LitCovid-sentences  

PMC:7340764 / 1989-42713 JSONTXT 12 Projects

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Id Subject Object Predicate Lexical cue
T12 0-12 Sentence denotes Introduction
T13 13-233 Sentence denotes The primary health care system in India has evolved since independence and there is an elaborate network of nearly 200,000 Government Primary Health Care Facilities (GPHCFs), both in rural and urban areas (Box 1) [1–30].
T14 234-379 Sentence denotes The existing GPHCFs deliver a narrow range of services, due to variety of reasons including, at times, the non-availability of providers as well.
T15 380-600 Sentence denotes Thus, the GPHCFs in India are grossly underutilized & excluding for the mother and child health services, in 2013-14, only 11.5% of rural and 3.9% in urban people in need of health services used this vast network [1, 2].
T16 601-902 Sentence denotes People in India either choose higher level of government facilities for primary health care (PHC) needs (which results in an issue of subsidiarity) or attend a private provider (which results in the out of pocket expenditure or OOPE), both situations are not good for a well-functioning health system.
T17 903-989 Sentence denotes The challenge of weak PHC in India are increasingly being recognized and acknowledged.
T18 990-1269 Sentence denotes The National Health Policy (NHP) 2017 of India proposed to strengthen PHC systems, invest two-third or more government health spending on PHC, with an increase in overall government funding for health to 2.5% of Gross Domestic Product (GDP) by 2025, against 1.18% in 2015–16 [3].
T19 1270-1683 Sentence denotes Following on the NHP 2017, the Government in India announced Ayushman Bharat Program (ABP) in February 2018 with two components of (a) Health and Wellness Centres (HWCs) to strengthen & deliver comprehensive Primary Health Care (cPHC) services for entire population and (b) Pradhan Mantri Jan Arogya Yojana (PMJAY) for secondary and tertiary level hospitalization services for bottom 40% of families in India [4].
T20 1684-1829 Sentence denotes The details of ABP in the context of Universal Health Coverage (UHC) has been published earlier [1] and a schematic of ABP is provided as Fig. 1.
T21 1830-1970 Sentence denotes These two arms, hence onwards, in this article, have also been referred as AB-HWCs and AB-PMJAY, to indicate that both are component of ABP.
T22 1971-2027 Sentence denotes Box 1 Evolution of Government PHC system in India [1–30]
T23 2028-2135 Sentence denotes Primary Health Care (PHC) has always been considered a foundation of stronger and efficient health systems.
T24 2136-2345 Sentence denotes The efforts to strengthen health services, based upon stronger PHC in India started when the ‘Health Survey and Development Committee’ was established in 1943 under the chairpersonship of Sir Joseph Bhore [5].
T25 2346-2562 Sentence denotes India started setting up primary health centres (PHCs) in 1952, when the first few PHCs were established in Najafgarh (Delhi), Singur (West Bengal) and Poonammalle (Tamilnadu) under Community Development Program [6].
T26 2563-2679 Sentence denotes This was part of establishing a three-tier healthcare system in the country, which has evolved since then [2, 7, 8].
T27 2680-2910 Sentence denotes India started efforts to build health system around the same time when National Health Services (NHS) in United Kingdom was set up and the constitution of World Health Organization (WHO) came into force, both in year 1948 [9, 10].
T28 2911-3104 Sentence denotes The successive governments continued to expand the network of PHCs, which received a major boost through various committees, set up nearly one to three in every decade for first 4 decades [11].
T29 3105-3204 Sentence denotes The efforts to strengthen PHC system in rural India have been made over the years [1, 3, 4, 12–20].
T30 3205-3310 Sentence denotes With these initiatives, by mid Sept 2019, country had an extensive network of 158,417 Health Sub Centres:
T31 3311-3472 Sentence denotes 25,743 Primary Health Centres in rural areas; 5,624 Urban PHCs; 764 district hospitals; 539 medical colleges and hospitals and 1,741 mobile medical units [7, 8].
T32 3473-3598 Sentence denotes The annual admission capacity in medical colleges was 80,000 for graduate medical seats and 41,000 for post graduate courses.
T33 3599-3814 Sentence denotes The efforts to strengthen PHC network in India apparently received a boost after Alma Ata conference on primary health care in 1978 and then with the release of India’s first National Health Policy in 1983 [14, 21].
T34 3815-4043 Sentence denotes A major initiative to further strengthen & make rural PHC system functional, started in April 2005, with the launch of National Rural Health Mission (NRHM) in India [22] soon after the second national health policy in 2002 [23].
T35 4044-4127 Sentence denotes The urban component as National Urban Health Mission was launched in May 2013 [24].
T36 4128-4217 Sentence denotes Two missions together were, thereafter, renamed as National Health Mission (NHM) [22–24].
T37 4218-4313 Sentence denotes The NRHM/NHM has focused on PHC system strengthening to make it functional to deliver services.
T38 4314-4738 Sentence denotes NRHM/NHM had a few strategies to strengthen health systems and PHC services: decentralized health planning; communization (community processes, behavior change communication and addressing social determinants of health); social protection function of public health services; partnership for NGOs and civil society; human resource strengthening; flexible funding for states, public health management and many others [22, 25].
