarian crises.1 The long-standing need for universal health coverage (UHC) in India has been brought into sharp focus by the pandemic. The mission of the Lancet Citizens’ Commission on reimagining India's health system is to lay out the path to achieving UHC in India in the coming decade. Full-Text PDF

Ayushman Bharat and Universal Health Coverage in India: Is our approach ethical?

The Ayushman Bharat Mission with its two inter-linked components, namely Health and Wellness centres and the Pradhan Mantri Jan Arogya Yojana, has been proposed as India's prime instrument for achieving universal health coverage. The insurance component of the mission has received priority over the primary healthcare component. Apart from efficiency reasons, there are strong ethical grounds to prioritize the primary care component over its insurance counterpart. There is also a need to consider the ethical dimensions of publicly financed health insurance in India. A robust priority setting process should guide the roll-out of universal health coverage. This is particularly crucial since a large scale expansion of PMJAY to the non-poor population is being currently envisaged by the government.

Can Mohalla Clinics be a Catalyst for Ayushman Bharat Pradhan Mantri Jan Arogya Yojna to achieve Universal Health Coverage in India?

BACKGROUND: Expenditure on health sector in India is one of the lowest public health expenditures in the world at just over 1% of GDP, with substantial disparities in population, infrastructure, availability and provision of services that define the Indian health care system. In a reform of Indian health systems approved by the Indian Government in March 2018, Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) was launched on 23rd September, 2018 to provide financial health insurance coverage of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalizations to more than 10.74 million poor families that form the bottom 40% of population in India. OBJECTIVES: The objective of this paper is to discuss and analyze the benefits and weaknesses of the AB-PMJAY model and investigating the position that these clinics can play in (I) improving the provision of urban health facilities (II) resolving health inequities (III) and enhancing primary health care.MATERIALS AND METHOD: The authors explored different databases. Government portals, research publications on AB-PMJAY and Mohalla clinics (MC) to do in-depth analysis of various parameters.RESULTS: Although there are significant obstacles to the programme, by building impetus for program reform, AB-PMJAY offers an opportunity for the nation to resolve long-standing and ingrained shortcomings in governance, quality control and stewardship, and to accelerate India's development towards the stated UHC supply goal. The main achievement of these facilities in the last 18 months has been to introduce wellness to civic and political dialogue. CONCLUSION: Mohalla Clinics can prove as a major catalyst for Ayushman Bharat Pradhan Mantri Jan Arogya Yojna for health reforms and progress towards universal health coverage in India.

Importance of Evidence-Based Health Insurance Reimbursement and Health Technology Assessment for Achieving Universal Health Coverage and Improved Access to Health in India

ObjectiveTo review the importance of evidence-based methods in health insurance reimbursement for achieving universal health coverage in India. MethodsA narrative literature review was performed. ResultsThe out-of-pocket (OOP) healthcare expenditure in India is among the highest in the world. This situation is despite the implementation of numerous government health schemes and the availability of a large number of health insurance programs, both public and private. Compromised quality of care in many public healthcare facilities is a major factor driving the average Indian citizen to increasingly depend upon private healthcare facilities, further escalating OOP spending. The low awareness and poor uptake of insurance policies among Indians is one of the biggest challenges in the implementation of universal health coverage (UHC) in India. The catastrophic burden of high OOP expenses on individual households could be reduced by taking steps to enhance health insurance uptake, which can be in turn achieved by strengthening the healthcare reimbursement system in India. ConclusionsThe application of the principles of evidence-based healthcare for reimbursement requires the systematic assessment of all health technologies, which is already being done in developed countries. The enactment of health schemes such as Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana and setting up of Health Technology Assessment in India are steps toward reducing OOP expenditure and achieving UHC in India. We review the importance and challenges of evidence-based reimbursement and health technology assessment toward achieving UHC in India.

