Yojana Magazine September 2022 - 4 | Monthly Yojana & Kurukshetra Magazine (English) - UPSC PDF Download

 Page 1


YOJANA   September 2022 51
n the post-pandemic period, the age-old 
adage “prevention is better than cure,” is 
more applicable today than ever before. The 
Sustainable Development Goal (SDG-3) 
reiterates the importance of promotion and prevention by 
introducing the concept of ‘Good Health and Well-Being’ 
of individuals as a major plank of Community Health 
Processes. Universal Health Coverage (UHC), SDG target 
3.8, a strategic priority of the World Health Organization 
(WHO), builds on the same to provide blanket assurance 
of an end-to-end range of essential health services, from 
health promotion to prevention, treatment, rehabilitation, 
and palliative care, to people across all regions, age 
groups, social and income groups, by enabling access to 
health services they need.
1
 Let us appreciate the keyword 
here - ‘Access’. 
In spite of ‘Health’ being listed as a State Subject in 
the 7
th
 Schedule of the Indian Constitution, the Ministry 
of Health and Family Welfare (MoHFW) still invests 
a lot of resources in the State systems. It focuses on 
establishing a strong community-based healthcare system 
strengthening in the form of the erstwhile RCH-1 in 1997, 
and subsequently through the massive National Health 
Mission (NHM), which has led to the creation of a robust 
grass-root level cadre of health workers including the 
ASHAs (Accredited Social Health Activists), who were 
recently acclaimed internationally by the WHO for their 
outstanding contribution towards protecting and promoting 
health. As with other States in the country such as UT of 
J&K, NHM has supported approximately 13,500 ASHA 
Universal Health Coverage in J&K
Yasin M Choudhary
The author is an IAS, Mission Director, National Health Mission (NHM) and Ayushman Bharat Digital Mission (ABDM), Jammu & 
Kashmir UT. Email: mdnhmjk@gmail.com
The Ayushman Bharat-Health and Wellness Centre programme (AB-HWC) of NHM, which 
includes the establishment of Health and Wellness Centres (HWC) is the biggest intervention in 
strengthening primary-level healthcare in recent years, by moving from selective primary health 
care to Comprehensive Primary Health Care (CPHC) to achieve universal health coverage. The 
UT of J&K is among the forerunners in achieving its target of converting all the Sub-Centres 
(SCs) and Primary Health Centres (PHC) to HWCs. This is crucial in community engagement and 
improving the demand for health care services in the region. 
I
workers network, to connect the community with the 
health system for primary health care services, intending 
to give doorstep uninterrupted delivery of service to the 
community and bridging the ‘access’ gap. Adding to them is 
the equally expansive network of ANMs (Auxiliary Nurse 
Midwives) and other field health staff to support and have 
an all-encompassing coverage system. The response of the 
populace across the UT of J&K, towards community-based 
interventions, has been overall positive, which is evident 
by a look at the gargantuan mass of legacy data present in 
the Health Management Information System (HMIS) and  
coNtiNuum oF care
Page 2


YOJANA   September 2022 51
n the post-pandemic period, the age-old 
adage “prevention is better than cure,” is 
more applicable today than ever before. The 
Sustainable Development Goal (SDG-3) 
reiterates the importance of promotion and prevention by 
introducing the concept of ‘Good Health and Well-Being’ 
of individuals as a major plank of Community Health 
Processes. Universal Health Coverage (UHC), SDG target 
3.8, a strategic priority of the World Health Organization 
(WHO), builds on the same to provide blanket assurance 
of an end-to-end range of essential health services, from 
health promotion to prevention, treatment, rehabilitation, 
and palliative care, to people across all regions, age 
groups, social and income groups, by enabling access to 
health services they need.
1
 Let us appreciate the keyword 
here - ‘Access’. 
In spite of ‘Health’ being listed as a State Subject in 
the 7
th
 Schedule of the Indian Constitution, the Ministry 
of Health and Family Welfare (MoHFW) still invests 
a lot of resources in the State systems. It focuses on 
establishing a strong community-based healthcare system 
strengthening in the form of the erstwhile RCH-1 in 1997, 
and subsequently through the massive National Health 
Mission (NHM), which has led to the creation of a robust 
grass-root level cadre of health workers including the 
ASHAs (Accredited Social Health Activists), who were 
recently acclaimed internationally by the WHO for their 
outstanding contribution towards protecting and promoting 
health. As with other States in the country such as UT of 
J&K, NHM has supported approximately 13,500 ASHA 
Universal Health Coverage in J&K
Yasin M Choudhary
The author is an IAS, Mission Director, National Health Mission (NHM) and Ayushman Bharat Digital Mission (ABDM), Jammu & 
Kashmir UT. Email: mdnhmjk@gmail.com
The Ayushman Bharat-Health and Wellness Centre programme (AB-HWC) of NHM, which 
includes the establishment of Health and Wellness Centres (HWC) is the biggest intervention in 
strengthening primary-level healthcare in recent years, by moving from selective primary health 
care to Comprehensive Primary Health Care (CPHC) to achieve universal health coverage. The 
UT of J&K is among the forerunners in achieving its target of converting all the Sub-Centres 
(SCs) and Primary Health Centres (PHC) to HWCs. This is crucial in community engagement and 
improving the demand for health care services in the region. 
I
workers network, to connect the community with the 
health system for primary health care services, intending 
to give doorstep uninterrupted delivery of service to the 
community and bridging the ‘access’ gap. Adding to them is 
the equally expansive network of ANMs (Auxiliary Nurse 
Midwives) and other field health staff to support and have 
an all-encompassing coverage system. The response of the 
populace across the UT of J&K, towards community-based 
interventions, has been overall positive, which is evident 
by a look at the gargantuan mass of legacy data present in 
the Health Management Information System (HMIS) and  
coNtiNuum oF care 52 YOJANA   September 2022
RCH Portal. These portals have ensured sustained monitoring 
and evaluation of fieldwork, along with giving us an idea of 
the sheer volume of services that have been delivered till  
now and continues to be provided, which has, in turn,  
resulted in improved health outcomes for the UT of J&K and 
reduced Infant Mortality Rate to 17 and Neonatal Mortality 
Rate to 15, which are far below the national average.