T39 4739-4957 Sentence denotes The NRHM/NHM in India is attributed to improving several services, though mostly Reproductive Maternal, Newborn, Child and Adolescent Health (RMNCH+A) services through Government Primary Health Care Facilities (GPHCF).
T40 4958-5206 Sentence denotes The reduction in Infant Mortality Rate (IMR) and Maternal Mortality Ratio (MMR), which these programs specifically targeted, were reduced at accelerated manner and India reached very close to achieve Millennium Development Goals (MDG) 4 and 5 [26].
T41 5207-5436 Sentence denotes Yet, it was increasingly being recognized that health services for emerging burden of diseases and changing epidemiological profile, i.e., Non-communicable diseases (NCDs) through GPHCFs were either not available or insufficient.
T42 5437-5503 Sentence denotes The need for a new approach to deliver comprehensive PHC was felt.
T43 5504-5616 Sentence denotes It was also the time when various discourses on Universal Health Coverage (UHC) were happening in India [27–29].
T44 5617-5827 Sentence denotes The ongoing & identified challenges of GPHCFs include a narrow range of services, insufficient infrastructure, shortage of healthcare providers; lack of medicines and diagnostics, and limited referral services.
T45 5828-5965 Sentence denotes These challenges have been documented in various review missions and also captured in situation analysis document of NHP 2017 [1, 3, 30].
T46 5966-6018 Sentence denotes Fig. 1 Ayushman Bharat Program in India: a schematic
T47 6019-6272 Sentence denotes This review article describes the concepts, provides an update on implementation of two components of ABP; documents & critically analyzes initiatives under AB-HWC in context of delivery of comprehensive PHC (cPHC) service & proposes a few ways-forward.
T48 6273-6487 Sentence denotes Early reflections on how challenges posed by and initial learnings from the response to Corona virus (SARS-CoV-2) disease or COVID-19 pandemic could be used for scale-up of HWCs in India, have also been summarized.
T49 6489-6568 Sentence denotes Health & Wellness Centres (HWCs) and Comprehensive Primary Health Care in India
T50 6569-6712 Sentence denotes 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].
T51 6713-6779 Sentence denotes The key events related to HWCs in India are summarized in Table 1.
T52 6780-6913 Sentence denotes As part of HWC components of ABP, the govt of India announced to make existing 150,000 GPHCFs in country functional by December 2022.
T53 6914-7106 Sentence denotes 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).
T54 7107-7317 Sentence denotes 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].
T55 7318-7394 Sentence denotes Table 1 Evolution of Health & Wellness Centres (HWCs) in India [1, 3, 4, 30]
T56 7395-7425 Sentence denotes Timeline Specific developments
T57 7426-7514 Sentence denotes July- Dec 2013 Initial discussion on Health and Wellness Centres (HWCs) in India started
T58 7515-7635 Sentence denotes 2015–16 Task Force on Primary Healthcare in India recommended formation of HWCs, with initial suggestions on the design.
T59 7636-7698 Sentence denotes 2017 India’s third National Health Policy (NHP 2017) released.
T60 7699-7753 Sentence denotes Union Budget announcement for setting up HWCs in India
T61 7754-7872 Sentence denotes 2018 HWC became one of the two pillars under Ayushman Bharat (AB) program announced in Union Budget on 1 February 2018
T62 7873-7963 Sentence denotes 14 April 2018 Inauguration of India’s first AB-HWC at Jangla, Bijapur, Chhattisgarh, India
T63 7964-8033 Sentence denotes 31 March 2019 A total of 17,149 AB-HWCs made functional across India.
T64 8034-8174 Sentence denotes This includes 8,801 Primary Health Centres; 6,795 Health Sub-centres (HSC) and 1,553 Urban Primary Health Centres (UPHCs) converted to HWCs.
T65 8175-8282 Sentence denotes 2019–20 25,000 additional AB-HWCs to be set up with all UPHC to be converted to HWCs in the financial year.
T66 8283-8334 Sentence denotes A total of 38,595 HWCs were set up by 31 March 2020
T67 8335-8415 Sentence denotes 31 December 2022 Indian states to have 150,000 functional AB-HWCs in the country
T68 8416-8475 Sentence denotes Fig. 2 Key components and design aspects of AB-HWCs [1, 31]
T69 8476-8524 Sentence denotes Fig. 3 Service provision through AB-HWCs [1, 31]
T70 8525-8641 Sentence denotes 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].
T71 8642-8704 Sentence denotes Cumulative target of 40,000 HWCs was set up for 31 March 2020.
T72 8705-8842 Sentence denotes 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.
T73 8843-8960 Sentence denotes 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.
T74 8961-9041 Sentence denotes Alongside, all UPHC across India were to be converted to HWCs by March 2020 [1].
T75 9042-9215 Sentence denotes 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.
T76 9216-9482 Sentence denotes 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].
T77 9483-9608 Sentence denotes The second component of AB-PMJAY was launched on 23 Sept 2018 and progress on this component is summarised in Box 2 [32, 33].