Performance Evaluation of Health Insurance: Ways for Winning Confidence

Health is a fundamental force that decides the overall quality of human life. The health of the population is a vital and essential issue for any country. The new National Health Policy of India (2017) emphasizes the growing burden of non- communicable diseases and corresponding growing expenditure. Indian Government announced the world's most massive health scheme, the Ayushman Bharat Yojana, in 2018, which is a significant step towards attaining universal health coverage in India. This scheme provides a cover of Rs.5 lakh per family per year for various medical procedures. Although India's Government is taking many such initiatives to improve public health, a lot more needs to be done to attain universal coverage. Out of pocket expenditure paid by individuals towards health care in India ranges at a high percentage over the years. Although health insurance premium has shown an increase over the years, there is no drop in this expenditure. This study shows the phenomenal growth achieved by health insurance, specifically after privatization, premium growth, and improvement in claims ratios. It is suggested that the insurance companies should modify the coverage of health insurance policies so that the uncovered expenses are reimbursed during hospitalization. Insurance companies also should shift their focus towards wellness instead of covering sickness to keep their businesses sustainable in the long run.

Interplaying role of healthcare activist and homemaker: a mixed-methods exploration of the workload of community health workers (Accredited Social Health Activists) in India

BackgroundGlobally, community health workers (CHWs) are integral contributors to many health systems. In India, Accredited Social Health Activists (ASHAs) have been deployed since 2005. Engaged in multiple health care activities, they are a key link between the health system and population. ASHAs are expected to participate in new health programmes prompting interest in their current workload from the perspective of the health system, community and their family.MethodsThis mixed-methods design study was conducted in rural and tribal Primary Health Centers (PHCs), in Pune district, Western Maharashtra, India. All ASHAs affiliated with these PHCs were invited to participate in the quantitative study, those agreeing to contribute in-depth interviews (IDI) were enrolled in an additional qualitative study. Key informants’ interviews were conducted with the Auxiliary Nurse Midwife (ANM), Block Facilitators (BFF) and Medical Officers (MO) of the same PHCs. Quantitative data were analysed using descriptive statistics. Qualitative data were analysed thematically.ResultsWe recruited 67 ASHAs from the two PHCs. ASHAs worked up to 20 h/week in their village of residence, serving populations of approximately 800–1200, embracing an increasing range of activities, despite a workload that contributed to feelings of being rushed and tiredness. They juggled household work, other paid jobs and their ASHA activities. Practical problems with travel added to time involved, especially in tribal areas where transport is lacking. Their sense of benefiting the community coupled with respect and recognition gained in village brought happiness and job satisfaction. They were willing to take on new tasks. ASHAs perceived themselves as ‘voluntary community health workers’ rather than as ‘health activists”.ConclusionsASHAs were struggling to balance their significant ASHA work and domestic tasks. They were proud of their role as CHWs and willing to take on new activities. Strategies to recruit, train, skills enhancement, incentivise, and retain ASHAs, need to be prioritised. Evolving attitudes to the advantages/disadvantages of current voluntary status and role of ASHAs need to be understood and addressed if ASHAs are to be remain a key component in achieving universal health coverage in India.

Reimagining India's health system: a Lancet Citizens’ Commission

Reimagining India's health system: a Lancet Citizens’ Commission

Health & Wellness Centers to Strengthen Primary Health Care in India: Concept, Progress and Ways Forward.

In February 2018, the Indian Government announced Ayushman Bharat Program (ABP) with two components of (a) Health and Wellness Centres (HWCs), to deliver comprehensive primary health care (PHC) services to the entire population and (b) Pradhan Mantri Jan Arogya Yojana (PMJAY) for improving access to hospitalization services at secondary and tertiary level health facilities for bottom 40% of total population. The HWC component of ABP aims to upgrade and make 150,000 existing Government Primary health care facilities functional by December 2022. The first HWC was launched on 14 April 2018 and by 31 March 2020, a total 38,595 AB-HWCs were operational across India. This article documents and analyses the key design aspects of HWCs, against core components of PHC & the health system functions. The article reviews the progress and analyses the potential of HWCs to strengthen PHC services and therefore, advance Universal Health Coverage in India. Challenges emerged from COVID-19 pandemic & learnings thus far has also been analyzed to guide the scale up of HWCs in India. It has been argued that effectiveness and success of HWCs will be dependent upon a rapid transition from policy to accelerated implementation stage; focus on both supply and demand side interventions, dedicated and increased funding by both union and state governments; appropriate use of information and communication technology; engagement of community and civil society and other stakeholders, focus on effective and functional referral linkages; attention on public health services & population health interventions; sustained political will & monitoring and evaluation for the mid-term corrections, amongst other. Experience from India may have lessons and learnings for other low and middle-income countries to strengthen primary healthcare in journey towards universal health coverage.