2
 
Indicator (NFHS5) J&K (%) Overall 
India (%)
Mothers who had at least 4 
antenatal care visits 
80.9 58.1
Institutional births- 92.4 88.6
Births attended by skilled 
health personnel
95.1 89.4
Children aged 12-23 
months fully immunised 
86.2 76.4
Source: MoHFW
There is ample evidence across countries showing-
partnerships between community and health are needed 
to achieve and sustain positive health outcomes, which is 
apparent in the UT of J&K with the huge progress made 
in RCH.
3
Health facilities Required as per 
IPHS norms
In position 
RHS 2020
District Hospital 21
Community Health 
Centre
83 77 
Primary Health 
Centre-Rural
333 923
Primary Health 
Centre-Urban
80 49
Sub Health Centre 2042 2470
Medical Colleges 
and Hospitals
9
Source: MoHFW
The better part of the modern Indian healthcare policy 
structure has addressed healthcare access as a supply-side 
concern, particularly infrastructural. Hence, in some parts 
of the country such as J&K UT, there is a fair amount of 
public health infrastructure penetration, which is even over 
and above the IPHS norms.
4
 
AB-HWC of NHM, which includes the establishment 
of Health and Wellness Centres (HWC) has been a flagship 
programme of Government of India and is hands down 
the biggest intervention in strengthening primary level 
healthcare in recent years, by moving from selective 
primary health care to CPHC to achieve Universal Health 
Coverage.
4
 UT of J&K is among the forerunners in 
achieving its target of converting all the Sub-Centres (SCs) 
and Primary Health Centres (PHC) to HWCs.
5
HWC Operational Target Dec 
2022
Current status 
(HWC portal)
HWC- SHC 1770 1415
HWC-PHC 923 543
HWC-UPHC 49 44
Total 2742 2002
Source: MoHFW
At SHC-HWC, a new cadre of health workers, 
a Community Health Officer (CHO) or a Mid-Level 
Health Provider (MLHP), is being introduced which as 
the name suggests, was a novel creation for instituting 
a functionary between a paramedic and a full-scale 
medical officer, who would be able to do non-prescriptive 
population-based screenings for limited diseases, thereby 
improving community outreach, clinical management 
and Continuum of Care (CoC). AB-HWC has introduced 
the Population Enrollment and Community Based 
Assessment Checklist (CBAC) form which is possibly 
the most primal but concrete individualised health record 
till now. The UT has taken a step ahead and is working 
on digitising the Population Enrollment, CBAC form, 
screening, diagnosis and treatment provided at different 
levels of care into the NCD App and hence generating a 
mountain of data.
However, before we overload our societies with 
excessive ‘Supply’ side resources it is crucial that we 
analyse the ‘Demand’ angle. Sociological studies lay down 
the concept of the ‘Aspirational Level’ of individuals and 
communities in determining the trajectory of societal 
development evolution. An educated and well-informed 
community will be better aware of the living scenario that 
they need and would hence have a higher ‘aspiration’ to 
better health standards resulting in them engaging more 
successfully with the ‘supply’ side resources. On the 
other hand, a less aware community would have a lower 
‘aspirational’ level and hence won’t be able to access and 
consume the health care resources provided to them even if 
J&K Overall India figures
Page 3


YOJANA   September 2022 51
n the post-pandemic period, the age-old 
adage “prevention is better than cure,” is 
more applicable today than ever before. The 
Sustainable Development Goal (SDG-3) 
reiterates the importance of promotion and prevention by 
introducing the concept of ‘Good Health and Well-Being’ 
of individuals as a major plank of Community Health 
Processes. Universal Health Coverage (UHC), SDG target 
3.8, a strategic priority of the World Health Organization 
(WHO), builds on the same to provide blanket assurance 
of an end-to-end range of essential health services, from 
health promotion to prevention, treatment, rehabilitation, 
and palliative care, to people across all regions, age 
groups, social and income groups, by enabling access to 
health services they need.
1
 Let us appreciate the keyword 
here - ‘Access’. 
In spite of ‘Health’ being listed as a State Subject in 
the 7
th
 Schedule of the Indian Constitution, the Ministry 
of Health and Family Welfare (MoHFW) still invests 
a lot of resources in the State systems. It focuses on 
establishing a strong community-based healthcare system 
strengthening in the form of the erstwhile RCH-1 in 1997, 
and subsequently through the massive National Health 
Mission (NHM), which has led to the creation of a robust 
grass-root level cadre of health workers including the 
ASHAs (Accredited Social Health Activists), who were 
recently acclaimed internationally by the WHO for their 
outstanding contribution towards protecting and promoting 
health. As with other States in the country such as UT of 
J&K, NHM has supported approximately 13,500 ASHA 
Universal Health Coverage in J&K
Yasin M Choudhary
The author is an IAS, Mission Director, National Health Mission (NHM) and Ayushman Bharat Digital Mission (ABDM), Jammu & 
Kashmir UT. Email: mdnhmjk@gmail.com
The Ayushman Bharat-Health and Wellness Centre programme (AB-HWC) of NHM, which 
includes the establishment of Health and Wellness Centres (HWC) is the biggest intervention in 
strengthening primary-level healthcare in recent years, by moving from selective primary health 
care to Comprehensive Primary Health Care (CPHC) to achieve universal health coverage. The 
UT of J&K is among the forerunners in achieving its target of converting all the Sub-Centres 
(SCs) and Primary Health Centres (PHC) to HWCs. This is crucial in community engagement and 
improving the demand for health care services in the region. 
I
workers network, to connect the community with the 
health system for primary health care services, intending 
to give doorstep uninterrupted delivery of service to the 
community and bridging the ‘access’ gap. Adding to them is 
the equally expansive network of ANMs (Auxiliary Nurse 
Midwives) and other field health staff to support and have 
an all-encompassing coverage system. The response of the 
populace across the UT of J&K, towards community-based 
interventions, has been overall positive, which is evident 
by a look at the gargantuan mass of legacy data present in 
the Health Management Information System (HMIS) and  
coNtiNuum oF care 52 YOJANA   September 2022
RCH Portal. These portals have ensured sustained monitoring 
and evaluation of fieldwork, along with giving us an idea of 
the sheer volume of services that have been delivered till  
now and continues to be provided, which has, in turn,  
resulted in improved health outcomes for the UT of J&K and 
reduced Infant Mortality Rate to 17 and Neonatal Mortality 
Rate to 15, which are far below the national average.
