In February 2017, Government of India had announced its plans to upgrade some of the existing primary healthcare facilities into Health and Wellness Centres (HWCs). However, the pace of implementation has been very slow. In this article, Dr Lahariya contends that the recently announced Ayushman Bharat, which includes a component on HWCs, can provide a much-needed impetus to this initiative – if certain concrete steps are taken.
In February 2017, in the Union Budget 2017-18, Government of India promised to upgrade 150,000 existing health facilities such as Health Sub-Centres (HSCs) and Primary Health Centres (PHCs) into Health and Wellness Centres1 (HWCs) in the country. This was closely followed by the release of India’s new National Health Policy (NHP) in March 2017, which aimed to switch from “selective to comprehensive primary healthcare” and proposed that “…facilities which start providing the larger package of comprehensive primary health care will be called “Health and Wellness Centers”.
These two announcements were indeed good news for India’s health sector. Considering that HSCs (proposed for every 5,000 rural population in India) are the first contact facility between people/community and the government health system, the move was widely welcomed. While there is a vast network of HSCs and PHCs across the country, their functioning is variable and often sub-optimal. The vast network of primary healthcare provides only around 10% of the total out-patient (OPD) services in India.
The announcement of HWCs received wide coverage and attention. However, promises are an integral part of Indian polity; the challenge is implementation. A year later, when the Union Budget 2018-19 was presented to Indian Parliament in February this year; work was in progress to establish 4,000 HWCs. At that speed it will take several years to reach the target of 150,000 HWCs.
Now, an opportunity seems to have emerged with the announcement of the ‘Ayushman Bharat’2 programme in the latest Union Budget, which has a component on HWCs. For 2018-19, a slightly more ambitious target of 11,000 HWCs has been set. Ayushman Bharat and combined with Prime Minister Modi’s call for ‘New India by 2022’ can provide an impetus for a time-bound transition to HWCs with proper oversight. A few concrete steps and measures should be taken in this context:
Conduct detailed costing exercise, agree on roadmap, and allocate commensurate financial resources
The Ministry of Health and Family Welfare (MoHFW) has estimated that an initial funding of Rs. 1,700,000 (Rs. 1,000,000 as capital cost to upgrade infrastructure, and Rs. 700,000 as recurrent expenditure) would be needed to convert to and establish each HWC. For establishing the proposed 150,000 HWCs, a capital expenditure of Rs. 15,000 crore would be needed. As per rural health statistics of India, 2017, there is shortfall of primary healthcare facilities. This mandates setting up around 50,000 additional facilities similar to HWCs. Setting up new HWCs (unlike converting existing facilities) require higher capital investment of Rs. 5,000,000 per facility and 50,000 new HWCs would need Rs. 25,000 crore of capital costs. Hence, a total capital investment of around Rs. 40,000 crore would be needed over a defined period of time. Clearly, a detailed costing exercise with timelines should be done, with a breakdown by states. Every subsequent Union Budget should have commensurate allocation to make HWCs functional, followed by linked allocation in budgets of Indian states as well.
Aggressive scale-up and not incremental approach
An incremental approach to set up these HWCs (about 4,000 in the first year and a few thousand extra each passing year) is unlikely to deliver expected outcomes. The country has suffered because of a laidback approach and slow paced implementation as the momentum and motivation is lost. To achieve 200,000 HWCs in five years, 40,000 HWCs need to be established every year. While it could be a phased approach for country as a whole, a few states and Union Territories such as Sikkim, Puducherry, or Himachal Pradesh can plan to have their full target of HWCs attained in a shorter period of a year or two only. Large states such as Uttar Pradesh and Bihar may need to be supported proactively in the process.
Sometimes health systems need to be pushed to boundaries
In India, for long, new vaccines were not introduced in the universal immunisation programme (UIP) as health systems were not considered to be ready. However, experience of the last decade has clearly indicated that the process of strengthening health systems is accelerated when we trust in people engaged in the task. The introduction of new vaccines was utilised as an opportunity to strengthen the system, and it succeeded. Additional vaccines were introduced and coverage of the existing ones was rapidly increased in parallel.
Give attention to urban primary healthcare as well
While rural India has health sub-centres of different levels of functionality, the urban areas has very limited infrastructure for primary healthcare. For urban population, the first contact between people and the government health system is usually the urban primary health centre – one for a population of 50,000, which is 10 times of population catered by HSCs in rural areas. The NHP, 2017 partially recognises this challenge and proposes that “…government would collaborate with the private sector for operationalizing such health and wellness centres to provide a larger package of comprehensive primary health care across the country.” Thus, to strengthen urban primary healthcare services, HWCs need to be established in urban areas.
Capital investment in urban areas
While the focus in rural areas would be on converting existing sub-health centres into HWCs, no such facilities exist in urban areas – a different approach is required. Urban areas would need more attention on capital investment to build a network of primary healthcare system as well. HWCs are a great opportunity in this context. At an estimated capital cost of Rs. 5,000,000 for 20,000 new HWCs3 in urban areas, additional total capital investment of Rs. 20,000 crore (10 times of the existing annual budget for National Urban Health Mission or NUHM) would be needed. Considering that urban health has its own challenges and the best way to tackle emerging burden of non-communicable diseases (NCDs) is primary healthcare, this should be prioritised4.
Establish autonomous authority/corporations to provide technical support for setting up HWCs
Establishing HWCs across the country is a mammoth task that would require huge government investment. This should be done well and efficiently. The existing government institutions including MoHFW and related institutions may not have sufficient capacity and time to support the process. It would be appropriate to dedicate 1-2% of total allocated budget for HWCs, to set up an autonomous corporation to implement the activities and ensure timeliness. This corporation could be managed by professional agency/management experts who would guide the process. Alternatively, in addition to a corporation at the national level to cater to Union Territories and select states, separate autonomous agencies/corporations could be set up in large states to facilitate and expedite the process. The state health system resource centres, functioning sub-optimally in many states, could be strengthened to support this process.
Information technology backbone, and other areas for intervention
The exercise of Setting up HWCs across the country has to be based upon a data backbone, to make timely and informed decisions. This opportunity of HWCs should be utilised to strengthen the data backbone through improving recording and reporting system. The engagement of medical colleges and monitoring the process of establishing HWCs on the lines of the approach adopted for Swachch Bharat Mission (SBM), could be other aspects.
In summary, India has seen many promising policy announcements and very few of those have been implemented fully. It is to be seen whether the proposal on HWCs is any different. The need for primary healthcare is increasingly being realised in the country at all levels. This decision to establish HWCs can introduce ‘gate-keeping’ to the health system, bring attention to preventive and promotive healthcare and public health services, and provides another chance to make health services people-centric and integrated. This is the right path to increase population coverage with additional health services and an appropriate strategy for the country to move towards universal health coverage, as aimed in NHP, 2017.
- HWCs would be created by upgrading existing HSCs and PHCs to provide a larger, comprehensive package of primary care services. In effect, HWCs would provide, in addition to existing services offered through HSCs, a package of services with focus on preventive, promotive, curative, and rehabilitative services. This would be facilitated by referral for consultation with specialists and follow- up.
- The Union Cabinet chaired by Prime Minister Modi approved the launch of a new Centrally Sponsored Ayushman Bharat - National Health Protection Mission (AB-NHPM) having central sector component under Ayushman Bharat Mission anchored in the Ministry of Health and Family Welfare. The scheme has the benefit cover of Rs. 500,000 per family per year. The target beneficiaries of the proposed scheme will be more than 100 million families belonging to poor and vulnerable population.
- This is a lower bound, to cater to 20 crore of urban population with one HWC for every 10,000 population. This is nearly half of the total urban population in India. Here, the assumption is to prioritise slums and the underserved population in the beginning.
- The current approach of one health facility for every 50,000 population is unlikely to work. It is well known that approximately 20-25% of total population above 30 years of age in India is in need of treatment for either hypertension or diabetes. Considering 40% of total population is comprised by this age group, there would be an estimated 4,000-5,000 people in need of care for NCDs. Therefore, if a facility is for 50,000 people, everyday there would 200 patients for NCDs alone. This model will not work. We need a health facility for a smaller group of population in urban areas.