The IGUHC Glossary introduces relevant terminology used in the PM-JAY implementation process as well as many commonly used terms in the domains of health systems, health financing, UHC and SDGs, health insurance, gender sensitive health communication, integration of primary, secondary and tertiary health care, research ethics and many more.
Access to Healthcare: is understood as the availability of good health services within reasonable reach of those who need them and of opening hours, appointment systems and other aspects of service organization and delivery that allow people to obtain the services when they need them.
Aspirational District Program: Living standards in India are affected by significant inter-state and inter-district variations. In order to remove this heterogeneity, the government has launched in January 2018, the ‘Transformation of Aspirational Districts’ programme (ADP). Aspirational Districts are affected by poor socio-economic indicators, aspirational in the context that improvement can lead to the overall improvement in human development in India. The 115 districts were identified from 28 states. At the government level, the programme is anchored by the National Institution for Transforming India (NITI Aayog). The objective of the programme is to monitor the real-time progress in the districts by 49 indicators from the 5 identified thematic areas, which focuses closely on improving people’s Health & Nutrition, Education, Agriculture & Water Resources, Financial Inclusion & Skill Development, and Basic Infrastructure. The programme is one of the largest experiments on outcomes-focused governance in the world.
Aversion to Risk: This refers to individual traits of a person who dislike taking risk/uncertainty. The greater an individual’s aversion to risk, the more he or she will be willing to pay in order to obtain insurance coverage
Burden of Diseases: The Global Burden of Disease Study (GBD) is a comprehensive regional and global research program of disease burden that assesses mortality and disability from major diseases, injuries, and risk factors. The GBD measures burden of disease using the disability-adjusted-life-year (DALY). This time-based measure combines years of life lost due to premature mortality and years of life lost due to time lived in states of less than full health. The DALY metric was developed in the original GBD 1990 study to assess the burden of disease consistently across diseases, risk factors and regions.
Beneficiaries: In the context of health insurance, beneficiaries are the individuals or households targeted by a scheme to benefit from a scheme.
Beneficiary Identification System (BIS): It is a process, of applying the identification criteria (as per ABNHPM guidelines) on the SECC and RSBY database to approve/reject the applications entitled for the benefits. AB-NHPM aims to target about 10.74 crore poor, deprived rural families and identified occupational category of urban workers’ families as per the latest Socio-Economic Caste Census (SECC) data. Additionally, all families enrolled under RSBY that do not feature in the targeted groups as per SECC data will also be included.
Brownfield States: states where there was already a state health insurance scheme in place, [as opposed to] greenfield states like Bihar and Haryana where no scheme before Ayushman Bharat was in place.
Catastrophic Health Expenditure: out-of-pocket spending for health care that exceeds a certain proportion of a household’s income with the consequence that the households suffer the burden of disease.
Claim adjudication: After a medical claim is submitted, the insurance company determines their financial responsibility for the payment to the provider. This process is referred to as claims adjudication. Usually, an insurance company can decide to pay the claim in full, deny the claim, or to reduce the amount paid to the provider.
Community Healthcare: is one of the categories in public health which focuses on people and their role as determinants of people’s health and their own health.
De-empanelment: A de-empanelment process can be initiated by an Insurance Company/SHA after conducting proper
disciplinary proceedings against empaneled hospitals on misrepresentation of claims, fraudulent billing, wrongful beneficiary identification, overcharging, unnecessary procedures, false/misdiagnosis, referral misuse and other frauds that impact delivery of care to eligible beneficiaries. A de-empaneled hospital cannot re-apply for empanelment for at least 2 years after de-empanelment.
Disability-adjusted-life-year (DALY): DALYs for a disease or health condition are calculated as the sum of the Years of Life Lost (YLL) due to premature mortality in the population and the Years Lost due to Disability (YLD) for people living with the health condition or its
E-card: At CSCs and empanelled hospital, a process is in place to verify beneficiary details, wherein s/he is asked to provide valid individual and family identification documents/photo-ID. The first time these details are captured, a ‘Silver’ Record is created. After due verification and approval by designated authority, the Silver Record is converted into a ‘Golden Record’ and an e-card is generated for giving it to beneficiary. Thereafter, the beneficiary can avail benefits under PM-JAY.
Empanelment of hospitals: For providing the benefits envisaged under the Mission, the State Health Agency (SHA) through State Empanelment Committee (SEC) will empanel or cause to empanel private and public health care service providers and facilities in their respective State/UTs as per the respective guidelines. The states are free to decide the mode of verification of empanelment application, conducting the physical verification either through District Empanelment Committee (DEC) or using the selected insurance company (source: NHA).
Escrow Account: The Central & State Government / UT shall have to open a separate designated escrow account viz. for Premium and Administrative Expense, with any of the banks as permissible by Ministry of Finance, through which the payment of premium i.e. States / UTs and Central Government’s Share of Premium will be released.
Evidence-based health promotion: The use of information derived from formal research and systematic investigation to identify causes and contributing factors to health needs and the most effective health promotion actions to address these in given contexts and populations.
Fiscal space: Fiscal space is commonly defined as the budgetary room that allows a government to provide resources for public purposes without undermining fiscal sustainability. According to the International Monetary Fund, fiscal space exists if a government can raise spending or lower taxes without endangering market access and putting debt sustainability at risk. Policy use of fiscal space for health assessments can be grouped into the following categories: advocacy for increased public spending on health, input into health financing reforms and strategies, basis for dialogue between health and finance authorities, academic and research purposes.