2
 
Indicator (NFHS5) J&K (%) Overall 
India (%)
Mothers who had at least 4 
antenatal care visits 
80.9 58.1
Institutional births- 92.4 88.6
Births attended by skilled 
health personnel
95.1 89.4
Children aged 12-23 
months fully immunised 
86.2 76.4
Source: MoHFW
There is ample evidence across countries showing-
partnerships between community and health are needed 
to achieve and sustain positive health outcomes, which is 
apparent in the UT of J&K with the huge progress made 
in RCH.
3
Health facilities Required as per 
IPHS norms
In position 
RHS 2020
District Hospital 21
Community Health 
Centre
83 77 
Primary Health 
Centre-Rural
333 923
Primary Health 
Centre-Urban
80 49
Sub Health Centre 2042 2470
Medical Colleges 
and Hospitals
9
Source: MoHFW
The better part of the modern Indian healthcare policy 
structure has addressed healthcare access as a supply-side 
concern, particularly infrastructural. Hence, in some parts 
of the country such as J&K UT, there is a fair amount of 
public health infrastructure penetration, which is even over 
and above the IPHS norms.
4
 
AB-HWC of NHM, which includes the establishment 
of Health and Wellness Centres (HWC) has been a flagship 
programme of Government of India and is hands down 
the biggest intervention in strengthening primary level 
healthcare in recent years, by moving from selective 
primary health care to CPHC to achieve Universal Health 
Coverage.
4
 UT of J&K is among the forerunners in 
achieving its target of converting all the Sub-Centres (SCs) 
and Primary Health Centres (PHC) to HWCs.
5
HWC Operational Target Dec 
2022
Current status 
(HWC portal)
HWC- SHC 1770 1415
HWC-PHC 923 543
HWC-UPHC 49 44
Total 2742 2002
Source: MoHFW
At SHC-HWC, a new cadre of health workers, 
a Community Health Officer (CHO) or a Mid-Level 
Health Provider (MLHP), is being introduced which as 
the name suggests, was a novel creation for instituting 
a functionary between a paramedic and a full-scale 
medical officer, who would be able to do non-prescriptive 
population-based screenings for limited diseases, thereby 
improving community outreach, clinical management 
and Continuum of Care (CoC). AB-HWC has introduced 
the Population Enrollment and Community Based 
Assessment Checklist (CBAC) form which is possibly 
the most primal but concrete individualised health record 
till now. The UT has taken a step ahead and is working 
on digitising the Population Enrollment, CBAC form, 
screening, diagnosis and treatment provided at different 
levels of care into the NCD App and hence generating a 
mountain of data.
However, before we overload our societies with 
excessive ‘Supply’ side resources it is crucial that we 
analyse the ‘Demand’ angle. Sociological studies lay down 
the concept of the ‘Aspirational Level’ of individuals and 
communities in determining the trajectory of societal 
development evolution. An educated and well-informed 
community will be better aware of the living scenario that 
they need and would hence have a higher ‘aspiration’ to 
better health standards resulting in them engaging more 
successfully with the ‘supply’ side resources. On the 
other hand, a less aware community would have a lower 
‘aspirational’ level and hence won’t be able to access and 
consume the health care resources provided to them even if 
J&K Overall India figures
YOJANA   September 2022 53
it is at their doorstep. Hence, ensuring 
the existence of ‘Demand’ among 
communities is critical to guaranteeing 
uptake and proper consumption of 
resources, schemes and facilities. The 
path-breaking example of Jan Swasthya 
Sahyog (JSS), Ganyari, Bilaspur, 
Chhattisgarh– the fountainhead 
of community-based primary care 
interventions in India, shows us that this 
‘Demand’ is largely based on literary 
and awareness levels in the community. 
A simple example— if a community 
is, for some reason, opposed to 
vaccination, then even if we flood the 
area with abundant stock of vaccines 
and vaccinators, it would still not result in inoculations. 
However, the step towards establishing HWCs in the 
UT of J&K is crucial in the community engagement and 
improving the demand for health care services, and are 
piggy-backing the ASHAs, VHNSCs, VHSND, support 
groups, and newly established JAS to do so.
Moving up the ladder, we have overcrowded 
Secondary and Tertiary Points of Care (PoC), which are 
struggling with a heavy footfall of patients, around 40% 
of which are routine OPD cases which otherwise can be 
very well dealt with at the Primary level. The reasons 
behind the discrepancy in many regions are poor referral 
linkages, poorly functioning government primary care 
facilities and also patients bypassing the lower level of 
care for getting more perfect treatment at the big city 
hospital even if they have to stand in long OPD counter 
queues for hours at end.
6
 There is an obvious economic 
repercussion here. Imagine a poor rural labourer who has 
to give up a day’s wage work to visit the big city hospital, 
who otherwise can get simple ailments diagnosed closer 
to home. The other fallout is that most of the patients then 
end up limiting their treatment courses to the few city 
visits they make without bothering about any follow-up in 
between. Even with a follow-up visit, 
they might not see the same doctor in 
the tertiary care government hospital 
and if they do see the same doctor, it is 
after a year, with the doctor not likely 
remembering the medical history from 
the last visit, and the patient starting 
his treatment from scratch with the 
probability of receiving same OPD 
treatment as earlier. In absence of 
digitised health records, most patients 
lug around incoherent bulky paper 
records, containing everything from 
old prescriptions to test results, which 
many times are hard to use. Also, with 
less consultation time per patient, the 
patient gets merely offered a symptomatic treatment 
course, compromising the quality of care. In view of the 
lack of a primary care gatekeeping and referral model, 
patients with chronic illness are unaware of the secondary 
or tertiary care hospital to approach. Also, with a lack of 
robust referral and individual guidance mechanisms, the 
illiterate rural patient is not able to navigate to the crowded 
big city hospital and feels utterly lost, uncomfortable and 
unwanted. This is in line with Oscar Lewis’s famous 
‘Culture of Poverty’ theory which states that the poor and 
the marginalised are generally suspicious of institutions 
and that factor is seemingly a reason why the rural poor 
don’t manage to partake in the benefits of services given 
by public institutions. 