T78 9609-9720 Sentence denotes Box 2 Progress under Pradhan Mantri Jan Arogya Yojana (PMJAY) component of Ayushman Bharat in India [1, 32, 33]
T79 9721-9795 Sentence denotes Ayushman Bharat Program, from the time of announcement has two components.
T80 9796-9895 Sentence denotes Other than Ayushman Bharat- Health and Wellness Centres (AB-HWC), AB-PMJAY is the second component.
T81 9896-9997 Sentence denotes It has built upon the erstwhile Rashtriya Swasthya Bima Yojana (RSBY), started in year 2008 in India.
T82 9998-10109 Sentence denotes Even since announcement of ABP, the scheme has witnessed a few evolutions in name before settling for AB-PMJAY.
T83 10110-10370 Sentence denotes 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.
T84 10371-10539 Sentence denotes 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.
T85 10540-10621 Sentence denotes AB-PMJAY provides health cover of up to INR 500,000 (Exchange rate in April 2020:
T86 10622-10636 Sentence denotes 1 USD= approx.
T87 10637-10796 Sentence denotes 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.
T88 10797-10910 Sentence denotes One thousand three hundred ninety three procedures in 24 specialties were part of the scheme, as on October 2019.
T89 10911-11026 Sentence denotes There is no cap on family size, age or gender, cashless and paperless treatment for beneficiaries at point of care.
T90 11027-11095 Sentence denotes Benefits are portable across the country in the empaneled hospitals.
T91 11096-11346 Sentence denotes 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.
T92 11347-11443 Sentence denotes On completion of 100 d of launch on 2 January 2019; National Health Authority or NHA was formed.
T93 11444-11560 Sentence denotes 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.
T94 11561-11611 Sentence denotes One hundred and three million e-cards were issued.
T95 11612-11827 Sentence denotes 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.
T96 11828-12014 Sentence denotes 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.
T97 12015-12217 Sentence denotes 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)].
T98 12218-12288 Sentence denotes This is not first such initiative to strengthen PHC services in India.
T99 12289-12456 Sentence denotes 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].
T100 12457-12634 Sentence denotes 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.
T101 12635-12752 Sentence denotes Table 2 Challenges in PHC system, provisions through AB-HWCs and complementarity with NHM in India [1, 3, 27, 28, 31]
T102 12753-12922 Sentence denotes Health System Function Challenges in PHC system (Indicative) AB-HWC and related initiatives Ongoing and other proposed initiatives (including NHM & other state specific)
T103 12923-13052 Sentence denotes Service provision and delivery ▪ Narrow range of six services (mostly focused on Maternal & child health and infectious diseases)
T104 13053-13081 Sentence denotes ▪ Curative care predominance
T105 13082-13253 Sentence denotes ▪ ‘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)
T106 13254-13390 Sentence denotes ▪ Attention on preventive and promotive health services; focus on wellness and lifestyle modification, specifically for chronic diseases
T107 13391-13540 Sentence denotes ▪ Integration with Indian systems of medicine, AYUSH, including the promotion of Yoga as form of lifestyle change to tackle non-communicable diseases
T108 13541-13615 Sentence denotes ▪ Population based screening for common conditions including three cancers
T109 13616-13730 Sentence denotes ▪ Attention on quality and patient safety; Develop standard treatment flows (STF) for peripheral health facilities
T110 13731-13791 Sentence denotes ▪ Extending prescription rights to CHO through legal process
T111 13792-13963 Sentence denotes ▪ Adopt ‘Resolve more & refer less’ approach at peripheral health facilities; strengthening of referral system to ensure continuity of care; Telemedicine and consultations
T112 13964-14146 Sentence denotes ▪ 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.
T113 14147-14217 Sentence denotes ▪ State specific models of service delivery to provide cross learnings
T114 14218-14296 Sentence denotes ▪ Build on systems for emergency referral and transport; established under NHM
T115 14297-14399 Sentence denotes ▪ Utilise strengthening of secondary care services & District hospitals for effective referral linkage
T116 14400-14484 Sentence denotes ▪ Build upon quality standards and mechanism for ensuring use of treatment protocols
T117 14485-14617 Sentence denotes ▪ Community Health Officers (CHO) proposed in the National Medical Commission (NMC) Act to strengthen public health service delivery
T118 14618-14701 Sentence denotes Human resources and infrastructure ▪ Shortage of infrastructure and human resources
T119 14702-14728 Sentence denotes ▪ Inequitable distribution
T120 14729-14847 Sentence denotes ▪ Health Sub-centres (HSCs) led by one or two Auxiliary nurse midwife (ANM) who has focus on Mother and child services
T121 14848-15038 Sentence denotes ▪ 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
T122 15039-15108 Sentence denotes ▪ Institutional strengthening for increased annual production of MLHP
T123 15109-15199 Sentence denotes ▪ Task shifting to different cadre of healthcare providers and team-based service delivery
T124 15200-15282 Sentence denotes ▪ Proposal to change the roles of ANMs as multi-purpose workers (female) or MPW- F
T125 15283-15463 Sentence denotes ▪ 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
T126 15464-15595 Sentence denotes ▪ Shift from doctor centric facilities to a team-based service delivery where provision of providers is dependent upon service need
T127 15596-15700 Sentence denotes ▪ AYUSH providers to be mainstreamed in PHC systems ▪ Recruitment of contractual providers in the system
T128 15701-15774 Sentence denotes ▪ Flexibility to states in salary for HR, under NHM to ensure recruitment
T129 15775-15829 Sentence denotes ▪ Institutionalize the mechanisms for training of MLHP
T130 15830-15958 Sentence denotes ▪ Consider an All India cadre of specialist doctors to tackle shortage of specialist doctors & that of public health specialists
T131 15959-16033 Sentence denotes ▪ Innovation in human resources including incentives to recruit and retain
T132 16034-16089 Sentence denotes Health financing ▪ Limited government funding on health
T133 16090-16149 Sentence denotes ▪ High OOPE to the range of 60% of total health expenditure
T134 16150-16194 Sentence denotes ▪ Budget mostly line item-based funding only
T135 16195-16241 Sentence denotes ▪ Limited use of strategic purchasing services
T136 16242-16405 Sentence denotes ▪ People get poor because of health expenditures ▪ Reforms on provider payment mechanisms including the introduction of performance-linked incentives in PHC system
T137 16406-16525 Sentence denotes ▪ Mechanisms to reduce cost of health seeking through assured provision of more medicines and point of care diagnostics
T138 16526-16606 Sentence denotes ▪ Performance-linked payments to the MLHP and to the team of front-line workers.
