Scope of Management of Noncommunicable Diseases in India through Ayushman Bharat

Abstract

India is a rapidly developing country, and has been going through a major epidemiological transition over the past 25 years. As per the India State-Level Disease Burden Initiative, every state of India now has a higher burden from noncommunicable diseases (NCDs) and injuries than from infectious diseases. Inspired by Sustainable Development Goal vision, mitigating the effect of NCDs will demand a comprehensive approach based on preventive, promotive, and curative cum rehabilitative services. Apart from the community-based approach, another key announcement made in the union budget of India, 2018–19, was the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (ABY) that intend to transform the primary, secondary, and tertiary health care system in India. In this article, we intend to analyze the scope of services offered through ABY at different levels of public health care, and possible constraints in realizing the goal of universal health coverage in terms of NCDs.

Keywords

noncommunicable diseases - universal health coverage - endocrinology - Ayushman Bharat - scheme - primary health care

Introduction

India is a rapidly developing country, which is known for its resilience and resourcefulness. These characteristics have helped the nation deal with many challenges and obstacles it faces. But, it has been going through a major epidemiological transition over the past 25 years. The burden of premature death and health loss due to noninfectious conditions such as heart disease, stroke, diabetes, chronic obstructive lung disease, and road traffic accidents has increased massively, and the burden due to lower respiratory infections, tuberculosis, diarrhea, and neonatal disorders still remains unacceptably high. The extent of the burden due to these major conditions varies significantly across the various population groups and the states of India. As per the India State-Level Disease Burden Initiative, every state of India now has a higher burden from noncommunicable diseases (NCDs) and injuries than from infectious diseases. In 2017, NCDs accounted for 63.7% of all mortality. NCDs also contribute a major portion to cost of treatment at inpatient admissions (40%) and outpatient levels (35%), which comes from household savings and loans in most of the cases (45%).[1] Key challenges related to health include inadequate access to services, limited availability of medicines, and catastrophic out-of-pocket expenditure (OOPE).[2] These challenges are a major impediment to India’s commitment to achieve universal health coverage (UHC).[3] Although, India’s National Health Policy-2017 (NHP-2017) is completely concordant with the global targets of achieving UHC, inadequate funding earmarked for health has slowed our progress.[4] Initially, peripheral health workers prioritized delivery of maternal and child heath, while assuming that NCDs can only be managed in the private sector.[5]

However, inspired by Sustainable Development Goal (SDG) vision, mitigating the effect of NCDs will demand a comprehensive approach based on preventive, promotive, and curative cum rehabilitative services. In India, some early momentum in this respect can already be witnessed with upsurge in leadership and intersectoral understanding, and a switch over from curative to prevention. Due to the web of causation determining the natural history of NCDs and recent changes in priority, handling the NCD-related SDG target 3.4—“by 2030 reduce by one-third premature mortality from NCDs through prevention and treatment, and promote mental health and well-being”—will require a community-based approach backed by adequate leadership support for national policy implementation.[6] Newer guidelines targeting comprehensive primary health care services have suggested a community outreach and preventive approach for tackling the NCDs. The recently launched guideline (2017), on the screening of NCDs under comprehensive primary care does tries to reach out to larger populations through community health workers and conducting community-based screening.[7] This guideline plans to develop an outreach population-based intervention for NCDs, complementing the National Program for the Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke.[8]

Apart from the community-based approach, another key announcement made in the union budget of India, 2018–19, was the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (ABY) that intend to transform the primary, secondary, and tertiary health care system in India.[9] ABY targets around 10 crore families that can be categorized as poor, also the vulnerable population.[10] The program has two components:

1. Provision of comprehensive primary health care by establishing approximately 150,000 health and wellness centers (HWCs) by year 2022.

2. Providing financial protection for secondary and tertiary level hospitalization as part of National Health Protection Scheme (NHPS) and

Secondary/Tertiary Care

The ABY aims to provide continuum of care across three levels of health system hierarchy, and deliver the entire range of preventive, promotive, curative, diagnostic, rehabilitative, and palliative care services. The first initiative is the NHPS, which has been referred as “the world’s largest government-funded health care (insurance) program.”[11] It aims to provide a coverage for expenses related to secondary- and tertiary-level hospitalization. Entitlements include financing of pre- and posthospitalization expenses and a defined transport allowance up to INR 500,000 per family per 6 hospitalizations per year. It aims to address the health care needs of India’s poorest 100 million households and has the potential to deliver what its predecessors over the past several decades have failed to do.

Primary Care

The second initiative, ABP aims to upgrade 150,000 (of the existing 180,000) subcenters (SCs) and primary health centers in India, to HWCs by December 2022. This is to curtail 72% of total OOPE on primary care. Lack of effective primary care also leads to fragmentation of services and burdening of secondary and tertiary levels.[12] This initiative is in concurrence to the NHP-2017 which recommends the strengthening of the primary health care service delivery, and calls for a commitment of two-thirds of the health budget to primary health care.

HWCs also propose to elaborate their current range of services to a broader package of 12 services. It is noteworthy that these include many conditions related to endocrine health. These are childhood and adolescent health care services, screening and management of NCDs, and mental health ailments.

The proposal to set up such a large number of HWCs is potentially a more impactful initiative.[13] One, the comprehensive primary health care delivered through HWCs would benefit the entire 1.3 billion people of India across rural and urban setting. Second, it would strengthen government primary health care system, which caters to only 10% health needs of the people at present while a well-functioning primary health care system has the potential to cater up to 80 to 90% of health needs.[14] Third, strengthening primary health care 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 several NCDs, and can tackle the epidemiological transition.

In realization of these goals, there are some key speculations as well. First, is the issue of budget that has been allocated to HWCs, that is, INR 1,200 crore for upgradation of 150,000 SCs, that looks grossly insufficient to provide the expanded range of services.11 Second, there is still shortage of human resource for health at different levels that may obliterate the referral pathway. Third, there are chances of underutilization of public health services due to the preference for private health services, which calls for adequate public–private partnership to deliver the services effectively.

Conclusion

In this article, we have tried to assess whether existing government policies are serious enough to deal with the rising epidemic of NCDs. By and large, in the early days of the SDG era in India, most progress has been made in terms of “ensuring leadership for intersectoral coherence and coordination on the structural drivers of health,” and “shifting the focus from treatment to prevention through locally led, politically smart approaches to a far broader agenda.” Comprehensive primary care reduces mortality and morbidity at much lower costs, and significantly reduces the need for secondary and tertiary care.[15] Endocrine and diabetes care providers should utilize these government initiatives to improve the penetration of health care services across India.

In conclusion, in present time, with high burden of NCDs, the ABY offers a window of opportunity to reimagine health as a social goal. Achieving these goals requires structural governance and policy shifts that are firmly rooted in a rights-based approach.

Conflict of Interest

None declared.

• References

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Publication History

Received: 06 September 2019

Accepted: 23 September 2019

Article published online:
30 March 2020