The end result is that many patients are undiagnosed 
or drop out of a successful continued follow-up process 
or don’t finish their treatment cycle properly and instead 
choose or are forced to live with the disease. This 
throws up a particularly dire situation for patients with 
undetected long-term illnesses like kidney diseases, 
cancers requiring chemotherapy, lifelong immunological 
disorders, blood disorders etc., if they drop out of the 
treatment.
The case of early detection 
closer to home is being made 
possible in the UT of J&K, 
by ensuring population-based 
screenings being done at HWCs 
for majorly Non-Communicable 
Diabetes and Common Cancers 
and evolving towards screening 
for an expanded range of 
diseases including Ophthalmic 
care, ENT care, Elderly care, 
and Palliative care. 
Page 4


YOJANA   September 2022 51
n the post-pandemic period, the age-old 
adage “prevention is better than cure,” is 
more applicable today than ever before. The 
Sustainable Development Goal (SDG-3) 
reiterates the importance of promotion and prevention by 
introducing the concept of ‘Good Health and Well-Being’ 
of individuals as a major plank of Community Health 
Processes. Universal Health Coverage (UHC), SDG target 
3.8, a strategic priority of the World Health Organization 
(WHO), builds on the same to provide blanket assurance 
of an end-to-end range of essential health services, from 
health promotion to prevention, treatment, rehabilitation, 
and palliative care, to people across all regions, age 
groups, social and income groups, by enabling access to 
health services they need.
1
 Let us appreciate the keyword 
here - ‘Access’. 
In spite of ‘Health’ being listed as a State Subject in 
the 7
th
 Schedule of the Indian Constitution, the Ministry 
of Health and Family Welfare (MoHFW) still invests 
a lot of resources in the State systems. It focuses on 
establishing a strong community-based healthcare system 
strengthening in the form of the erstwhile RCH-1 in 1997, 
and subsequently through the massive National Health 
Mission (NHM), which has led to the creation of a robust 
grass-root level cadre of health workers including the 
ASHAs (Accredited Social Health Activists), who were 
recently acclaimed internationally by the WHO for their 
outstanding contribution towards protecting and promoting 
health. As with other States in the country such as UT of 
J&K, NHM has supported approximately 13,500 ASHA 
Universal Health Coverage in J&K
Yasin M Choudhary
The author is an IAS, Mission Director, National Health Mission (NHM) and Ayushman Bharat Digital Mission (ABDM), Jammu & 
Kashmir UT. Email: mdnhmjk@gmail.com
The Ayushman Bharat-Health and Wellness Centre programme (AB-HWC) of NHM, which 
includes the establishment of Health and Wellness Centres (HWC) is the biggest intervention in 
strengthening primary-level healthcare in recent years, by moving from selective primary health 
care to Comprehensive Primary Health Care (CPHC) to achieve universal health coverage. The 
UT of J&K is among the forerunners in achieving its target of converting all the Sub-Centres 
(SCs) and Primary Health Centres (PHC) to HWCs. This is crucial in community engagement and 
improving the demand for health care services in the region. 
I
workers network, to connect the community with the 
health system for primary health care services, intending 
to give doorstep uninterrupted delivery of service to the 
community and bridging the ‘access’ gap. Adding to them is 
the equally expansive network of ANMs (Auxiliary Nurse 
Midwives) and other field health staff to support and have 
an all-encompassing coverage system. The response of the 
populace across the UT of J&K, towards community-based 
interventions, has been overall positive, which is evident 
by a look at the gargantuan mass of legacy data present in 
the Health Management Information System (HMIS) and  
coNtiNuum oF care 52 YOJANA   September 2022
RCH Portal. These portals have ensured sustained monitoring 
and evaluation of fieldwork, along with giving us an idea of 
the sheer volume of services that have been delivered till  
now and continues to be provided, which has, in turn,  
resulted in improved health outcomes for the UT of J&K and 
reduced Infant Mortality Rate to 17 and Neonatal Mortality 
Rate to 15, which are far below the national average.
2
 
Indicator (NFHS5) J&K (%) Overall 
India (%)
Mothers who had at least 4 
antenatal care visits 
80.9 58.1
Institutional births- 92.4 88.6
Births attended by skilled 
health personnel
95.1 89.4
Children aged 12-23 
months fully immunised 
86.2 76.4
Source: MoHFW
There is ample evidence across countries showing-
partnerships between community and health are needed 
to achieve and sustain positive health outcomes, which is 
apparent in the UT of J&K with the huge progress made 
in RCH.
3
Health facilities Required as per 
IPHS norms
In position 
RHS 2020
District Hospital 21
Community Health 
Centre
83 77 
Primary Health 
Centre-Rural
333 923
Primary Health 
Centre-Urban
80 49
Sub Health Centre 2042 2470
Medical Colleges 
and Hospitals
9
Source: MoHFW
The better part of the modern Indian healthcare policy 
structure has addressed healthcare access as a supply-side 
concern, particularly infrastructural. Hence, in some parts 
of the country such as J&K UT, there is a fair amount of 
public health infrastructure penetration, which is even over 
and above the IPHS norms.
4
 
AB-HWC of NHM, which includes the establishment 
of Health and Wellness Centres (HWC) has been a flagship 
programme of Government of India and is hands down 
the biggest intervention in strengthening primary level 
healthcare in recent years, by moving from selective 
primary health care to CPHC to achieve Universal Health 
Coverage.
4
 UT of J&K is among the forerunners in 
achieving its target of converting all the Sub-Centres (SCs) 
and Primary Health Centres (PHC) to HWCs.
5
HWC Operational Target Dec 
2022
Current status 
(HWC portal)
HWC- SHC 1770 1415
HWC-PHC 923 543
HWC-UPHC 49 44
Total 2742 2002
Source: MoHFW
At SHC-HWC, a new cadre of health workers, 
a Community Health Officer (CHO) or a Mid-Level 
Health Provider (MLHP), is being introduced which as 
the name suggests, was a novel creation for instituting 
a functionary between a paramedic and a full-scale 
medical officer, who would be able to do non-prescriptive 
population-based screenings for limited diseases, thereby 
improving community outreach, clinical management 
and Continuum of Care (CoC). AB-HWC has introduced 
the Population Enrollment and Community Based 
Assessment Checklist (CBAC) form which is possibly 
the most primal but concrete individualised health record 
till now. The UT has taken a step ahead and is working 
on digitising the Population Enrollment, CBAC form, 
screening, diagnosis and treatment provided at different 
levels of care into the NCD App and hence generating a 
mountain of data.