T139 16607-16921 Sentence denotes ▪ 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
T140 16922-16971 Sentence denotes ▪ Capacity building of states in health financing
T141 16972-17107 Sentence denotes Medicines and vaccines ▪ Many states started free medicines and diagnostics scheme, yet govt spending as share on cost of medicines low
T142 17108-17204 Sentence denotes ▪ Medicines and access to diagnostics mostly at higher level facilities and no assured provision
T143 17205-17242 Sentence denotes ▪ Medicines major cost paid by people
T144 17243-17340 Sentence denotes ▪ Irrational use of medicines ▪ Revision and expansion of essential medicines & diagnostics lists
T145 17341-17450 Sentence denotes ▪ Assured provision of larger basket of medicines with inclusion of additional medicines for chronic diseases
T146 17451-17520 Sentence denotes ▪ Assured dispensing of medicines for longer duration of 4 wk or more
T147 17521-17590 Sentence denotes ▪ Attention on expanded range of diagnostic services of Point of Care
T148 17591-17692 Sentence denotes ▪ Proposal for rapid expansion of Pradhan Mantri Jan Aushadhi stores for low cost & generic medicines
T149 17693-17766 Sentence denotes ▪ Proposal for setting up state level procurement and supply corporations
T150 17767-17990 Sentence denotes ▪ 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
T151 17991-18105 Sentence denotes ▪ Strengthening of Mission Indradhanush for increasing coverage with vaccines under Universal Immunization Program
T152 18106-18211 Sentence denotes ▪ Launch of state specific free medicines and free diagnostics schemes with enhanced budgetary allocation
T153 18212-18271 Sentence denotes Health information systems ▪ Weak health information system
T154 18272-18302 Sentence denotes ▪ Limited use of ICT platforms
T155 18303-18467 Sentence denotes ▪ 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
T156 18468-18539 Sentence denotes ▪ Attention on registration of beneficiaries at associated HWC facility
T157 18540-18604 Sentence denotes ▪ Increased use of mobile based technology and hand-held devices
T158 18605-18666 Sentence denotes ▪ Provision of tele-health and tele-medicine at each facility
T159 18667-19007 Sentence denotes ▪ 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
T160 19008-19065 Sentence denotes ▪ Health Management Information System (HMIS) established
T161 19066-19109 Sentence denotes Governance and leadership ▪ Weak regulation
T162 19110-19160 Sentence denotes ▪ Limited transition of policy into implementation
T163 19161-19205 Sentence denotes ▪ Health state subject and variable priority
T164 19206-19382 Sentence denotes ▪ 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
T165 19383-19468 Sentence denotes ▪ System and coordination mechanism being proposed to link PHC services with AB-PMJAY
T166 19469-19540 Sentence denotes ▪ National Knowledge Platform for implementation & operational research
T167 19541-19578 Sentence denotes ▪ Revisions of operational guidelines
T168 19579-19629 Sentence denotes ▪ Enhanced community-based monitoring for AB-HWCs.
T169 19630-19675 Sentence denotes ▪ Regular reviews on progress and performance
T170 19676-19942 Sentence denotes ▪ 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.
T171 19943-20009 Sentence denotes ▪ The Clinical Establishment Registration and Regulation Act, 2010
T172 20010-20081 Sentence denotes ▪ Stronger community and civil society participation in health services
T173 20082-20598 Sentence denotes 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
T174 20600-20646 Sentence denotes Making Health & Wellness Centres of India Work
T175 20647-20734 Sentence denotes HWCs aim to build upon what has been started under NRHM/ National Health Mission (NHM).
T176 20735-20930 Sentence denotes However, considering even in the past, the similar attempt to strengthen PHC services have met partial success, more is needed to ensure that AB-HWCs does better than the initiatives in the past.
