W&M ScholarWorks Undergraduate Honors Theses Theses, Dissertations, & Master Projects 5-2020 Assessing the Implementation of India’s New Health Reform Program, Ayushman Bharat, in Two Southern States: Kerala and Tamil Nadu Kalyani Pillai College of William & Mary Follow this and additional works at: https://scholarworks.wm.edu/honorstheses Part of the Public Health Commons Recommended Citation Pillai, Kalyani, "Assessing the Implementation of India’s New Health Reform Program, Ayushman Bharat, in Two Southern States: Kerala and Tamil Nadu" (2020). Undergraduate Honors Theses. Paper 1523. https://scholarworks.wm.edu/honorstheses/1523 This Honors Thesis is brought to you for free and open access by the Theses, Dissertations, & Master Projects at W&M ScholarWorks. It has been accepted for inclusion in Undergraduate Honors Theses by an authorized administrator of W&M ScholarWorks. For more information, please contact [email protected]. Implementation of India’s Health Reform Program Assessing the Implementation of India’s New Health Reform Program, Ayushman Bharat, in Two Southern States: Kerala and Tamil Nadu Kalyani Pillai College of William & Mary Undergraduate Honors Thesis May 7, 2020 Implementation of India’s Health Reform Program Acknowledgements First and foremost, I would like to express my deepest gratitude to my honors advisor, Dr. Iyabo Obasanjo, for the invaluable guidance, support and direction that has led to the successful completion of this research project. In addition, I would also like to thank my committee members, Dr. Elyas Bakhtiari and Dr. Alison Scott for their encouragement and advice during the span of this study. I would also like to express my heartfelt appreciation for all the participants in Kerala and Tamil Nadu who spared their invaluable time to share their knowledge and experiences. Finally, I would like to sincerely thank my parents, family and friends for their unwavering support and confidence in me. Implementation of India’s Health Reform Program 2 Table of Contents List of Figures and Tables………………………………………………………………………..3 List of Abbreviations………………………………………………………………………….….4 Overview……………………………………………………………………………………….…7 Chapter 1: Introduction…………………………………………………………………………..10 Chapter 2: Ayushman Bharat Initiative……………………………………………………….…13 Chapter 3: Introduction to Kerala…………………………………………………………..…....22 Chapter 4: Introduction to Tamil Nadu…………………………………………………………..31 Chapter 5: Geographical Maps and Data Tables.……………………………………….……….41 Chapter 6: Methods……………………...……………………………………………………….47 Chapter 7: Results………………………………………………………………………………..50 Chapter 8: Discussion……………………………………………………………………………68 Chapter 9: Conclusion……………………………………………………………………………76 References………………………………………………………………………………………..81 Appendix A………………………………………………………………………………………89 Appendix B………………………………………………………………………………………90 Appendix C………………………………………………………………………………………91 Appendix D……………………………………………………………………………………..127 Implementation of India’s Health Reform Program 3 List of Figures and Tables Figure A- Map of India………………………………………………………………………….41 Figure B- Map of South India…………………………………………………………………...42 Figure C- Map of Kerala………………………………………………………………………...43 Figure D- Map of Tamil Nadu…………………………………………………………………..44 Table 1- Socio-Economic Indicators…………………………………………………………….45 Table 2- Percentage of Total Population in Rural Areas Using Public Health Sector…………..45 Table 3- Health Indicators……………………………………………………………………….46 Implementation of India’s Health Reform Program 4 List of Abbreviations AB-PMJAY Ayushman Bharat- Pradhan Mantri Jan Aarogya Yojana AIADMK All India Anna Dravida Munnetra Kazhagam APL Above Poverty Line BJP Bharatiya Janata Party BPL Below Poverty Line CDR Crude Death Rate CGHS Central Government Health Scheme CHC Community Health Center CHIS Comprehensive Health Insurance Scheme CMCHIS Chief Minister’s Comprehensive Health Insurance Scheme DMK Dravida Munnetra Kazhagam DNB Diplomate of National Board DNO Districts Nodal Officer FHC Family Health Center GDP Gross Domestic Product HDI Human Development Index HWC Health and Wellness Center IMR Infant Mortality Rate INR Indian Rupees KASP Karunya Arogya Suraksha Paddhati KBF Karunya Benevolent Fund KKT Kalaignar Kappeetu Thittam Implementation of India’s Health Reform Program 5 LG Local Government LSG Local State Government MD Doctor of Medicine MMR Maternal Mortality Rat MoHFW Ministry of Health and Family Welfare MoU Memorandum of Understanding NABH National Accreditation Board for Hospitals & Healthcare Providers NCD Non-Communicable Diseases NHA National Health Authority NITI National Institute for Transforming India NSSO National Sample Survey Organization OECD Organization for Economic Co-operation and Development OOP Out-Of-Pocket OOPE Out-Of-Pocket Expenditure