Ayushman Bhav initiative: implementation and trend analysis of Medical Camps in Chandigarh

INTRODUCTION

‘Ayushman Bhav’ initiative incepted in 2023, was envisioned to saturate all health care services in every village/ town reaching to the last mile and enabling enhanced health care accessibility to everyone in the community. One of its key components is 'Ayushman-Apke Dwar 3.0', building on the successes of its earlier versions, 1.0 and 2.0. These iterations have focused on three main objectives: raising awareness about the scheme, increasing the distribution of Ayushman cards, and establishing a seamless continuum of care to encourage greater utilization of services under the Pradhan Mantri Jan Arogya Yojana (PM-JAY) scheme.¹

Through the 'Ayushman-Apke Dwar' initiative, over 19 crore Ayushman cards have been distributed, reflecting its substantial impact on improving healthcare access for millions of beneficiaries. The correlation between the penetration of Ayushman cards and the utilization of healthcare services has been evident from the experience of the PM-JAY scheme.¹ Our health care system comprises of a large base of primary health centers and health and wellness centers, for provision of services to community at door step. The secondary care facilities encompass community health centres, sub-district hospitals and district hospitals followed by apex being tertiary care hospitals, which include medical college hospitals.² Medical colleges at the apex of the pyramid provides high-end clinical care. The potential of the medical colleges needs to be utilized for strengthening of health care through existing well-established support systems as envisaged in the National Health Policy.³ In a strive to achieve UHC, a target of SDG, Ayushman Bhav initiative was taken by GOI.

Through this campaign optimal delivery of health services would be ensured along with saturation coverage of health schemes via engaging medical colleges. Involving Medical Colleges creates synergy in implementing public health strategies, benefiting communities. The medical camp's core objectives include providing screening, diagnosis, and comprehensive healthcare, offering specialist services at the block level, and enhancing clinical training for students and faculty, enriching their skills and experience.⁴

In India, several significant health challenges persist, including restricted access, inadequate availability, uncertain quality of healthcare services, and excessive out-of-pocket expenditure (OOPE).⁵ These issues coexist amidst a global dialogue centered on achieving universal health coverage (UHC), which aims to enhance access to high-quality healthcare services at reasonable costs for all individuals.⁶ In recent years, India has made significant economic strides, yet it remains classified as a lower-middle-income nation due to ongoing disparities in both socioeconomic status and health. More than a fifth of the population lives below the poverty line, and there has been a notable shift in demographics, with 34% of the population aged between 15 and 35, as per the 2021 census.⁷ Moreover, India is facing a "triple burden of disease," which includes enduring communicable diseases, an increasing prevalence of non-communicable diseases, and injuries.² Seventy percent of health care is accessed from the private health-care sector and the rest from the public health-care system.⁸

The medical college aims to extend outreach services through community health camps at selected community health centers (CHCs). These CHCs, chosen in consultation with the overseeing committee, prioritize aspirational districts, areas with remote or vulnerable populations, and high population density regions, both urban and rural.⁹ Each medical college supports four CHCs, conducting monthly camps lasting 1-2 days, ideally from 9 am to 4 pm. For a health camp to run smoothly, strategic infrastructural planning is essential. Locating the camp within ensures CHCs easy access, while maintaining clear pathways for vehicles and ambulances enhances efficiency. Inside the camp, consultation rooms should be designed to optimize patient flow, and strict adherence to fire safety protocols is necessary. If surgeries are planned, CHC operation theatres must be well-equipped and adhere to infection prevention measures. Additionally, a designated central waste collection area should be established to ensure safe disposal of biomedical waste, safeguarding public health and the environment.¹⁰ CHCs are mandated to submit quarterly physical work reports and annual financial reports to the district health society. CHCs are encouraged to share medical camp photos on the Ministry's social media for greater visibility. Post-Ayushman Mela camps, analysis and reflection occur through the health report, guiding us through outcomes and impacts, highlighting successes, and areas for improvement in public health.

Analyzing the health report helps us to identify opportunities for enhancing services and improving health outcomes at Ayushman Mela camps. By leveraging insights from the report, targeted interventions can be implemented to address gaps in service delivery and disparities in health. Hence the objective of the study is to analyze the distribution, footfall, and trends of utilization of healthcare services in Ayushman Bhav medical camps at CHC Sector 22 and CHC Sector 45 in Chandigarh.