T177 20931-21077 Sentence denotes Therefore, it will be important that learnings from past are used and challenges identified, and focused attention is given to effective scale up.
T178 21078-21115 Sentence denotes A few approaches could be as follows:
T179 21116-21239 Sentence denotes First, give sufficient attention, visibility and priority to AB-HWCs as vehicle to strengthen primary health care services.
T180 21240-21423 Sentence denotes Of the two components in ABP, the HWCs seem to be getting comparatively less attention, in spite of being recognized that cPHC can take care of up to 80% of health needs [30, 38, 39].
T181 21424-21510 Sentence denotes AB-HWCs is also a more difficult component to implement than insurance-based AB-PMJAY.
T182 21511-21619 Sentence denotes Getting less public and political attention may appear a minor issue but may result in lower prioritization.
T183 21620-21736 Sentence denotes There is a need to bring attention back on AB-HWCs and make these politically visible through advocacy and evidence.
T184 21737-21927 Sentence denotes There is role for technical experts, professional associations and civil society representatives in ensuring that cPHC is not lost in the noise for more secondary and tertiary care services.
T185 21928-22030 Sentence denotes People also need to demand for better primary healthcare services from their elective representatives.
T186 22031-22124 Sentence denotes Second, develop a detailed ‘primary health care investment plan’ for India and Indian states.
T187 22125-22188 Sentence denotes The policy announcements are often equated with political will.
T188 22189-22339 Sentence denotes The real test of the ‘political will’ is whether policy announcements have been followed by commensurate, sufficient & sustained financial allocation.
T189 22340-22437 Sentence denotes In 2015–16, around 45% of total government spending on health was allocated to PHC services [40].
T190 22438-22661 Sentence denotes Though National Health Policy (NHP) 2017 has proposed to increase government funding for PHC and health services, the reality is that government funding for health in India has increased only marginally in last two decades.
T191 22662-22845 Sentence denotes Similarly, the state government spending on health, proposed to be increased to 8% of state budget has remained at 5% of state budget since 2001–02 and increased very marginally [41].
T192 22846-22981 Sentence denotes There is a need for more and active public attention and prioritization to increase govt funding for health in India and Indian states.
T193 22982-23161 Sentence denotes The initial allocation to AB-HWCs in union budget while may be sufficient in the beginning; however, with each passing year the recurrent expenditure for each HWC would be needed.
T194 23162-23289 Sentence denotes This requires a detailed ‘primary healthcare investment plan’, preceded by, a detailed cost analysis for PHC services in India.
T195 23290-23502 Sentence denotes In addition, there is a need for capital expenditure for setting up additional GPHCFs to address the shortage of facilities and meeting the health care needs of growing population, especially in urban areas [42].
T196 23503-23642 Sentence denotes Third, the service availability through AB-HWCs need to be continuously upgraded and made locally adapted to meet 80% or more health needs.
T197 23643-23791 Sentence denotes In most of the HWCs set up till now, one additional package of services [the seventh package of non-communicable diseases (NCDs)] has been included.
T198 23792-23846 Sentence denotes However, 5 more packages need to be added and assured.
T199 23847-23988 Sentence denotes In efforts to achieve the number-based targets for AB-HWCs, for every financial year, focus should not be lost from already established HWCs.
T200 23989-24212 Sentence denotes The provision of services through these facilities, the utilization by public, assured availability of providers and functioning as per guidelines need to be ensured through continuous oversight, monitoring and innovations.
T201 24213-24436 Sentence denotes Another approach could be that all the eligible GPHCFs in single geographical area, a block or tehsil, need to be made functional simultaneously to increase utilization and change the perception about government facilities.
T202 24437-24569 Sentence denotes Fourth, focus on demand generation for health services through mechanisms such as community participation and social accountability.
T203 24570-24850 Sentence denotes Getting the facilities functional or strengthening supply side through HWCs (or other similar state specific initiatives) is important; however, it is unlikely to generate utilization; specifically when the previous encounter of people with these facilities has not been pleasant.
T204 24851-24919 Sentence denotes Simply an upgrade of government health facility might not be enough.
T205 24920-25038 Sentence denotes People need to come to the health system and experience the change, which will contribute to further demand genration.
T206 25039-25124 Sentence denotes The supply side strengthening through PHC needs to be augmented by demand generation.
T207 25125-25325 Sentence denotes This can be achieved with increased and active community involvement; accountability and involving local body representatives and civil society organizations in the process, from the very early stage.
T208 25326-25554 Sentence denotes In backdrop of recent policy dialogues and approaches adopted for Swachh Bharat Mission (clean Indian mission) and the approach to behavioral economics of nudge need to be examined for suitable adoption in health sector [43–45].
T209 25555-25656 Sentence denotes Fifth, the entire process should be guided by use of evidence to scale up interventions and services.
T210 25657-26070 Sentence denotes A recently published study reported a few common characteristics of better functioning government facilities in India, which included (a) an assured package health services with ‘limited intention to availability gap’; (b) Appropriate mix & sufficient availability of providers; (c) continuum of care with functional referral linkages; (d) initiatives to achieve quality standard; & (e) community engagement [46].