PHC Primary Health Center PMJAY Pradhan Mantri Jan Aarogya Yojana RSBY Rashtriya Swasthya Bima Yojana SC Scheduled Castes SECC Socio-Economic Caste Census SES Socio-Economic Status SHA State Health Agency ST Scheduled Tribes TNHSP Tamil Nadu Health Systems Project Implementation of India’s Health Reform Program 6 TNMSC Tamil Nadu Medical Services Corporation UN United Nations UNICEF United Nation’s International Children Emergency Fund USD United States Dollar WHO World Health Organization Implementation of India’s Health Reform Program 7 Overview India is the most populous country in South Asia, having the largest rural population in the world. According to data published by the World Bank in 2019, roughly 22% of the population (273 million individuals) live in poverty. The country also has an exceedingly low percentage of its GDP spent on health care at 1.28%. The purpose of this research is to evaluate the implementation of a health reform program instituted by the government of India to improve financial access to healthcare for the population living in poverty. Each chapter’s content is explained as follows. Chapter 1 explains the historical development of India’s health care system while detailing the roles of the public and private sector. It highlights the challenges the system faces and introduces previous health care policies that the Government of India has had. Chapter 2 introduces the Ayushman Bharat Initiative, India’s new health insurance reform scheme which includes two sections: Pradhan Mantri Jan Aarogya Yojana (AB-PMJAY) and Health and Wellness Centers (HWCs). The various aspects of the program including background, eligibility criteria, coverage, implementation methods and financing are provided. Chapter 3 is an introduction to Kerala, the southern-most state of India. This section describes the state’s health indicators, health care performance, past health care initiatives and financing of its health care system. The chapter then moves on to detailing Kerala’s implementation of AB-PMJAY and the adaptations the state chose to make in rolling out the program. In Chapter 4, Tamil Nadu is introduced through a historical background while explaining the state’s prior health care policies, effectiveness of its health care delivery systems and state implementation of AB-PMJAY. Chapter 5 moves on to the methods providing information on patient recruitment and data collection followed by tables that illustrate the socio-economic and health indicators of both states. The purpose of the study was to investigate the implementation process of Ayushman Implementation of India’s Health Reform Program 8 Bharat, specifically the AB-PMJAY portion of the program, and its effectiveness in the two southern states of India: Kerala and Tamil Nadu through the opinions of health care professionals working in the two respective states. These two states were chosen because of having similar demographics, success in rolling out prior state health care programs and an overall progressiveness in health care delivery and indicators compared to many other Indian states. While AB-PMJAY is expected to have discernable positive effects in states that are not as advanced as Kerala and Tamil Nadu, this research study attempts to understand the implementation in such progressive states as a way to explore problems that implementation will encounter in less developed states in India where the program will serve to improve India’s health indicators by providing health access to millions of people in poverty. To gain better understanding of the scheme’s implementation and roll out, the viewpoints of individuals working in the health care field who engaged with AB-PMJAY on a day-to-day basis were gathered using qualitative semi-structured interviews. The conceptual framework for this research project is that the World Health Organization is encouraging governments to implement Universal Health Coverage (UHC) and this is the first step of the Government of India’s effort in moving towards universal health coverage and the implementation strategies the country is undertaking to attain that goal. Within this framework, the study examines the accessibility, availability, and affordability of health care to the people of India by researching the roll out of AB-PMJAY in Kerala and Tamil Nadu. The results of the study highlighted the opinions of the participants, including personal experiences with the program, advantages and disadvantages of the individual state implementations of AB-PMJAY. The discussion provides an analysis of all the findings while a final conclusion presents an overall summary of AB-PMJAY implementation successes and drawbacks in Kerala and Tamil Nadu. The conclusion ends with Implementation of India’s Health Reform