Health & Wellness Centres (HWCs) and Comprehensive Primary Health Care in India
The first HWCs was launched in Jangla village in Bhairamgarh tehsil of Bijapur district of Chhattisgarh state in India on 14 April 2018 [1, 4]. The key events related to HWCs in India are summarized in Table 1. As part of HWC components of ABP, the govt of India announced to make existing 150,000 GPHCFs in country functional by December 2022. AB-HWCs are not new facilities and are being set up as an upgraded version of existing GPHCFs such as Health Sub-Centers (HSC); Primary Health Centers and Urban Primary Health Centers (UPHCs). The proposed increase in provision of services (shift from erstwhile provision of 6 sub-group of services to 12 sub-group of services) and upgrade on other key design aspects are shown in Figs. 2 and 3 [1, 31].
Table 1 Evolution of Health & Wellness Centres (HWCs) in India [1, 3, 4, 30]
Timeline Specific developments
July- Dec 2013 Initial discussion on Health and Wellness Centres (HWCs) in India started
2015–16 Task Force on Primary Healthcare in India recommended formation of HWCs, with initial suggestions on the design.
2017 India’s third National Health Policy (NHP 2017) released.
Union Budget announcement for setting up HWCs in India
2018 HWC became one of the two pillars under Ayushman Bharat (AB) program announced in Union Budget on 1 February 2018
14 April 2018 Inauguration of India’s first AB-HWC at Jangla, Bijapur, Chhattisgarh, India
31 March 2019 A total of 17,149 AB-HWCs made functional across India. This includes 8,801 Primary Health Centres; 6,795 Health Sub-centres (HSC) and 1,553 Urban Primary Health Centres (UPHCs) converted to HWCs.
2019–20 25,000 additional AB-HWCs to be set up with all UPHC to be converted to HWCs in the financial year. A total of 38,595 HWCs were set up by 31 March 2020
31 December 2022 Indian states to have 150,000 functional AB-HWCs in the country
Fig. 2 Key components and design aspects of AB-HWCs [1, 31]
Fig. 3 Service provision through AB-HWCs [1, 31]
Against the target of 15,000 of HWC in year 1, a total of 17,149 AB-HWCs were made functional by 31 March 2019 [30]. Cumulative target of 40,000 HWCs was set up for 31 March 2020. There was slow-down in setting up HWCs in March 2020 due to COVID-19 pandemic and total of 38,595 HWCs were operational by 31 March 2020. The cumulative target is 70,000 HWCs by 31 March 2021, then 110,000 by 31 March 2022 and 150,000 by 31 December 2022. Alongside, all UPHC across India were to be converted to HWCs by March 2020 [1]. Official data on utilization of services from HWCs was available till 22 Sept 2019, when nearly 21,000 AB-HWCs were operational which had reported a foot-fall of 17 million. In these Centres 950,000 yoga sessions were conducted; 7 million people received treatment for hypertension and 3.1 million for diabetes mellitus, Sixteen million beneficiaries received essential medicines and 4.9 million received free essential diagnostics [1, 32]. The second component of AB-PMJAY was launched on 23 Sept 2018 and progress on this component is summarised in Box 2 [32, 33].
Box 2 Progress under Pradhan Mantri Jan Arogya Yojana (PMJAY) component of Ayushman Bharat in India [1, 32, 33]
Ayushman Bharat Program, from the time of announcement has two components. Other than Ayushman Bharat- Health and Wellness Centres (AB-HWC), AB-PMJAY is the second component. It has built upon the erstwhile Rashtriya Swasthya Bima Yojana (RSBY), started in year 2008 in India. Even since announcement of ABP, the scheme has witnessed a few evolutions in name before settling for AB-PMJAY. It was announced as AB-National Health Protection scheme or AB-NHPS in February 2018, renamed as National Health Protection Mission (AB-NHPM) in early March 2018 and then Pradhan Mantri Rashtriya Swasthya Suraksha Mission (PM-RSSM) in third week of March 2018. In mid August 2018, it was referred as Pradhan Mantri Jan Aarogya Abhiyan (PMJAA) (15 August 2018) before finally being renamed as AB-PMJAY towards the end of Aug 2018. AB-PMJAY provides health cover of up to INR 500,000 (Exchange rate in April 2020: 1 USD= approx. 75 INR) per family per year on floater basis; covers 3-day pre-hospitalization and 15 d post hospitalization; expenses on medicines, follow up and diagnostics. One thousand three hundred ninety three procedures in 24 specialties were part of the scheme, as on October 2019. There is no cap on family size, age or gender, cashless and paperless treatment for beneficiaries at point of care. Benefits are portable across the country in the empaneled hospitals.