METHODS

Study design

Descriptive study design.

Study area

The current study was conducted in Chandigarh, a city in North India. The Ayushman Bhav medical health camps were organized in two CHCs (Community Health Centers) of Sector 22 and Sector 45, Chandigarh out of the three CHCs in the city by a tertiary care hospital i.e. GMCH (Government Medical College and Hospital), Sector 32, Chandigarh.

Study duration

The duration of the study was of six months from 15^th September 2023 to 15^th March 2024.

Inclusion criteria

Beneficiaries attending Ayushman Bhav medical camps at the specified CHCs during the study period were included.

Study procedure

Ayushman Bhav medical health camps were initiated with an aim to leverage the resources of existing medical colleges to enhance specialist and outreach services at CHCs by adopting a comprehensive approach that involves both government and society. GMCH is the sole medical college in the city. Hence, a committee was formed by the director health services, Chandigarh administration involving representatives from GMCH and CHCs for organizing the health camps. CHCs possess the necessary infrastructure and healthcare personnel to deliver secondary care services. The initiative relied on effective utilization of available resources in a camp-based model and fixed-day approach to bring specialized clinical services closer to the community. The approach hence had been on enhanced service delivery, aligning with the goals of Ayushman Bharat.

GMCH organized Ayushman Bhav medical health camps at the two chosen CHCs in Sector 22 and Sector 45, located 4.2 Km and 2.3 Km from GMCH, respectively. The Director Principal of GMCH assigned the charge to department of community medicine to coordinate with all hospital specialties for proper execution of health camps.

A structured schedule was developed to hold the health camps weekly at selected CHCs. Accordingly, these camps were organized every Thursday, alternating between CHC, Sector 22 and CHC, Sector 45. Thus, two health camps were held every month at each CHC.

A team of doctors including consultants, senior residents, junior residents from various specialties such as general medicine, community medicine, general surgery, dermatology, pulmonary medicine, obstetrics and gynecology, psychiatry, paediatric, ophthalmology, ent and dentistry along with interns posted in department of community medicine and other medical staff including lab technicians and medical officers participated in these camps adhering to the pre-determined schedule. The duty roster was designed on a rotational basis to ensure specialist services at the health camps without disrupting the delivery of healthcare facilities at GMCH. The initiative featured real-time portal-based reporting and comprehensive analysis, focusing on the footfall distribution across different medical specialties.

This approach was adopted to ensure efficient monitoring and improve the delivery of healthcare services and make it easier to identify and address the needs of the patients attending these events. The cases which were difficult to manage at CHCs and those requiring surgical intervention were referred to GMCH for specialized treatment.

Statistical analysis

The data was entered into Microsoft Excel and analyzed using the Statistical Package for the Social Sciences (SPSS) version 26. Descriptive statistics were presented as means, standard deviations, and frequencies. Linear correlation coefficient was utilized for trend analysis of health care services. Chi square test was utilized to compare the variability among means of different groups. Significant values were identified using 95% confidence intervals, with a significance threshold set at p<0.05.

RESULTS

The Ayushman Bhav health camps in CHCs in Sector 22 and Sector 45 registered a total of 16,331 patients.

The number of patients registered in both sector 22 (51.5%), and sector 45(48.5%) were almost same with Sector 22 registering 8,410 patients (51.5%) and Sector 45 registering 7,921 patients (48.50%). The majority of patients who consulted through general OPDs were from CHC, Sector 22 (71.7%) whereas a comparable percentage of patients from both CHCs, Sector 22 (49.67%) and CHC, Sector 45 (50.3%) consulted through specialist OPDs. Interestingly, all major surgeries (4) performed were in CHC of Sector 22, though minor surgeries were mainly performed (86.0%) in health camps in CHC, Sector 45. Screening services varied, with camps in CHC-22 having higher rates of screening for Hypertension (54.6%), screening with diabetes (56.4%), screening for oral cancer (100%), cervical cancer (60.9%), and cataract (76.8%). In contrast, Sector 45 CHC had higher rates of screening/diagnosed with breast cancer (82.8%). Availing RCH services showed a preference towards CHC-22, with 65.6% of patients, while laboratory tests were more equivalently performed in health camps in both the sectors. A substantial number of patients were referred to higher facilities, with a higher percentage from CHC, Sector 45 (67.8%). Planning for major surgery procedures also leaned slightly towards camps in CHC, Sector 45 (60%), while minor surgery procedures were more evenly distributed (Table 1).