T211 26071-26159 Sentence denotes There is similar evidence from countries such as Brazil; Ghana and South Africa [47–49].
T212 26160-26456 Sentence denotes Mohalla Clinics of Delhi and Basthi Dawakhana of Telangana, are empirical evidence that people start attending the government facilities if the facilities are made functional and the services are available in an assured manner, people prefer PHC over complicated and overpowering large hospitals.
T213 26457-26602 Sentence denotes These initiatives have become popular amongst people and brought poor, marginalized, women and children to government health care system [50–52].
T214 26603-26716 Sentence denotes Sixth, ‘continuum of care’ through coordination between two arms of ABP will contribute to effective utilization.
T215 26717-26897 Sentence denotes Establishing a functioning referral linkage between HWCs/PHCs and from secondary and tertiary care services including AB-PMJAY should be focus for policy design and implementation.
T216 26898-27087 Sentence denotes A good coordination between AB-PMJAY and AB-HWCs is not only imperative for streamlining access to care but will be pivotal in providing timely and quality care to the target beneficiaries.
T217 27088-27373 Sentence denotes A few indicative approaches for ‘continuity of care’ could be: one, common process for registration of patients at AB-HWCs as well as for AB-PMJAY, through common health identifier with community linkage and registration; two, awareness generation for beneficiaries at grassroot level.
T218 27374-27551 Sentence denotes Three, the training curriculum of Accredited Social Health Activist (ASHA) and other field workers should include a module on AB-HWCs and services and provisions under AB-PMJAY.
T219 27552-27853 Sentence denotes For a forward referral, AB-HWC can become source of information for AB-PMJAY beneficiaries; fourth, develop effective and two-way referral and inclusion of some outpatient components in AB-PMJAY benefit package and fifth, AB-PMJAY and AB-HWCs to analyse disease and population health risks and trends.
T220 27854-28048 Sentence denotes The service delivery approach should be beyond referral and the PHC systems need to facilitate the care seeking by proactively seeking appointments for patient going to next level of facilities.
T221 28049-28217 Sentence denotes Once the treatment plan is prepared at next level of facility, the referral back to PHC level should also be ensured for continuity of treatment and required follow up.
T222 28218-28331 Sentence denotes This could prove extremely essential and important in context of NCD (including diabetes, hypertension) services.
T223 28332-28430 Sentence denotes Seventh, AB-HWCs also need to have dedicated focus on population-based and public health services.
T224 28431-28512 Sentence denotes It is not a PHC service, if focus is on curative services at facility level only.
T225 28513-28611 Sentence denotes A well-functioning PHC system needs to cater to those who are not attending the health facilities.
T226 28612-28746 Sentence denotes People in communities with undiagnosed health conditions need to be identified and brought to treatment, is also part of PHC services.
T227 28747-28841 Sentence denotes Establishing All India Public Health management Cadre could be one complementary step [3, 53].
T228 28842-28984 Sentence denotes A few more suggestions on how to make AB-HWCs more effective and better functional are provided in articles published earlier [1, 30, 45, 46].
T229 28986-28996 Sentence denotes Discussion
T230 28997-29093 Sentence denotes AB-HWC could, arguably, be termed as the second wave of PHC reforms in India after NRHM in 2005.
T231 29094-29206 Sentence denotes There is a higher likelihood of success of this initiative than all the earlier initiative, due to many factors.
T232 29207-29349 Sentence denotes The most important being that AB-HWCs start on an advantage of already strengthened and existing PHC system through NHM between 2005 and 2018.
T233 29350-29595 Sentence denotes The other factors being the ongoing attention on advancing UHC; states showing increasing and more than ever interest in improving PHC services through their own mechanism and increasing civil society participation and engagement in health [45].
T234 29596-29720 Sentence denotes The AB-HWCs could be considered a national initiative to harmonize PHC service delivery on a common platform for all states.
T235 29721-29826 Sentence denotes This is a major approach in federal system, where health is a state subject as per constitution of India.
T236 29827-30055 Sentence denotes In the recent years, a number of Indian states have started initiatives to strengthen PHC services, which should provide learnings for AB-HWC and potential harmonization between state initiatives and HWCs (Box 3) [50–52, 54–58].
T237 30056-30166 Sentence denotes Clearly, for success, the Indian states have to take leadership in designing their own additional initiatives.
T238 30167-30288 Sentence denotes Even when implementing AB-HWCs, innovative context specific approaches and adaptations for local setting would be needed.
T239 30289-30367 Sentence denotes Box 3 PHC strengthening initiatives by Indian states since 2015 [50–52, 54–58]
T240 30368-30405 Sentence denotes ▪ Mohalla Clinics, Delhi [50–52, 54]:
T241 30406-30535 Sentence denotes India’s first large scale state government led community clinics initiative in urban settings was launched in July 2015 in Delhi.
T242 30536-30750 Sentence denotes These clinics, one each for every 10,000 population, are two to three room facilities with provision of primary care services including consultation by doctor with provision of nurse or pharmacist and an attendant.
T243 30751-30910 Sentence denotes In addition to out-patient consultation services, there is provision of nearly 212 diagnostics tests and 108 medicines available free of cost at these clinics.