The scheme was announced in Union Budget of India on 1 February 2018; Cabinet approval was received on 21 March 2018; National Health Agency got incorporated on 11 May 2018; AB-PMJAY was formally launched on 23 September 2018, from Ranchi, Jharkhand. On completion of 100 d of launch on 2 January 2019; National Health Authority or NHA was formed.
At 1 y of completion of AB-PMJAY on 22 Sept 2019; a total of 32 states of 36 states/UT were implementing the scheme. One hundred and three million e-cards were issued. There were 18,236 hospitals empaneled [8,571 (47%) public and 9,665 (53%) private] and there were 4.65 million total hospital admissions with 2.18 million (47%) in govt. and 2.47 million (53%) in private facilities. The total treatment equal to Indian Rupee (INR) 7,490 Cr (US$ 1.07 billion) was provided, which included INR 2,846 Cr (38%) in Public and INR 4,644 Cr (62%) in private sector facilities.
The HWCs aims to address the identified challenges in PHC systems in India, by focusing upon holistic PHC strengthening through various initiatives [Table 2 (structured as per health system functions)]. This is not first such initiative to strengthen PHC services in India. Yet, why AB-HWCs appears more promising than all earlier initiatives to strengthen and deliver comprehensive PHC has been explained in Appendix 1 [1, 3, 27–29, 31–37]. This is relevant considering much of 14 y since the launch of National Rural Health Mission (NRHM) in the year 2005, had also focused on strengthening PHC system in the country.
Table 2 Challenges in PHC system, provisions through AB-HWCs and complementarity with NHM in India [1, 3, 27, 28, 31]
Health System Function Challenges in PHC system (Indicative) AB-HWC and related initiatives Ongoing and other proposed initiatives (including NHM & other state specific)
Service provision and delivery ▪ Narrow range of six services (mostly focused on Maternal & child health and infectious diseases)
▪ Curative care predominance
▪ ‘Continuum of care’ mostly for maternal and child health services ▪ Stronger focus on service delivery with an enhanced package of 12 services (from existing 6 services)
▪ Attention on preventive and promotive health services; focus on wellness and lifestyle modification, specifically for chronic diseases
▪ Integration with Indian systems of medicine, AYUSH, including the promotion of Yoga as form of lifestyle change to tackle non-communicable diseases
▪ Population based screening for common conditions including three cancers
▪ Attention on quality and patient safety; Develop standard treatment flows (STF) for peripheral health facilities
▪ Extending prescription rights to CHO through legal process
▪ Adopt ‘Resolve more & refer less’ approach at peripheral health facilities; strengthening of referral system to ensure continuity of care; Telemedicine and consultations
▪ Enhanced provision of point of care diagnostics at both levels HWC- HSC and HWC-PHC ▪ Community based network of ASHA and VHNSC to support preventive and promotive health services.
▪ State specific models of service delivery to provide cross learnings
▪ Build on systems for emergency referral and transport; established under NHM
▪ Utilise strengthening of secondary care services & District hospitals for effective referral linkage
▪ Build upon quality standards and mechanism for ensuring use of treatment protocols
▪ Community Health Officers (CHO) proposed in the National Medical Commission (NMC) Act to strengthen public health service delivery
Human resources and infrastructure ▪ Shortage of infrastructure and human resources
▪ Inequitable distribution
▪ Health Sub-centres (HSCs) led by one or two Auxiliary nurse midwife (ANM) who has focus on Mother and child services
▪ Narrow range of skills and services at lower level PHC facilities ▪ Provision of Mid-level healthcare provider (MLHP), trained in 6-month course at AB-HWCs to address common health problem
▪ Institutional strengthening for increased annual production of MLHP
▪ Task shifting to different cadre of healthcare providers and team-based service delivery
▪ Proposal to change the roles of ANMs as multi-purpose workers (female) or MPW- F
▪ Services at the HWC-HSC, to be delivered through a team, led by a new cadre of non-physician health worker, a MLHP or CHO, supported by one or two multipurpose workers, and ASHAs
▪ Shift from doctor centric facilities to a team-based service delivery where provision of providers is dependent upon service need
▪ AYUSH providers to be mainstreamed in PHC systems ▪ Recruitment of contractual providers in the system
▪ Flexibility to states in salary for HR, under NHM to ensure recruitment
▪ Institutionalize the mechanisms for training of MLHP
▪ Consider an All India cadre of specialist doctors to tackle shortage of specialist doctors & that of public health specialists
▪ Innovation in human resources including incentives to recruit and retain
Health financing ▪ Limited government funding on health
▪ High OOPE to the range of 60% of total health expenditure
▪ Budget mostly line item-based funding only
▪ Limited use of strategic purchasing services
▪ People get poor because of health expenditures ▪ Reforms on provider payment mechanisms including the introduction of performance-linked incentives in PHC system
▪ Mechanisms to reduce cost of health seeking through assured provision of more medicines and point of care diagnostics
▪ Performance-linked payments to the MLHP and to the team of front-line workers.
▪ MLHP to get salary on blended formula –a fixed component and incentives linked to key outcomes, measured through IT platform-based monitoring system with key performance indicators ▪ Increased government allocation for primary health care, through formula-based approach and sharing between union and state level
▪ Capacity building of states in health financing
Medicines and vaccines ▪ Many states started free medicines and diagnostics scheme, yet govt spending as share on cost of medicines low
▪ Medicines and access to diagnostics mostly at higher level facilities and no assured provision
▪ Medicines major cost paid by people
▪ Irrational use of medicines ▪ Revision and expansion of essential medicines & diagnostics lists
▪ Assured provision of larger basket of medicines with inclusion of additional medicines for chronic diseases
▪ Assured dispensing of medicines for longer duration of 4 wk or more
▪ Attention on expanded range of diagnostic services of Point of Care
▪ Proposal for rapid expansion of Pradhan Mantri Jan Aushadhi stores for low cost & generic medicines
▪ Proposal for setting up state level procurement and supply corporations
▪ Provision of dispensing medicines from HWCs, for patients who need long term treatment and initially attended care at higher level of facilities ▪ Provision of free medicines and diagnostics (as well as schemes) under NHM
▪ Strengthening of Mission Indradhanush for increasing coverage with vaccines under Universal Immunization Program
▪ Launch of state specific free medicines and free diagnostics schemes with enhanced budgetary allocation
Health information systems ▪ Weak health information system
▪ Limited use of ICT platforms
▪ Delay in recording and reporting of health data ▪ Attention to build a robust ICT system for population enumeration, enrolment, tracking and follow-up of patients
▪ Attention on registration of beneficiaries at associated HWC facility
▪ Increased use of mobile based technology and hand-held devices
▪ Provision of tele-health and tele-medicine at each facility
▪ Use of Digital technology and ICT platforms (proposed for) to ensure continuity of care through universal population empanelment and registration to a HWC, facilitating performance payments and ensuring continuity of care and also for improved recording & reporting system ▪ Telemedicine and tele-radiology services as per the local needs
▪ Health Management Information System (HMIS) established
Governance and leadership ▪ Weak regulation
▪ Limited transition of policy into implementation
▪ Health state subject and variable priority
▪ The job -descriptions of various health staff are not aligned with the activities they do ▪ High level political and administrative priority assigned to AB-HWCs at all levels
▪ System and coordination mechanism being proposed to link PHC services with AB-PMJAY
▪ National Knowledge Platform for implementation & operational research
▪ Revisions of operational guidelines
▪ Enhanced community-based monitoring for AB-HWCs.
▪ Regular reviews on progress and performance
▪ Revision in responsibilities of auxiliary nurse midwife to make them multi-purpose workers ▪ A number of governance and leadership mechanisms were established under NHM level including mission steering groups at top level to community based VHSNC at village level.
▪ The Clinical Establishment Registration and Regulation Act, 2010
▪ Stronger community and civil society participation in health services
AB-HWCs Ayushman Bharat- Health & Wellness Centres; AB-PMJAY Ayushman Bharat- Pradhan Mantri Jan Arogya Yojana; ASHA Accredited Social Health Activist; HR Human resources; HWC-HSC Health & Wellness Centres- Health Sub-Centers; HWC-PHC Health & Wellness Centres- Primary Health Care; ICT Information and communication technology; NHM National Health Mission; NMC Act The National Medical Commission Act; OOPE Out of pocket expenditure; PHC Primary Health care; VHNSC Village health, nutrition and sanitation committee