However, before we overload our societies with 
excessive ‘Supply’ side resources it is crucial that we 
analyse the ‘Demand’ angle. Sociological studies lay down 
the concept of the ‘Aspirational Level’ of individuals and 
communities in determining the trajectory of societal 
development evolution. An educated and well-informed 
community will be better aware of the living scenario that 
they need and would hence have a higher ‘aspiration’ to 
better health standards resulting in them engaging more 
successfully with the ‘supply’ side resources. On the 
other hand, a less aware community would have a lower 
‘aspirational’ level and hence won’t be able to access and 
consume the health care resources provided to them even if 
J&K Overall India figures
YOJANA   September 2022 53
it is at their doorstep. Hence, ensuring 
the existence of ‘Demand’ among 
communities is critical to guaranteeing 
uptake and proper consumption of 
resources, schemes and facilities. The 
path-breaking example of Jan Swasthya 
Sahyog (JSS), Ganyari, Bilaspur, 
Chhattisgarh– the fountainhead 
of community-based primary care 
interventions in India, shows us that this 
‘Demand’ is largely based on literary 
and awareness levels in the community. 
A simple example— if a community 
is, for some reason, opposed to 
vaccination, then even if we flood the 
area with abundant stock of vaccines 
and vaccinators, it would still not result in inoculations. 
However, the step towards establishing HWCs in the 
UT of J&K is crucial in the community engagement and 
improving the demand for health care services, and are 
piggy-backing the ASHAs, VHNSCs, VHSND, support 
groups, and newly established JAS to do so.
Moving up the ladder, we have overcrowded 
Secondary and Tertiary Points of Care (PoC), which are 
struggling with a heavy footfall of patients, around 40% 
of which are routine OPD cases which otherwise can be 
very well dealt with at the Primary level. The reasons 
behind the discrepancy in many regions are poor referral 
linkages, poorly functioning government primary care 
facilities and also patients bypassing the lower level of 
care for getting more perfect treatment at the big city 
hospital even if they have to stand in long OPD counter 
queues for hours at end.
6
 There is an obvious economic 
repercussion here. Imagine a poor rural labourer who has 
to give up a day’s wage work to visit the big city hospital, 
who otherwise can get simple ailments diagnosed closer 
to home. The other fallout is that most of the patients then 
end up limiting their treatment courses to the few city 
visits they make without bothering about any follow-up in 
between. Even with a follow-up visit, 
they might not see the same doctor in 
the tertiary care government hospital 
and if they do see the same doctor, it is 
after a year, with the doctor not likely 
remembering the medical history from 
the last visit, and the patient starting 
his treatment from scratch with the 
probability of receiving same OPD 
treatment as earlier. In absence of 
digitised health records, most patients 
lug around incoherent bulky paper 
records, containing everything from 
old prescriptions to test results, which 
many times are hard to use. Also, with 
less consultation time per patient, the 
patient gets merely offered a symptomatic treatment 
course, compromising the quality of care. In view of the 
lack of a primary care gatekeeping and referral model, 
patients with chronic illness are unaware of the secondary 
or tertiary care hospital to approach. Also, with a lack of 
robust referral and individual guidance mechanisms, the 
illiterate rural patient is not able to navigate to the crowded 
big city hospital and feels utterly lost, uncomfortable and 
unwanted. This is in line with Oscar Lewis’s famous 
‘Culture of Poverty’ theory which states that the poor and 
the marginalised are generally suspicious of institutions 
and that factor is seemingly a reason why the rural poor 
don’t manage to partake in the benefits of services given 
by public institutions. 
The end result is that many patients are undiagnosed 
or drop out of a successful continued follow-up process 
or don’t finish their treatment cycle properly and instead 
choose or are forced to live with the disease. This 
throws up a particularly dire situation for patients with 
undetected long-term illnesses like kidney diseases, 
cancers requiring chemotherapy, lifelong immunological 
disorders, blood disorders etc., if they drop out of the 
treatment.
The case of early detection 
closer to home is being made 
possible in the UT of J&K, 
by ensuring population-based 
screenings being done at HWCs 
for majorly Non-Communicable 
Diabetes and Common Cancers 
and evolving towards screening 
for an expanded range of 
diseases including Ophthalmic 
care, ENT care, Elderly care, 
and Palliative care. 
54 YOJANA   September 2022
Hence, arises the case for 
decongesting tertiary and secondary care 
and strengthening primary healthcare 
closer to the community with a strong 
referral and follow-up system. This is 
further augmented by the fact that by 
providing closer-to-home treatment, 
we can detect and treat diseases more 
quickly than allowing them to fester and 
hence throng to tertiary care in panic 
later on. Imagine a scenario, where all 
patients with a high risk of developing 
diabetics in a community are detected 
early on and put on the wellness track 
through a strengthened primary care system, then likely 
there would be much fewer patients with full-blown 
diabetic complications, who crowd the tertiary care. 
The next logical question that arises is that with a 
strengthened primary level infrastructure, where is the 
missing gap here? What are we doing after screening our 
population? CoC model envisions two things– extending 
access to next-level services at the village level or assisted 
referral and linking back to his home/community across 
times of care. The former includes ensuring access to 
critical care, free diagnostics and drugs in a guaranteed 
manner, while the latter ensures continuity of care to 
improve the quality of care.
7
 The case of early detection 
closer to home is being made possible in the UT of J&K, 
by ensuring population-based screenings being done at 
HWCs for majorly Non-Communicable Diabetes and 
Common Cancers and evolving towards screening for an 
expanded range of diseases including Ophthalmic care, 
ENT care, Elderly care, and Palliative care. Imagine a poor 
elderly person in a remote rural area, ignorantly taking an 
arduous trip to the big city hospital for a musculoskeletal 
issue that can be easily screened in 
advance at his village Health and 
Wellness Centre before it worsens or 
which can be easily dealt with by a 
CHO/MLHP. Our State-level health 
systems do push citizens detected out 
of population-based screenings into 
IPD care but because there is a lack of 
integration between the levels of care 
in a disparate movement of patients 
from primary level to higher levels. 