T244 30911-31027 Sentence denotes Soon after launch, these clinics had become immensely popular amongst target beneficiaries and political leadership.
T245 31028-31120 Sentence denotes As on March 2020, there were 480 clinics functioning with plan to set up 1,000 such clinics.
T246 31121-31157 Sentence denotes ▪ Basthi Dawakhana in Telangana[51]:
T247 31158-31241 Sentence denotes Basthi Dawakhana are arguably India’s first urban local body led community clinics.
T248 31242-31385 Sentence denotes These have been openly claimed to be replication of Mohalla Clinics of Delhi and started by the Greater Hyderabad Municipal Corporation (GHMC).
T249 31386-31443 Sentence denotes First few Basthi Dawakhana were launched on 6 April 2018.
T250 31444-31549 Sentence denotes By end of November 2019, there were 115 such clinics with plan to open additional 132 in Telangana state.
T251 31550-31818 Sentence denotes These clinics have been set up in close collaboration with state Govt of Telangana, Greater Hyderabad Municipal Corporation (the Urban local bodies); Mission for Poverty Elimination in Municipal Areas (MEPMA) and the union government led National Urban Health Mission.
T252 31819-32021 Sentence denotes There is an improvisation on Mohalla Clinics of Delhi by provision of more services such as public health, preventive and promotive, more integrated referral system and provision of specialist services.
T253 32022-32066 Sentence denotes ▪ Family Health Centres, Kerala, India [55]:
T254 32067-32265 Sentence denotes Government of Kerala in mid-2017 started to upgrade and transform all primary health centres in states as part of Mission Aardram program and renamed these facilities as Family Health Centres (FHC).
T255 32266-32455 Sentence denotes These facilities focus on upgrading the infrastructure, and provision of more doctors and staff, in closer collaboration with rural elected governments (Panchayati raj Institution) members.
T256 32456-32624 Sentence denotes There is attention of preventive and promotive health services and by mid of 2018, of nearly 700 PHC in state, nearly 170 were upgraded to Family Health Centres (FHCs).
T257 32625-32837 Sentence denotes The initial response to initiative has been very positive and utilization to most facilities has nearly doubled with wider community-based services and participation elected representatives and community members.
T258 32838-32912 Sentence denotes Such facilities are also being considered as future of rural PHC in India.
T259 32913-32971 Sentence denotes ▪ Community Clinics in other Indian states [50–52, 56–58]:
T260 32972-33136 Sentence denotes Inspired by Mohalla Clinics of Delhi, at least a dozen Indian states or Municipal Corporations have either set up or announced similar facilities in their settings.
T261 33137-33221 Sentence denotes First such clinics were started in Pune by the Municipal Corporation in August 2016.
T262 33222-33452 Sentence denotes Since then Appla Clinics in Mumbai, Maharashtra (June 2019) and Atal Clinics in Jharkhand (August 2019) have been started, though, the numbers of most such new clinics is in range of 10–50 with promise for more similar facilities.
T263 33453-33558 Sentence denotes States such as Punjab, Karnataka and Chhattisgarh governments have also planned to start similar clinics.
T264 33559-33702 Sentence denotes Most recent addition to this list are the ‘Sanjivani Clinics’ of Madhya Pradesh, & Janata Clinics of Rajasthan, both launched in December 2019.
T265 33703-34003 Sentence denotes In early February 2020, Govt of Andhra Pradesh had announced ‘Village Clinics’ for every 2,000 population in rural parts of state, which appear another promising approach to deliver PHC services in rural areas. However, success of each of these will be dependent upon how well these are implemented. 
T266 34004-34255 Sentence denotes As part of accountability and governance, the union government initiative such as ranking of states on health, and the proposed ranking of district hospitals should be further expanded to rank the states/districts on their performance on PHC [59, 60].
T267 34256-34370 Sentence denotes As a next step, responsibility for such ranking can be assigned to an independent & non-governmental organization.
T268 34371-34517 Sentence denotes The annual report on state of primary health care in India can be started, on the line of Annual Status of Education Reports (ASER) in India [61].
T269 34518-34624 Sentence denotes These could be built upon NITI Aayog’s state health index and proposed district hospital ranking [59, 60].
T270 34625-34881 Sentence denotes As India plans to strengthen cPHC, the learnings and initiatives from NRHM/NHM can facilitate the strengthening of AB-HWCs (and the harmonized and integrated NHM and ABP convergence) can help India to make rapid progress towards UHC as analyzed in Table 2.
T271 34882-35006 Sentence denotes The ongoing attention on health by various approaches should be optimally used to place health higher on development agenda.
T272 35007-35476 Sentence denotes These opportunities includes the reforms in medical education through the NMC Act, 2019 [34]; dialogue and discourse on the Right to Health [62] which has become stronger following three Indian states considering enactment of a legislation; the recommendation from health subcommittee of 15th Finance commission [62, 63] and the renewed global focus on UHC and PHC, as reflected in Astana 2018 and United Nations High Level Meeting (UNHLM) on UHC in Sept 2019 [17, 18].
