17.4 Health Care Delivery System, Ayushman Bharat & National Health Mission

17.4 Health Care Delivery System, Ayushman Bharat & National Health Mission

A structured health care delivery system is the backbone of public health administration. For the UPSC CMS examination, candidates must possess in-depth knowledge of India's rural health infrastructure norms (IPHS 2022), frontline healthcare workforce responsibilities, major National Health Mission (NHM) flagship schemes, Ayushman Bharat PM-JAY implementation, and key historical health committee recommendations.

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1. Structure of Rural Health Infrastructure in India

India's rural health care system is organized into a three-tiered structure based on population norms, specified under the Indian Public Health Standards (IPHS):

1. Primary Level Care: Sub-Centres / Ayushman Arogya Mandirs & Primary Health Centres (PHCs)
2. Secondary Level Care: Community Health Centres (CHCs) & Sub-District Hospitals
3. Tertiary Level Care: District Hospitals, Medical Colleges, and Apex Institutes (e.g., AIIMS)

First Referral Unit (FRU)

A Community Health Centre, Sub-District Hospital, or District Hospital is designated as an FRU only if it provides all three of the following mandatory critical services 24x7:

1. Emergency Obstetric Care (including surgical capabilities for Caesarean section).
2. 24-hour Blood Storage / Banking Facility.
3. Newborn and Child Care Unit (Sick Newborn Care Unit - SNCU / Newborn Stabilization Unit - NBSU).

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2. Grassroots Health Personnel

A. Accredited Social Health Activist (ASHA)

• Population Coverage: 1 per 1,000 population in rural plain areas (1 per village/habitation in hilly/tribal areas).
• Selection Criteria: Female resident of the village, married/widowed/divorced, aged 25 to 45 years, educated up to 10th standard (formal education requirement relaxed if no suitable candidate is available).
• Status: An honorary volunteer who receives performance-based financial incentives (not a salaried regular employee) under NHM programs (e.g., incentive for institutional delivery under JSY, complete child immunization, TB DOTS notification, toilet construction).
• Core Functions: Health activist, mobilization for Village Health Sanitation and Nutrition Days (VHSND), distributing ORS, zinc, condoms, oral contraceptive pills, pregnancy test kits (Nischay kits), tracking pregnant women and newborns.

B. Anganwadi Worker (AWW)

• Operating under the Integrated Child Development Services (ICDS) scheme (Ministry of Women and Child Development).
• Population Coverage: 1 per 400 to 800 population (1 Anganwadi Centre per 400-800 population; 1 mini-Anganwadi per 150-400 in difficult areas).
• Core Services Provided:
  1. Supplementary Nutrition (children 6 months to 6 years, pregnant & lactating mothers).
  2. Pre-school Non-formal Education (children 3 to 6 years).
  3. Nutrition and Health Education.
  4. Immunization monitoring & Referral services (in coordination with ANM).
  5. Growth monitoring (using WHO Growth Charts - plotting weight for age).

C. Auxiliary Nurse Midwife (ANM) / Female Health Worker

• Posted at Sub-Centres and PHCs. Salaried healthcare worker.
• Functions as the vital field vaccinator, manages pregnant women registration (Mother and Child Tracking System - MCTS / Anmol), conducts normal deliveries, inserts IUCDs, and supervises ASHAs.

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3. National Health Mission (NHM) & Flagship Initiatives

The National Health Mission (NHM) encompasses two sub-missions: the National Rural Health Mission (NRHM) launched in 2005 and the National Urban Health Mission (NUHM) launched in 2013. Its core framework revolves around the RMNCH+A (Reproductive, Maternal, Newborn, Child Health + Adolescent Health) strategy.

Key Flagship Initiatives under NHM

1. Janani Suraksha Yojana (JSY)

• Objective: Safe motherhood intervention promoting institutional delivery among poor pregnant women to reduce Maternal Mortality Ratio (MMR) and Infant Mortality Rate (IMR).
• Strategy: Conditional Cash Transfer scheme modifying the earlier National Maternity Benefit Scheme (NMBS).
• Categorization of States:
  • Low Performing States (LPS): States with low institutional delivery rates (UP, MP, Bihar, Jharkhand, Odisha, Rajasthan, CG, UK, Assam, J&K). All pregnant women delivering in government/empaneled private hospitals receive cash assistance regardless of age, parity, or caste.
  • High Performing States (HPS): Other states. Cash assistance restricted to BPL/SC/ST pregnant women.
• Financial Assistance Norms (Rural LPS): ₹1,400 to the mother and ₹600 to the ASHA (Total package ₹2,000 per delivery).