To be fair, in a way, the AB-HWC is 
strengthening primary health care, 
evolving to build robust referral and 
follow-up systems to ensure CoC approach.
The Ayushman Bharat Digital Mission (ABDM), 
may single-handedly be the most ambitious health sector 
intervention of the decade. If data is the new oil, then 
health data is the new gold, as no other form of data is more 
valuable or special than a person’s individual health record. 
ABDM’s sophisticated service architecture aims to record 
every health consultation, be it OPD or IPD or even a lab 
test result, as a transaction between recognised entities (an 
ABHA ID– Ayushman Bharat Health Account, holding 
patient, an HPR– Healthcare Professionals Registry, 
registered doctor in an HFR registered hospital) and in that 
process build up individualised Electronic Medical Records 
(EMR) that can be accessed by the patient through the PHR 
(Patient Health Record) App. The Aadhaar-enabled patient 
consent-based system is built to ensure that a person’s 
past health records are not shared or divulged without his 
consent. Under the ABDM, the UT is on an uphill task of 
digitising and linking with ABHA ID and HPR, the record of 
an individual as soon as he/she enters the SHC/PHC/CHC/
DH, which includes screening, diagnosis, investigations, 
treatment, drug dispensing, etc., through the Information 
Management Systems. Also, releasing the importance of 
data speaking at different platforms and available at each 
level of care, integration of the systems has been a vital 
piece that the UT is constantly working on. 
Let us go back to the examples of the bewildered 
patient who is lugging around bulky paper health records, 
the ABDM Digilocker-based EMR aims to resolve that. 
However, in all fairness, with the digital divide still running 
strong, it remains to be seen whether the illiterate labourer 
would be able to understand and engage with the digital 
record. The other aspect is the big question of tiding over 
the huge expenses incurred in IPD treatment – a challenge 
which our country finally managed to resolve significantly 
in recent years. The Ayushman Bharat-Pradhan Mantri 
Jan Arogya Yojana, (AB-PMJAY) which seeks to provide 
free IPD expenses coverage for BPL patients throughout 
the country with an annual wallet cover of Rs 5 lakh, is a 
landmark disruption in things. J&K, with the aim to cover 
J&K, with the aim to cover 
its entire population with 
healthcare services without any 
financial hardship, is among 
few States/UTs in India to 
have a universalised Scheme 
AB-PMJAY SEHAT which is 
a top-up to ensure complete 
end-to-end coverage of their 
populations.
Page 5


YOJANA   September 2022 51
n the post-pandemic period, the age-old 
adage “prevention is better than cure,” is 
more applicable today than ever before. The 
Sustainable Development Goal (SDG-3) 
reiterates the importance of promotion and prevention by 
introducing the concept of ‘Good Health and Well-Being’ 
of individuals as a major plank of Community Health 
Processes. Universal Health Coverage (UHC), SDG target 
3.8, a strategic priority of the World Health Organization 
(WHO), builds on the same to provide blanket assurance 
of an end-to-end range of essential health services, from 
health promotion to prevention, treatment, rehabilitation, 
and palliative care, to people across all regions, age 
groups, social and income groups, by enabling access to 
health services they need.
1
 Let us appreciate the keyword 
here - ‘Access’. 
In spite of ‘Health’ being listed as a State Subject in 
the 7
th
 Schedule of the Indian Constitution, the Ministry 
of Health and Family Welfare (MoHFW) still invests 
a lot of resources in the State systems. It focuses on 
establishing a strong community-based healthcare system 
strengthening in the form of the erstwhile RCH-1 in 1997, 
and subsequently through the massive National Health 
Mission (NHM), which has led to the creation of a robust 
grass-root level cadre of health workers including the 
ASHAs (Accredited Social Health Activists), who were 
recently acclaimed internationally by the WHO for their 
outstanding contribution towards protecting and promoting 
health. As with other States in the country such as UT of 
J&K, NHM has supported approximately 13,500 ASHA 
Universal Health Coverage in J&K
Yasin M Choudhary
The author is an IAS, Mission Director, National Health Mission (NHM) and Ayushman Bharat Digital Mission (ABDM), Jammu & 
Kashmir UT. Email: mdnhmjk@gmail.com
The Ayushman Bharat-Health and Wellness Centre programme (AB-HWC) of NHM, which 
includes the establishment of Health and Wellness Centres (HWC) is the biggest intervention in 
strengthening primary-level healthcare in recent years, by moving from selective primary health 
care to Comprehensive Primary Health Care (CPHC) to achieve universal health coverage. The 
UT of J&K is among the forerunners in achieving its target of converting all the Sub-Centres 
(SCs) and Primary Health Centres (PHC) to HWCs. This is crucial in community engagement and 
improving the demand for health care services in the region. 
I
workers network, to connect the community with the 
health system for primary health care services, intending 
to give doorstep uninterrupted delivery of service to the 
community and bridging the ‘access’ gap. Adding to them is 
the equally expansive network of ANMs (Auxiliary Nurse 
Midwives) and other field health staff to support and have 
an all-encompassing coverage system. The response of the 
populace across the UT of J&K, towards community-based 
interventions, has been overall positive, which is evident 
by a look at the gargantuan mass of legacy data present in 
the Health Management Information System (HMIS) and  
coNtiNuum oF care 52 YOJANA   September 2022
RCH Portal. These portals have ensured sustained monitoring 
and evaluation of fieldwork, along with giving us an idea of 
the sheer volume of services that have been delivered till  
now and continues to be provided, which has, in turn,  
resulted in improved health outcomes for the UT of J&K and 
reduced Infant Mortality Rate to 17 and Neonatal Mortality 
Rate to 15, which are far below the national average.
2
 
Indicator (NFHS5) J&K (%) Overall 
India (%)
Mothers who had at least 4 
antenatal care visits 
80.9 58.1
Institutional births- 92.4 88.6
Births attended by skilled 
health personnel
95.1 89.4
Children aged 12-23 
months fully immunised 
86.2 76.4
Source: MoHFW
There is ample evidence across countries showing-
partnerships between community and health are needed 
to achieve and sustain positive health outcomes, which is 
apparent in the UT of J&K with the huge progress made 
in RCH.
3
Health facilities Required as per 
IPHS norms
In position 
RHS 2020
District Hospital 21
Community Health 
Centre
83 77 
Primary Health 
Centre-Rural
333 923
Primary Health 
Centre-Urban
80 49
Sub Health Centre 2042 2470
Medical Colleges 
and Hospitals
9
Source: MoHFW
The better part of the modern Indian healthcare policy 
structure has addressed healthcare access as a supply-side 
concern, particularly infrastructural. Hence, in some parts 
of the country such as J&K UT, there is a fair amount of 
public health infrastructure penetration, which is even over 
and above the IPHS norms.
4
 
AB-HWC of NHM, which includes the establishment 
of Health and Wellness Centres (HWC) has been a flagship 
programme of Government of India and is hands down 
the biggest intervention in strengthening primary level 
healthcare in recent years, by moving from selective 
primary health care to CPHC to achieve Universal Health 
Coverage.
4
 UT of J&K is among the forerunners in 
achieving its target of converting all the Sub-Centres (SCs) 
and Primary Health Centres (PHC) to HWCs.
5
HWC Operational Target Dec 
2022
Current status 
(HWC portal)
HWC- SHC 1770 1415
HWC-PHC 923 543
HWC-UPHC 49 44
Total 2742 2002
Source: MoHFW
At SHC-HWC, a new cadre of health workers, 
a Community Health Officer (CHO) or a Mid-Level 
Health Provider (MLHP), is being introduced which as 
the name suggests, was a novel creation for instituting 
a functionary between a paramedic and a full-scale 
medical officer, who would be able to do non-prescriptive 
population-based screenings for limited diseases, thereby 
improving community outreach, clinical management 
and Continuum of Care (CoC). AB-HWC has introduced 
the Population Enrollment and Community Based 
Assessment Checklist (CBAC) form which is possibly 
the most primal but concrete individualised health record 
till now. The UT has taken a step ahead and is working 
on digitising the Population Enrollment, CBAC form, 
screening, diagnosis and treatment provided at different 
levels of care into the NCD App and hence generating a 
mountain of data.
However, before we overload our societies with 
excessive ‘Supply’ side resources it is crucial that we 
analyse the ‘Demand’ angle. Sociological studies lay down 
the concept of the ‘Aspirational Level’ of individuals and 
communities in determining the trajectory of societal 
development evolution. An educated and well-informed 
community will be better aware of the living scenario that 
they need and would hence have a higher ‘aspiration’ to 
better health standards resulting in them engaging more 
successfully with the ‘supply’ side resources. On the 
other hand, a less aware community would have a lower 
‘aspirational’ level and hence won’t be able to access and 
consume the health care resources provided to them even if 
J&K Overall India figures
YOJANA   September 2022 53
it is at their doorstep. Hence, ensuring 
the existence of ‘Demand’ among 
communities is critical to guaranteeing 
uptake and proper consumption of 
resources, schemes and facilities. The 
path-breaking example of Jan Swasthya 
Sahyog (JSS), Ganyari, Bilaspur, 
Chhattisgarh– the fountainhead 
of community-based primary care 
interventions in India, shows us that this 
‘Demand’ is largely based on literary 
and awareness levels in the community. 
A simple example— if a community 
is, for some reason, opposed to 
vaccination, then even if we flood the 
area with abundant stock of vaccines 
and vaccinators, it would still not result in inoculations. 
However, the step towards establishing HWCs in the 
UT of J&K is crucial in the community engagement and 
improving the demand for health care services, and are 
piggy-backing the ASHAs, VHNSCs, VHSND, support 
groups, and newly established JAS to do so.
Moving up the ladder, we have overcrowded 
Secondary and Tertiary Points of Care (PoC), which are 
struggling with a heavy footfall of patients, around 40% 
of which are routine OPD cases which otherwise can be 
very well dealt with at the Primary level. The reasons 
behind the discrepancy in many regions are poor referral 
linkages, poorly functioning government primary care 
facilities and also patients bypassing the lower level of 
care for getting more perfect treatment at the big city 
hospital even if they have to stand in long OPD counter 
queues for hours at end.
6
 There is an obvious economic 
repercussion here. Imagine a poor rural labourer who has 
to give up a day’s wage work to visit the big city hospital, 
who otherwise can get simple ailments diagnosed closer 
to home. The other fallout is that most of the patients then 
end up limiting their treatment courses to the few city 
visits they make without bothering about any follow-up in 
between. Even with a follow-up visit, 
they might not see the same doctor in 
the tertiary care government hospital 
and if they do see the same doctor, it is 
after a year, with the doctor not likely 
remembering the medical history from 
the last visit, and the patient starting 
his treatment from scratch with the 
probability of receiving same OPD 
treatment as earlier. In absence of 
digitised health records, most patients 
lug around incoherent bulky paper 
records, containing everything from 
old prescriptions to test results, which 
many times are hard to use. Also, with 
less consultation time per patient, the 
patient gets merely offered a symptomatic treatment 
course, compromising the quality of care. In view of the 
lack of a primary care gatekeeping and referral model, 
patients with chronic illness are unaware of the secondary 
or tertiary care hospital to approach. Also, with a lack of 
robust referral and individual guidance mechanisms, the 
illiterate rural patient is not able to navigate to the crowded 
big city hospital and feels utterly lost, uncomfortable and 
unwanted. This is in line with Oscar Lewis’s famous 
‘Culture of Poverty’ theory which states that the poor and 
the marginalised are generally suspicious of institutions 
and that factor is seemingly a reason why the rural poor 
don’t manage to partake in the benefits of services given 
by public institutions. 
The end result is that many patients are undiagnosed 
or drop out of a successful continued follow-up process 
or don’t finish their treatment cycle properly and instead 
choose or are forced to live with the disease. This 
throws up a particularly dire situation for patients with 
undetected long-term illnesses like kidney diseases, 
cancers requiring chemotherapy, lifelong immunological 
disorders, blood disorders etc., if they drop out of the 
treatment.
The case of early detection 
closer to home is being made 
possible in the UT of J&K, 
by ensuring population-based 
screenings being done at HWCs 
for majorly Non-Communicable 
Diabetes and Common Cancers 
and evolving towards screening 
for an expanded range of 
diseases including Ophthalmic 
care, ENT care, Elderly care, 
and Palliative care. 
54 YOJANA   September 2022
Hence, arises the case for 
decongesting tertiary and secondary care 
and strengthening primary healthcare 
closer to the community with a strong 
referral and follow-up system. This is 
further augmented by the fact that by 
providing closer-to-home treatment, 
we can detect and treat diseases more 
quickly than allowing them to fester and 
hence throng to tertiary care in panic 
later on. Imagine a scenario, where all 
patients with a high risk of developing 
diabetics in a community are detected 
early on and put on the wellness track 
through a strengthened primary care system, then likely 
there would be much fewer patients with full-blown 
diabetic complications, who crowd the tertiary care. 
The next logical question that arises is that with a 
strengthened primary level infrastructure, where is the 
missing gap here? What are we doing after screening our 
population? CoC model envisions two things– extending 
access to next-level services at the village level or assisted 
referral and linking back to his home/community across 
times of care. The former includes ensuring access to 
critical care, free diagnostics and drugs in a guaranteed 
manner, while the latter ensures continuity of care to 
improve the quality of care.
7
 The case of early detection 
closer to home is being made possible in the UT of J&K, 
by ensuring population-based screenings being done at 
HWCs for majorly Non-Communicable Diabetes and 
Common Cancers and evolving towards screening for an 
expanded range of diseases including Ophthalmic care, 
ENT care, Elderly care, and Palliative care. Imagine a poor 
elderly person in a remote rural area, ignorantly taking an 
arduous trip to the big city hospital for a musculoskeletal 
issue that can be easily screened in 
advance at his village Health and 
Wellness Centre before it worsens or 
which can be easily dealt with by a 
CHO/MLHP. Our State-level health 
systems do push citizens detected out 
of population-based screenings into 
IPD care but because there is a lack of 
integration between the levels of care 
in a disparate movement of patients 
from primary level to higher levels. 
To be fair, in a way, the AB-HWC is 
strengthening primary health care, 
evolving to build robust referral and 
follow-up systems to ensure CoC approach.
The Ayushman Bharat Digital Mission (ABDM), 
may single-handedly be the most ambitious health sector 
intervention of the decade. If data is the new oil, then 
health data is the new gold, as no other form of data is more 
valuable or special than a person’s individual health record. 
ABDM’s sophisticated service architecture aims to record 
every health consultation, be it OPD or IPD or even a lab 
test result, as a transaction between recognised entities (an 
ABHA ID– Ayushman Bharat Health Account, holding 
patient, an HPR– Healthcare Professionals Registry, 
registered doctor in an HFR registered hospital) and in that 
process build up individualised Electronic Medical Records 
(EMR) that can be accessed by the patient through the PHR 
(Patient Health Record) App. The Aadhaar-enabled patient 
consent-based system is built to ensure that a person’s 
past health records are not shared or divulged without his 
consent. Under the ABDM, the UT is on an uphill task of 
digitising and linking with ABHA ID and HPR, the record of 
an individual as soon as he/she enters the SHC/PHC/CHC/
DH, which includes screening, diagnosis, investigations, 
treatment, drug dispensing, etc., through the Information 
Management Systems. Also, releasing the importance of 
data speaking at different platforms and available at each 
level of care, integration of the systems has been a vital 
piece that the UT is constantly working on. 
Let us go back to the examples of the bewildered 
patient who is lugging around bulky paper health records, 
the ABDM Digilocker-based EMR aims to resolve that. 
However, in all fairness, with the digital divide still running 
strong, it remains to be seen whether the illiterate labourer 
would be able to understand and engage with the digital 
record. The other aspect is the big question of tiding over 
the huge expenses incurred in IPD treatment – a challenge 
which our country finally managed to resolve significantly 
in recent years. The Ayushman Bharat-Pradhan Mantri 
Jan Arogya Yojana, (AB-PMJAY) which seeks to provide 
free IPD expenses coverage for BPL patients throughout 
the country with an annual wallet cover of Rs 5 lakh, is a 
landmark disruption in things. J&K, with the aim to cover 
J&K, with the aim to cover 
its entire population with 
healthcare services without any 
financial hardship, is among 
few States/UTs in India to 
have a universalised Scheme 
AB-PMJAY SEHAT which is 
a top-up to ensure complete 
end-to-end coverage of their 
populations.
YOJANA   September 2022 55
its entire population with health care services without 
any financial hardship, is among few States/UTs in India 
to have a universalised Scheme AB-PMJAY SEHAT 
(Social, Endeavour for Health and Telemedicine), which is 
a top-up to ensure complete end-to-end coverage of their 
populations. 
In conclusion, in the UT of J&K, AB-HWC, AB-PMJA Y 
and ABDM put together are rapidly changing the face of 
primary, secondary and tertiary care access, economically 
and digitally. Decongesting bigger hospitals from routine 
OPD burden by strengthening primary healthcare while 
ensuring CoC-driven access to free IPD for deserving 
citizens should be the underlying principle of our health 
systems. As India looks forward to an era of improved and 
modernised healthcare system, it is imperative that we face 
the challenges.                                                                     ?
References
1. World Health Organization. 2020. Monitoring progress on 
Universal Health Coverage and the health-related Sustainable 
Development Goals in the WHO South-East Asia Region: 2020 
update, India.
2. Office of the Registrar General, New Delhi. SRS Bulletin 2022.
Office of the Registrar General, New Delhi. Sample Registration 
System 2019.
3. International Institute for Population Sciences (IIPS) and ICF. 
2021. National Family Health Survey (NFHS-5), India, 2020-21: 
Rajasthan. Mumbai: IIPS.
4. National Health Systems Resource Centre. 2018. AYUSHMAN 
BHARAT Comprehensive Primary Health Care through Health and 
Wellness Centers Operational Guidelines.
5. AB-HWC Portal. https://ab-hwc.nhp.gov.in/
6. Srivastava, S., Karan, A. K., Bhan, N., Mukhopadhya, I., & World 
Health Organization. (2022). India: health system review. Health 
Systems in Transition, 11(1).
7. National Health Systems Resource Centre. 2018. AYUSHMAN 
BHARAT Comprehensive Primary Health Care through Health and 
Wellness Centers Operational Guidelines.