Dr Basant Garg explains the role and impact of the National Health Authority (NHA) in India, including its pivotal role in executing the Ayushman Bharat universal health coverage initiative. Dr Garg touches on the scale and scope of this enormous undertaking, and some of the implementation challenges of ensuring access to quality healthcare for a vast and economically disadvantaged population. He also outlines how the NHA is using technology to ensure a seamless, cashless, and paperless healthcare delivery.


What role does the National Health Authority (NHA) play in India?

The NHA operates as an attached office to the Ministry of Health and Family Welfare, established in 2018. Its primary mandate is to implement the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana, recognized as the world’s largest social health assurance scheme. The scheme is aimed at providing cashless and free secondary and tertiary care to the poorest 40 percent of India’s population. The scheme addresses the challenges faced by those unable to afford private healthcare and overcrowded public sector facilities. The broader objectives include ensuring affordability, accessibility, and quality healthcare for the economically disadvantaged, aligning with India’s commitment to universal health coverage as part of the Sustainable Development Goals.


What are the needs and challenges encountered in conceptualizing and implementing the Ayushman Bharat initiative, considering its scale and impact on approximately 700 million individuals?

The Ayushman Bharat initiative, supporting 12 Crore families (120 million) and additional state government support for 70 million families (250 million individuals), has reached close to 700 million people through the NHA’s IT platform. With a track record of providing 60 million treatments over the past five years, amounting to 70,000 crore rupees in expenditure, the initiative has notably achieved strategic purchasing of health services, resulting in a substantial saving of 40,000 crore rupees. This large-scale operation faces the challenge of ensuring seamless access to quality healthcare for a vast population while addressing the complex healthcare needs of the economically deprived. The initiative’s success lies in not only providing essential medical treatments but also in achieving significant cost savings through efficient and strategic service procurement.


Can you elaborate on the eligibility criteria for the Ayushman Bharat initiative and how the NHA navigates the challenges of identifying and enrolling the targeted 40 percent of the poor population in India?

The eligibility criteria for the Ayushman Bharat initiative rely on socio-economic databases, such as the socio-economic caste census survey conducted in 2011 and the National Food Security Act data. Leveraging the success of Aadhaar, the unique ID system, these databases help identify individuals belonging to the bottom 40 percent of India’s population. The scheme operates on an entitlement basis rather than enrollment, meaning those present in the designated databases are automatically eligible for services. This approach streamlines the identification process for beneficiaries.

Addressing awareness challenges among the illiterate population, the NHA emphasizes the use of Aadhaar, which serves as a powerful tool in verifying eligibility. Additionally, the issuance of physical Ayushman cards, despite the fully digital system, contributes to empowering beneficiaries and enabling them to demand services. With nearly half of the clientele possessing physical cards, the initiative has successfully created awareness and engagement among the target population.


How is technology, especially digitalization, harnessed by the NHA to enhance access to healthcare services, considering India’s significant expertise in this domain?

India’s experience with digitalization, notably through Aadhaar, COVID vaccination campaigns, UPI, and digital signatures, has laid a strong foundation for the NHA’s efforts. The Ayushman Bharat Digital Mission leverages technology to ensure not only subsidized access but also the availability of health information, interoperability of data, and services, contributing to the broader goal of achieving universal health coverage. The Ayushman Bharat operates on a completely cashless and paperless IT platform, seamlessly connecting over 26,000 empaneled hospitals and serving more than 50,000 people daily. The verification processes, involving Aadhaar and biometrics at different stages, aim to minimize fraud and ensure genuine citizens benefit from the system.


How is the financing managed for the Ayushman Bharat initiative, given the low proportion of healthcare spending by the Indian government (1.5 percent of GDP)? Can you shed light on the financial aspects?

The government in India is dedicated to increasing healthcare expenditure while prioritizing outcomes, emphasizing its commitment to achieving the Sustainable Development Goals (SDGs). The goal is to enhance healthcare accessibility and reduce out-of-pocket expenditure for citizens. Notably, over the past two years, out-of-pocket expenses have decreased from 71 percent to 49 percent, attributed to initiatives like Ayushman Bharat PMJAY in secondary and tertiary treatments and Ayushman Bharat Health and Wellness Centers in primary healthcare. The awareness among stakeholders about the need for addressing healthcare challenges is growing.

Further, the key point to keep in mind over here is that it is not just about increasing the expenditure, rather the effort at NHA is also to spend the existing finances more efficiently and to achieve better outcomes in healthcare delivery. In other words, it is about deriving more value out of each penny spent.

Moreover, The NHA in India actively collaborates with various stakeholders to enhance the efficiency and impact of healthcare initiatives. Notable partnerships include working with the insurance regulator, IRDAI, to develop the National Health Claims Exchange, streamlining health claims processing. Collaborations extend to hospitals—both large and small—academia, and the government, fostering a network of over 12,000 private hospitals. Initiatives like Ayushman Bharat involve close cooperation with the Ministry of Home for paramilitary forces and the Ministry of Health for government pensioners. Additionally, international collaborations play a crucial role, providing valuable insights, studies, and best practices to further enrich the healthcare landscape in India.


What key lessons have you and the NHA learned, particularly in overcoming challenges related to connectivity and diverse geographical regions? Are there success stories or best practices from Ayushman Bharat that you believe could provide valuable insights for global healthcare initiatives facing similar challenges?

Implementing the Ayushman Bharat initiative in India has been a significant learning experience for the NHA and its members. Operating across the vast and diverse landscape of India, the initiative has provided insights into overcoming challenges related to geographic and cultural diversity, connectivity issues, and the need for offline services in remote areas. Lessons learned include improving efficiency, preventing fraud, and ensuring judicious spending of public funds. These practical experiences can be immensely valuable for global south countries struggling to provide similar services.

The NHA acknowledges its openness to learning from others, recognizing that there are entities running programs more efficiently, even on smaller scales. The organization actively shares best practices annually, both in print and online, facilitating widespread dissemination of knowledge across India. We emphasise the importance of a robust system of checks and balances within the Indian polity, allowing for course corrections and steady growth over time.