2. Janani Shishu Suraksha Karyakram (JSSK)

• Launched in June 2011 to eliminate out-of-pocket expenditure for pregnant women and sick infants.
• Entitlements for Pregnant Women:
  • Completely free and cashless delivery (including C-section).
  • Free drugs and consumables.
  • Free diagnostics (blood, urine tests, ultrasonography).
  • Free diet during stay in health institution (up to 3 days for normal delivery, 7 days for C-section).
  • Free transport from home to health facility, inter-facility transfer, and drop back home.
  • Exemption from all user charges.
• Entitlements for Sick Newborns & Infants (up to 1 year): Completely free treatment, drugs, diagnostics, blood, and transport.

3. Rashtriya Bal Swasthya Karyakram (RBSK)

• Comprehensive child health screening and early intervention service for children from 0 to 18 years (covering newborns, Anganwadi children, and government school students).
• Target: Screening for 4 "Ds":
  1. Defects at birth (e.g., Congenital heart disease, Cleft lip/palate, Clubfoot, Neural tube defects).
  2. Diseases of childhood (e.g., Dental caries, Otitis media, Rheumatic heart disease, Reactive airway disease).
  3. Deficiencies (e.g., Severe anemia, Vitamin A/D deficiency, Severe Acute Malnutrition - SAM).
  4. Developmental delays including Disability (e.g., Vision impairment, Hearing impairment, Cerebral palsy, Autism spectrum disorder).

4. Mission Indradhanush & Intensive Mission Indradhanush (IMI)

• Launched to achieve >90% full immunization coverage for children up to 2 years and pregnant women across high-focus districts. Covers 12 vaccine-preventable diseases under Universal Immunization Programme (UIP).

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4. Ayushman Bharat Scheme

Launched on 23rd September 2018 (Ranchi, Jharkhand), Ayushman Bharat is India's flagship national health initiative designed to achieve Universal Health Coverage (UHC). It rests on Two Interconnected Pillars:

Pillar 1: Ayushman Arogya Mandirs (AAM) / Health & Wellness Centres (HWCs)

• Transformation of 1,50,000 Sub-Centres and PHCs into Ayushman Arogya Mandirs across India.
• Shift from selective primary care to Comprehensive Primary Health Care (CPHC).
• Expands services to include: Screening and management of Non-Communicable Diseases (Hypertension, Diabetes, Oral, Breast, and Cervical Cancers), Mental health care, Ophthalmic & ENT care, Elderly care, Palliative care, and Tele-consultation (e-Sanjeevani portal).
• Led by: Community Health Officers (CHOs) posted at AAM-Sub-Centres.

Pillar 2: Pradhan Mantri Jan Arogya Yojana (AB-PMJAY)

• World's largest government-funded health assurance scheme.
• Financial Cover: Provides a health cover of ₹5,000,000 (₹5 Lakh) per family per year for secondary and tertiary care hospitalization.
• Target Beneficiaries: Covers over 12 crore poor and vulnerable families (approx. 55 crore individual beneficiaries), selected based on the Deprivation and Occupational criteria of the Socio-Economic Caste Census 2011 (SECC 2011) and expanded vulnerable age categories (e.g., senior citizens aged 70+ added in 2024).
• Key Operating Principles:
  • No restriction on family size, age, or gender (no cap on family members).
  • Pre-existing diseases/conditions are covered from Day 1 of empanelment.
  • Cashless and Paperless access at empaneled public and private hospitals across the country.
  • Pre-hospitalization expenses covered for up to 3 days, and post-hospitalization expenses for up to 15 days (including drugs and diagnostics).

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5. Historical Health Committees in India

Understanding the recommendations of historical committees is a frequent source of questions in UPSC CMS: