The Ayushman Bharat Yojana, or Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), has benefited numerous poor families since its launch by Prime Minister Shri Narendra Modi in 2018 to achieve the vision of Universal Health Coverage (UHC). The gigantic step was taken to meet the Sustainable Development Goals (SDGs) and its underlining commitment is ‘Leave no one behind’, which fits well with PM’s own slogan, ‘Sabka Sath, Sabka Vikas, Sabka Vishwas’.
Considering the importance of technology as an enabler, PM Modi, on 15th August, 2020, launched the National Digital Health Mission (NDHM), which aims to bring a paradigm shift in our healthcare system and boost AB-PMJAY. We appreciate this new development as digital health has great potential in reducing inequity in provisioning and distribution of healthcare resources and services. We all want a ‘Swasth Bharat’ and NDHM is undoubtedly the right step towards this goal. Hopefully, the government will take care of data safety and privacy issue, which are one of the top concerns of citizens.
Here, I would like to discuss a crucial, but often ignored part of healthcare system — rehabilitation — without which no medical care is complete. The PMJAY includes three days of pre and 15 days of post hospitalisation, a laudable step. However, not only in India but also in many other countries, comprehensive healthcare is conspicuously absent. Integration of rehabilitation and therapeutic services in mainline healthcare system is more important.
Currently, rehabilitation exists as a ‘standalone’ segment under which patients have to bear a considerable financial burden post surgery or hospitalisation; it often represents an out-of-pocket expense, quite unaffordable for the most vulnerable and marginalised population including persons with disabilities, senior citizens and farmers. Rehabilitation often ends up being neglected from the healthcare system of most countries.
Since rehab is an integral part of hospitalisation, patients cannot be left to look at this separately, as an additional financial burden. If rehab is well integrated in government health systems such as Ayushman Bharat, it can provide rehabilitation services at all levels of the healthcare system. Therefore, it is expected of nations to align their health policies with the WHO’s ‘Recommendations on rehabilitation in health systems’, which talks about rehabilitation services at all stages of life.
Universal Health Coverage will not be fruitful if it is sheared from the rest of medical care. The Health Ministry and concerned departments such as National Health Authority (NHA) have to think about rehabilitation services as high-priority interventions so as to make AB-PMJAY effective at all levels – primary, secondary and tertiary healthcare.
In order to strengthen the rehabilitation segment, it is also crucial to look at the acute shortage of professionals, especially in rural areas. As per a 2017 report by the WHO titled The Need To Scale Up Rehabilitation, there are less than 10 skilled rehabilitation professionals per million people in low and middle-income countries. To correct this, we need to put more effort towards improving and expanding training opportunities, and promoting Community-Based Rehabilitation/Inclusive Development (CBR/CBID) to cut on costs. It will also help us achieve the goal of Universal Health Coverage by 2030, as envisaged by the SDGs.
As per a report by the US National Institutes of Health (NIH) Research Plan on Rehabilitation released in 2017, the development of systems that enable home therapy can minimise cost and maximise access as well as the amount of time that can be spent pursuing rehabilitation activities.
If a surgery gives life to a patient, rehab enables them to live life once again. People recuperating from stroke, spinal cord injury, traumatic brain injury, etc. have to depend on rehab services for a long time. Persons with disabilities, particularly those with post-polio residual paralysis (PPRP), cerebral palsy and other neurologically disabling conditions, often have to depend on rehabilitation for most of their lives. Therefore, accessible and affordable rehabilitation that incorporates accessibility in rehab centres is a fundamental requirement.
Accessible washrooms, right gradient ramps, handrails on stairs and ramps, accessible lifts, non-slippery surfaces, wide doors, sign language interpreters, sensitised professionals, etc. will also help make rehab experiences more inclusive and safe for diverse users. Therefore, inclusion of palliative care and rehabilitation under Ayushman Bharat will be of great help for patients with disabilities and the elderly.
The Rights of Persons with Disabilities (RPWD) Act, 2016, covers issues such as social security, health and rehabilitation under Chapter V, and mandates in Section 27 (1) that respective governments and local authorities shall, within their economic capacity and development, undertake or cause to be undertaken services and programmes of rehabilitation, particularly in areas of health, education and employment for all persons. But, it is surprising that rehabilitation for persons with disabilities has been left to be implemented through financial assistance to Non-Government Organisations that is further subject to be within the economic capacity and development as well as discretion of the appropriate government and local authorities who may grant financial assistance.
Though Section 28 of the RPWD Act mandates research and development on issues that shall enhance habilitation, rehabilitation and other such issues that are necessary for the empowerment of persons with disabilities, it remains completely detached from the healthcare sector and left to be undertaken through individual and institutions. Such a fragmented approach to rehabilitation is bound to fail in realising the goal of ‘comprehensive healthcare’ for all.
The Covid-19 pandemic has considerably changed the world and disrupted the healthcare delivery, especially in services that require physical interaction, such as rehabilitation. As the government has now added Digital Health to its Ayushman scheme, Information and Communication Technology (ICT) has the potential to revolutionise medical rehabilitation with mobile applications and real time monitoring. However, if the ICT is not accessible, it would fail to benefit all. Therefore, empowering every stakeholder is crucial.
This would also be in line with Chapter 1, Section 2(n) of the RPWD Act, 2016, which mandates accessibility in every mode of information to make it ‘inclusive’: “….information and communication technology includes all services and innovations relating to information and communication, such as telecom services, web based services, electronic and print services, digital and virtual services.”
Talking about the lack of accessible communication, Mr Som Dutt Tyagi describes his ordeal: “I am a deaf person and have to face a great deal of difficulty whenever I visit a hospital; staff and doctors remain clueless about what I say. Presence of a sign language interpreter would help many more people like me when we step out to seek these services.”
We need to ensure that that every document, app and website, including the Health ID, is in a format accessible to visually impaired users. Telemedicine is increasingly being used due to the pandemic. Closed captioning would help make communication between doctors and people with hearing impairment smooth and effective. Employing sign language interpreters at each level of care is also crucial to prevent communication gaps.
We need to focus on needs-based evaluation of the ICT and testing of new technology solutions suitable for rehabilitation in virtual healthcare environments that can be integrated with home healthcare. Emphasising on the need of improvement in the basic infrastructure and services, Ms. Sminu Jindal, Founder, Svayam, says:
“Ayushman Bharat and National Digital Health Mission are brilliant steps. However, we should also focus on the basics – making infrastructure accessible for all. We don’t find any accessible toilet in hospitals or primary healthcare centres. Accessible healthcare infrastructure is the fundamental right. Therefore, the appropriate governments and local authorities must ensure primary, secondary and tertiary healthcare infrastructure is accessible to all. No medical care system is complete without rehabilitation, so obviously it should be included in the system.”
The paradigm shift in our healthcare system would not be possible unless healthcare is understood in its comprehensive form, right from diagnosis to effective rehabilitation. To achieve this goal, rehabilitation has to be considered an essential part of healthcare. Rehabilitation of persons with disabilities cannot be implemented in isolation through discretionary grants by the Ministry of Social Justice and Empowerment to NGOs alone. There is no denying the fact that the voluntary sector has a lot of expertise in rehabilitation that can come handy to supplement the efforts of the nodal ministry i.e. Ministry of Health. However, there is a need to prioritise integration of rehabilitation with the Indian public healthcare system at the earliest so as to make the AB-PMJAY effective, affordable and accessible for all.