T273 35477-35566 Sentence denotes This brings in an important question of when can AB-HWC be considered a success in India?
T274 35567-35686 Sentence denotes To answer this question, the performance of PHC system in India needs to be measured based upon health system outcomes.
T275 35687-35845 Sentence denotes There would be a need of explicit attention, engagement and linkage to deliver interventions to tackle Social Determinants of Health (SDH) through PHC system.
T276 35846-36070 Sentence denotes World over, including in India, while inputs to health systems are measured regualrly, the goals on improved health (outcomes  and equity), responsiveness, efficiency, and financial protection are not monitored sufficiently.
T277 36071-36190 Sentence denotes It is expected that this challenge would partially be resolved through initiative of the global UHC monitoring reports.
T278 36191-36331 Sentence denotes The progress and success of AB-HWCs should also need to be measured against some of the objectives of health systems and functions (Fig. 4).
T279 36332-36525 Sentence denotes AB-HWCs will be credited with the real and lasting fixing of the primary health care system in India, if people start using services at the upgraded facilities, for broad range of health needs.
T280 36526-36639 Sentence denotes A few more approaches and ideas for effective roll-out of AB-HWCs are provided in Appendix 2 [34, 35, 62, 64–68].
T281 36640-36715 Sentence denotes Fig. 4 AB-HWCs and potential to impact various components of health systems
T282 36716-36810 Sentence denotes In early 2020, novel Corona virus (SARS-CoV2) disease or COVID-19 pandemic hit the world [69].
T283 36811-36922 Sentence denotes Across the countries, hundreds of thousand people got affected and many thousands died due to the disease [70].
T284 36923-37202 Sentence denotes Experience from countries, affected at the start of pandemic indicated that the asymptomatic patients visiting hospitals for non-COVID-19 health reasons partly contributed in spread of infections to many other people- attending the same facility- for some other health condition.
T285 37203-37468 Sentence denotes Learning from these experiences, in India, from the start of cases being reported, except for the large hospitals, most of the private facilities were either partially functioning or out patient departments were completely closed, at least for short period of time.
T286 37469-37664 Sentence denotes There were reports of gross shortage of even essential health services for non-COVID-19 patients, which were mostly provided through government primary health care facilities and smaller clinics.
T287 37665-37815 Sentence denotes COVID-19 pandemic has underscored the relevance of stronger primary health care and is a proof that the world needs better health systems than it has.
T288 37816-38112 Sentence denotes The weak health systems and primary health care facilities are in those countries, where the burden of diseases are already high and the epidemics and pandemic can further devastate those settings, as had been experienced during the Ebola epidemic in three African countries around 2014 [71, 72].
T289 38113-38275 Sentence denotes In late March 2020, COVID-19 pandemic resulted in the government of India to release the guidelines to legalize prescription through telephonic consultation [73].
T290 38276-38350 Sentence denotes The home delivery of medicines were allowed during COVID-19 pandemic [74].
T291 38351-38475 Sentence denotes These initiatives may be continued through AB-HWCs and have potential to change the PHC service delivery in the years ahead.
T292 38476-38673 Sentence denotes COVID-19 has indicated that ensuring healthier population in the time ahead would need approaches such as mass education on hand washing, cough etiquettes, personal hygiene and physical distancing.
T293 38674-38737 Sentence denotes The mental health issues are a major health challenge in India.
T294 38738-38811 Sentence denotes However, there are not enough mental health services in the country [75].
T295 38812-38962 Sentence denotes COVID-19 is expected to exacerbate the psychosocial and mental health issues and the provision of such services should be prioritized through AB-HWCs.
T296 38963-39163 Sentence denotes COVID-19 challenge should be used as an opportunity to deliver broader public health messages and services and PHC system is expected to be the most appropriate as well as the cost-effective approach.
T297 39164-39495 Sentence denotes Alongside, while designing health services, the specific focus needs to be retained on how to make primary health care, in specific, and the health systems, in general, ready and resilient for epidemics, pandemics and natural calamities, which keep affecting, one or other part of the country (and the world), on regular intervals.
T298 39497-39508 Sentence denotes Conclusions
T299 39509-39646 Sentence denotes There is a global consensus that universal health coverage can only be achieved on the foundation of stronger primary health care system.
T300 39647-39796 Sentence denotes There is a renewed attention on strengthening and delivering comprehensive primary health care services in India through health and wellness centres.
T301 39797-40435 Sentence denotes While the AB-HWCs aims to address the existing challenges in PHC system, the effectiveness and success will be dependent upon a rapid transition from policy to implementation stage; focus on both supply and demand side interventions, engagement of community and civil society and other stakeholders, focus on effective and functional referral linkages; ongoing learnings, innovations and mid-course corrections, effective linkage and coordination between two components of Ayushman Bharat program, additional & complementary initiatives by Indian states, sustained political will & monitoring and evaluation of the process, amongst other.
T302 40436-40545 Sentence denotes COVID-19 pandemic has further underscored the need for strengthening the primary health care at the earliest.
T303 40546-40724 Sentence denotes The experience from India can have lessons and learnings for other low and middle-income countries to strengthen primary health care in journey towards universal health coverage.