Table 2 depicts the average footfall of patients at the Ayushman Bhav Camps in CHC, Sector 22 and CHC, Sector 45 varied across different healthcare services. For consultations through general OPDs, CHC-22 had a significantly higher average of 75 patients (SD=29.35) compared to CHC-45 (p=0.00), which had an average of 30 patients (SD=17.59). Similar trend was observed in surgeries too as camps in CHC-22 had a higher average footfall for minor surgeries performed, with an average of 6 patients (SD=5.54), whereas camps in Sector 45 CHC had a significantly higher average for minor surgeries, with an average of 35 patients (SD=18.89).

While Sector 22 generally saw more footfalls for various screenings, breast cancer screening was an exception, with Sector 45 averaging 6 patients (SD=8.86) compared to Sector 22's 1 patient (SD=1.31). In health camps, Sector 22 had a higher average of 161 patients availing RCH services (SD=71.74), whereas Sector 45 had 85 patients on average (SD=29.41). However, CHC, Sector 45 notably had a significantly higher average number of patients referred to higher facilities, with 21 patients (SD=12.06) versus sector 22's 10 patients (SD=7.98) (p=0.01).

The study revealed several positive and negative trends in healthcare service utilization across CHCs in Sector 22 and Sector 45. In CHC-22, a positive trend was observed in the number of patients screened for oral cancer (r=0.55, p=0.04) and those diagnosed with breast cancer (r=0.74,

p=0.00). Similarly, in CHC -45, there was a positive trend in patients screened for breast cancer (r=0.69, p=0.00) indicating a proactive approach towards cancer screening and detection. However, both CHCs showed negative trends in several areas. For instance, camps in CHC, sector 45 demonstrated a negative trend in the number of patients registered (r=-0.64, p=0.01), consultations through general (r=-0.80, p=0.00) and specialist OPDs (r=-0.59, p=0.03), and those screened for diabetes (r=-0.67, p=0.01). CHC in Sector 22 also showed significant negative correlations in patients registered (r=-0.39), consulted through specialist OPDs (r=-0.40), and laboratory tests performed (r=-0.66), suggesting a similar decrease in healthcare utilization. Notably, both sectors exhibited negative trends in the number of patients referred to higher facilities (Table 3).

Table 4 depicts the combined trend analysis across both CHCs, Sector 22 and CHC, Sector 45 revealed several significant patterns in healthcare service utilization. There was a significant positive correlation between the number of patients screened for oral cancer (r=0.34, p=0.08), screened with cervical cancer (r=0.38, p=0.05) and those diagnosed with breast cancer (r=0.49, p=0.0099). Additionally, there was a notable positive trend in the number of patients screened for hypertension(r=0.18). However, the correlation for availing RCH services (r=0.02) and minor surgery procedures (r=0.01) planned was minimal, which indicated a weaker association in these areas. Conversely, several negative trends were observed. The number of patients registered shows a strong negative correlation (r=-0.49, p=0.0094). Similarly, consultations through general (r=-0.16) and specialist OPDs (r=-0.50) exhibited a negative trend, indicating a potential decrease in outpatient visits. Also, there was a significant negative correlation with laboratory tests (r=-0.60, p=0.0011) performed and in the number of patients who were referred to higher facilities (r=-0.50, p=0.0087). However, the correlation for major surgery procedures (r=-0.07) planned showed non-significant association.

