AAM, AYUSH in Public Health

When someone wants to know in general about a wellness center, he/she gets to know that ‘A wellness center is a place that offers health services for both mind & body. Till 2018, these were therapeutic centers that provided only treatment’.

The Ayushman Bharat Health Wellness Center (ABHWCC) were launched under the AB programs in a bid to move away from selective health care to a more comprehensive range of services that includes preventive, promotive, curative, rehabilitative & palliative care for all ages. National Health Policy, 2017 saw these as the foundation of India’s health system.

The indicators related to Reproductive & Child Health (RCH) & communicable diseases improved with the efforts of National Health Mission but the range of services delivered at the primary care level did not take into account the increasing disease burden & rising costs of care on account of chronic diseases [1,2,3].

Ayushman Bharat (AB) launched by the National Health Policy (NHP), 2017 was to achieve Universal Health Care (UHC). AB has two interrelated components. These are given below.

1. Establishment of Health & Wellness Centres.
2. Pradhan Mantri Jan Arogya Yojana (PMJAY).

In February 2018, Government of India (GoI) announced the creation of 1,50,000 HWCs by transforming the existing Sub Centers (SC) & Primary Health Center (PHC) as the base pillar of AB. The centers are expected to deliver Comprehensive Primary Health Care (CPHC) bringing health care closer to homes of people covering both Maternal & Child Health (MCH) services & Non-Communicable Diseases (NCD) including free essential drugs & diagnostic services [1,2,3]. In the state of Uttara Khand, across the 13 districts & 95 development blocks, there are 1847 centers that will act as HWCs. Out of this 1847, 1439 are the Sub Centers currently and 408 are PHCs [1,2,3]. PMJAY, the second component of AB provides financial protection for secondary & tertiary care to about 40% of India’s House Holds (HH) [1,2,3]. In the HWCs, ‘time of care’ is proposed to be no more than 30 minutes. HWCs provide seamless continuum of care that ensures principles of equity, universality & no financial hardship in health services [1,2,3].

Team structures at the HWCs

Sub Health Center (SHC)- Health & Wellness Center team. At the SC level, Multi-Purpose Worker (MPW) Male and MPW Female, Accredited Social Health Activists (ASHAs), Mid-Level Health Providers (MLHP) will be the team members. In addition, all the Additional Primary Health Centers (APHC) of the state will be converted to AWCs. A PHC that is linked to a cluster of HWCs would serve as the first point of referral for many of disease conditions for the HWCs [1,2,3].

PHC/UPHC-HWC team

At the PHC level, the Medical Officer (MO) at PHC will be in the team. The state will adhere to the number & qualification of the MOs as per the Indian Public Health Standards (IPHS) [1,2,3].

The HWCs will follow 13 (Thirteen) key principles. These are mentioned below.

1. Expanded services
2. Expanded range of services
3. Expanded service delivery
4. Population enumeration
5. Empanelment of families at the HWC.
6. Organization of services/ delivery of services at three levels- family/household & community, at the HWCs, referral sites/facilities
7. Service delivery framework
8. Maternal & Child Health
9. Address Communicable Diseases (CD) & Non-Communicable Diseases (NCD)
10. Service for elderly & palliative care
11. Free Essential Medicines (EM)
12. Diagnostic Services & Tele Consultations
13. Health promotion including wellness activities like Yoga.

The expansions of services are planned and will be given in an incremental way. In the beginning, screening, prevention, control and management of Non-Communicable Diseases (NCDs), Chronic Communicable Diseases (CD) like Tuberculosis & Leprosy has been introduced [1,2,3]. The centers will follow operational guidelines for Ear, Nose & Throat (ENT) care at Health & Wellness Center (HWC). These centers will also adhere to operational guidelines for mental, neurological & substance use disorders care. The operational guidelines for Jan Arogya Samiti & operational guidelines for primary eye care will also be followed [1,2,3].

National Programs at AB-HWC

The following list gives the names of the national programs that are to be implemented at the HWCs [1,2,3].

1. National Program for Control of Blindness & Visual Impairment (NPCBVI)
2. National Program for Prevention & Control of Cardio Vascular accidents, Diabetes, Cancer & Stroke (NPCDCS)
3. Mission Indradhanush (MI)
4. Janani Suraksha Yojana (JSY)
5. National Tobacco Control Program (NTCP)
6. Janani Shishu Suraksha Karyakram (JSSK)
7. Rashtriya Bal Swasthya Karyakram (RBSK)
8. Rashtriya Kishor Swasthya Karyakram (RKSK)
9. National Program for the Health Care of the Elderly (NPHCE)
10. National Rabies Control Program (NRCP)
11. National Viral Hepatitis Control Program (NVHCP)
12. Pradhan Mantri National Dialysis Program (PMNDP)
13. Non-Communicable & Communicable Diseases (CD & NSD)
14. National Viral Hepatitis Surveillance Program (NVHSP)
15. Filing a Complaint Against a Registered Medical Practtioner
16. Uttara Khand state specific health programs
17. Digital portal for crowd funding & voluntary donations for patients of rare disease
18. Women Health (WH)
19. Facts for Life (FL)
20. Use of Ayurveda, Yoga, Unani, Siddha & Homoeopathy (AYUSH) systems of medicine.

The figure below gives a snap shot of all the components of HWCs [1,2,3].

Figure

More Updates 

Currently,India’s five-year-old Ayushman Bharat-Health and Wellness Centres (AB-HWCs) program has 1.60 lakhs centres and registered a footfall of over 178.87 crore by June 23 end. Currently, the AB-HWCs are undergoing expansion of services [5].

Services that are added include screening, prevention, control & management of non-communicable diseases, care for common ophthalmic & ENT problems, basic oral health care, elderly and palliative health care services, emergency medical services, and screening and management of mental health ailments [5]. “The expansion programme is underway, and the aim is to cover all the centres by next month-end,” a senior official said, adding that the expansion plan has been worked upon since 2020[5]. Additionally, to complement the expanded services, the essential list of medicines and diagnostics has been expanded to make available 171 medicines at Primary Health Care-Health and Wellness Centres (HWCs) and 105 at Secondary Health Care-HWC and 63 diagnostics at PHC-HWC and 14 at SHC-HWC [5].

A new cadre of Community Health Officers, 1.29 lakh in position, has been introduced at the level of SHC-HWC to act as clinicians as well as public health managers and to lead the team of Accredited Social Health Activists (ASHA), Anganwadi Workers (AWW) and Auxiliary Nurse Midwifes (ANM) [5].

The AB-HWC team is continuously motivated through team-based incentives for the team and performance-linked incentives for CHOs. The official added that the facilities are being encouraged to undergo the National Quality Assurance Standards (NQAS) assessment and certification with a target to realize 50% of the public health facilities being certified by 2026. AB-HWCs, started in 2018, is aimed at bringing in promotive, preventive, curative, palliative and rehabilitative aspects of Universal Health Coverage. “The goal is to provide Comprehensive Primary Health Care (CPHC), including both maternal and child health services and non-communicable diseases as well as free essential drugs and diagnostic services through AB-HWCs closer to the homes of people,’’ the official explained. “The idea is that through these centres, we go beyond the management of illnesses. Comprehensive primary health care and wellness package activities at AB-HWC include yoga, zumba, meditation, counselling for healthy diet and lifestyle, marathons, cyclothons, celebration of annual health days etc. As on June 30, more than 2.16 crores wellness sessions have been conducted with participation of 23.83 crores individuals,’’ the official said. As per Central government records, more than 122.02 crore cumulative screenings for non-communicable diseases have been conducted. This includes 41.81 crore for hypertension, 36.16 crore for diabetes, 24.75 crore for oral cancer, 11.44 crore for breast cancer and 7.83 crore for cervical cancer.

HWCs in India- a Look Back 

The concept of Health & Wellness Centres (HWC) got into focus of discussion in the months of July to December 2023 in India. A task force was formed to focus on Primary Health Care in 205-16. Subsequently in 2017, the third National Health Policy (NHP) mentioned the budget for HWCs. In 2018, the Ayushman Bharat Health & Wellness Centres (ABHWC) were included in the budget. The first HWC started in Jangla, Bijapur in the state of Chhatisgrah in 14th April 2018. By 31st March 2019, HWCs had spread across the country. Further, it was decided in 2019-2020 that Urban Primary Health Centres (UPHC) are to be converted to HWCs. The target to set up 150,000 HWCs across India was conceptualized on 31.12.2002. Currently, the HWCs have been renamed as Ayushman Arogya Mandir (AAM) since November 2023.

Studies on HWCs   

A study to analyze the costs of HWCS in 2022 cited that the average total cost per Primary Health Centre (PHC) was ₹ 11,714,113. The cost per catchment population of $ 4.72 per PHC. The incremental cost per OPD visit for the HWC initiative was found to be quite economical. The study also founded that the Sub Centres (SC) converted HWCs are economical to run. The Primary Health Centres converted HWCs was found to be costly to run followed by Community Urban Primary Health Centres converted facilities. The study also elicited the Human Resources (HR) continued to take up the major share of the total expenditures on HWCs. The drug data indicated that communicable diseases still dominated the demand for medicines. Another study informs that the HWC initiative strengthens the lowest rung of the preexisting system & envisages addressing the changing health priorities but the vulnerabilities & weakness of the older system were likely to persist & threatens its success unless specifically addressed with strong commitment at the top management of the public health system. An Odisha state-based study showed that infrastructure, HR & 12 service packages of health care & drugs should be addressed on a priority basis to achieve desired goals as envisaged by Ayushman Bharat to achieve the full potential of the HWCS. A study puts emphasis on the fact that the future public health system should be stringent enough to ensure that health care services are not provided randomly. Further it cites that the existing system should be resilient enough & making the dream of the Universal Health Coverage to be true in the nation.

A step in UHC & AYUSH- A conclusion

The national Ayush Morbidity & Standardized Terminologies Electronic (NAMASTE) portal was launched on 17th October 2017. It was inaugurated with the inauguration of All India Institute of Ayurveda in Delhi. In January 2023, the Traditional Medicines (TM) have been classified as per the International Classification of Diseases (ICD) criteria by more than 25 World Health Organization (WHO) member countries.

The NAMASTE portal developed by ministry of AYUSH provides information about standardized terminologies & morbidity codes along with dedicated data entry module for updating morbidity statistics in consolidated form as well as on real time basis. It lends a promise to bring in equity with the mainstream health care system. As mentioned, the terminologies are for Ayurveda, Unani & Siddha systems of medicines only. It is significant to note that Homoeopathy is already aligned with the modern system in terms of terminologies. Hence, it will be prudent to mainstream homoeopathy at the sub-center level that are converted to HWCs. The economical property of HWCs at sub-centers has been discussed above already.

Declaration of the lead author

Prof. Shankar Das, a co-author of the current article was the Ph.D. guide of the lead author at Tata Institute of Social Sciences, Mumbai. Prof. D.P. Singh was the teacher of the lead author at TISS, Mumbai during 1995-1997. The lead author also certifies that he has expressed his personal opinion based upon his public health and clinical experiences.

Acknowledgement

The lead author thanks Dr. Umakant, Dr. Pramod, Dr. Jeevan, Dr. Dixit & Dr. Pandey for their inputs in the Homoeopathic section and all the other co-authors for their inputs in the non-Homoeopathic section. 

Financial support and sponsorship

Nil

Conflict of interest

Nil