DISCUSSION

The primary goal of the Ayushman Health Camps was to offer comprehensive health services, including screenings, diagnoses, and basic and advanced medical care. They also provided referrals to specialized diagnostic services and tertiary care hospitals. Moreover, the camp strives to make specialist services available at the block level and to improve the clinical training and materials available to medical students and faculty.¹ A total of 16,331 patients were registered at the Ayushman Bhav Camps in the CHCs located in Sector 22 and Sector 45, Chandigarh with 8,410 patients (51.50%) in CHC-22 and 7,921 patients (48.50%) in CHC-45 which amounts to 0.105% of the total registration of 1,54,41,950 people across 37,664 Community Health Centre camps organized from September to December, 2023 all over the country.¹¹

In the Chandigarh CHC health camps, approximately 8.3% (1,359) of the patients consulted through General OPDs, while a substantial 91.67% (14,972) sought consultations through specialist OPDs. This aligns with the Ayushman health camps organized by IGMC Shimla, where 87.24% of participants utilized specialist services, and 12.74% received services from general physicians.4In contrast, at the national level, the distribution was markedly different, with 71.27% (1,10,05,931) of patients consulting general OPDs and 32.16% (49,67,675) opting for specialist OPDs. This highlights a notable preference for specialist OPDs in Chandigarh compared to the national trend, where General OPDs were more commonly utilized. During the CHC health camps, Chandigarh reported a mere 4 major surgeries and 530 minor surgeries, while the nationwide statistics showed 38,309 major surgeries and 1,30,760 minor surgeries were conducted during health camps.¹¹

The RCH services in Chandigarh Ayushman camps were availed by 3,197 individuals, constituting 0.27% of the total 11,70,126 RCH services across India. In the CHCs of Chandigarh, 29,846 lab tests were performed, representing 0.57% of the 51,59,634 lab tests carried out under CHCs camps all over the country. Across the country, 164,821 patients were referred to higher centers from these camps, with Chandigarh health camps contributing just 0.24% (397) of the referrals. Nationwide, 175,087 major surgeries and 111,454 minor surgeries were planned, while in Chandigarh, only 30 major and 26 minor surgeries planned.¹¹ These findings indicate varying healthcare utilization patterns, highlighting the need for tailored healthcare interventions based on local demands and resources. In Chandigarh health camps, 181 individuals were diagnosed with diabetes, 21 with oral cancer, 99 with breast cancer, 41 with cervical cancer, and 142 with cataracts. In comparison, IGMC Shimla's screenings revealed 1,492 cases of diabetes, 804 cases of oral cancer, 468 cases of breast cancer, and 299 cases of cataracts. The Chandigarh screenings focused more on breast and cervical cancers, while IGMC Shimla's screenings detected higher numbers of diabetes and oral cancer cases.⁴ The current study highlights variations in patient demographics, service utilization and healthcare needs between CHC Health camps in sector 22 and Sector 45. Across both CHCs, a significant moderate positive correlation exists between the number of patients screened for oral cancer, cervical cancer and breast cancer diagnosis reflecting a proactive stance toward cancer screening and preventive healthcare measures. However, negative correlation is observed in patient registration, general consultations and specialist OPDs, indicating reduced outpatient visits and declining trends in healthcare-seeking behaviour across health camps in both CHCs. The number of laboratory tests performed also displayed a negative trend suggesting a decline in diagnostic evaluations. Furthermore, the number of patients referred to more specialized facilities showed a declining trend.

Overall, these findings emphasize the importance of targeted interventions to address declining healthcare utilization trends, ensure continued access to quality healthcare services, and promote proactive measures like cancer screening and preventive healthcare initiatives. The study's limitations include its geographical scope being restricted to Chandigarh. The evaluation of the 'Ayushman Bhav' initiative's impact is based on short-term outcomes, and it does not account for long-term health improvements. Also, there may be confounding factors, such as socio-economic conditions and pre-existing health infrastructure that were not fully accounted for, potentially influencing the results.

CONCLUSION

The study highlights the substantial impact of the 'Ayushman Bhav' initiative, through its community health camps, in improving healthcare access and service delivery in Chandigarh. By involving medical colleges and leveraging specialist services, the initiative addresses critical health challenges and reduces disparities in healthcare access.

These findings underscore the importance of integrating educational institutions in public health strategies and ensuring sustained efforts to raise awareness and distribute Ayushman cards. This would encourage policymakers and health workers to expand such collaborative models, enhance resource allocation for primary and secondary care facilities, and maintain a strong focus on preventive healthcare measures to achieve broader health coverage and better health outcomes for all communities.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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