Fraud: means and includes acts committed by a party to a contract, or with his connivance, or by his agent, with intent to deceive another party thereto of his agent, or to induce him to enter into the contract.
Global Health: Global health refers to the transnational impacts of globalization upon health determinants and health problems which are the beyond the control of individual nations. The distinction between global health problems and those which could be regarded as international health issues is that the former defy control by the institutions of individual countries.
Grievance Redressal: means the mechanisms for receiving, registering and addressing grievances received from any of the aggrieved stakeholders for example beneficiaries.
Health and Wellness Centers (HWC): According to PM-JAY, these centers are to deliver comprehensive primary health care bringing healthcare closer to the homes of people. They cover both, maternal and child health services and non-communicable diseases, including free essential drugs and diagnostic services. Health and Wellness Centers are envisaged to deliver an expanded range of services to address the primary health care needs of the entire population in their area, expanding access, universality and equity close to the community. The emphasis of health promotion and prevention is designed to bring focus on keeping people healthy by engaging and empowering individuals and communities to choose healthy behaviours and make changes that reduce the risk of developing chronic diseases and morbidities.
Health Benefit Packages: According to PM-JAY, to ensure that the hospitals do not overcharge and rates do not vary across hospitals, empanelled health care providers are paid based on specified package rates. A package consists of all the costs associated with the treatment, including pre and post hospitalisation expenses. The treatment packages are very comprehensive, covering treatment for nearly 24 specialities that include super speciality care like oncology, neurosurgery and cardio-thoracic and cardiovascular surgery, etc.
Soon after rollout of the first set of health benefit packages (HBP 1.0), NHA started receiving feedback from stakeholders and various other sources on different aspects of AB PM-JAY’s. All the concerns were deliberated upon in the first Governing Board meeting of NHA, with a mandate given to NHA for rationalization of HBP and development of packages and rates under HBP 2.0.
Health Financing is a core function of health systems that can enable progress towards universal health coverage by improving effective service coverage and financial protection.
Health Insurance:A contract between the insured and the insurer to the effect that in the event of specified events (determined in the insurance contract) occurring the insurer will pay compensation either to the insured person or to the health service provider. There are two major forms of health insurance. One is private health insurance, with premiums based on individual or group risks. The other is social security, whereby in principle society’s risks are pooled, with contributions by individuals usually dependent on their capacity to pay.
Health literacy: Represents the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health. Health literacy implies the achievement of a level of knowledge, personal skills and confidence to take action to improve personal and community health by changing personal lifestyles and living conditions. Thus, health literacy means more than being able to read pamphlets and make appointments. By improving people’s access to health information, and their capacity to use it effectively, health literacy is critical to empowerment.
Health outcomes: A change in the health status of an individual, group or population which is attributable to a planned intervention or series of interventions, regardless of whether such an intervention was intended to change health status. Interventions may include government policies and consequent programmes, laws and regulations, or health services and programmes, including health promotion programmes. Health outcomes will normally be assessed using health indicators.
Health policy: A formal statement or procedure within institutions (notably government) which defines priorities and the parameters for action in response to health needs, available resources and other political pressures. Health policy is currently distinguished from healthy public policy by its primary concern with health services and programmes. Future progress in health policies may be observed through the extent to which they may also be defined as healthy public policies.
Implementation mode of PM-JAY: In case of an insurance mode, implementation is outsourced to insurance companies. These are able to contract operational and administrative aspects of the scheme to third party administrators (TPAs). In case of an assurance mode/ Trust mode, the implementation is handed to a public trust contracting third party administrators. A hybrid or mixed mode can be implemented, too.
According to NHA, earlier experiences in publicly financed health protection schemes suggest that since Trusts share the objectives of the State government, which is to improve access to hospital based care for eligible beneficiaries, they are likely to undertake fewer rejections of claims and the empanelment of more hospitals, for service delivery. On the other hand, Trusts may lack the level of expertise of an Insurance company (IC) in dealing with complex tasks, specifically related to premium pricing and claims management.
Mid-Level Health Care Providers: Mid-level providers are health workers with 2-3 years of post- secondary school healthcare training who undertake tasks usually carried out by doctors and nurses, such as clinical or diagnostic functions. They are increasingly being used to render services autonomously, particularly in rural and remote areas to make up for the gaps in health workers with higher qualifications. Despite their growing role, they are seldom properly integrated into the health system and are not adequately planned for nor managed. (source: WHO)
Needs assessment: It denotes a systematic procedure for determining the nature and extent of health needs in a population, the causes and contributing factors to those needs and the human, organizational and community resources which are available to respond to these.
Noncommunicable Diseases (NCD) – Including heart disease, stroke, cancer, diabetes and chronic lung disease, are collectively responsible for almost 70% of all deaths worldwide. Almost three quarters of all NCD deaths occur in low- and middle-income countries. The rise of NCDs has been driven by primarily four major risk factors: tobacco use, physical inactivity, the harmful use of alcohol and unhealthy diets. The epidemic of NCDs poses devastating health consequences for individuals, families and communities, and threatens to overwhelm health systems. The socioeconomic costs associated with NCDs make the prevention and control of these diseases a major development imperative for the 21st century.
Out of pocket expenditures (OOP): Defined as direct payments made by individuals to health care providers at the time of service use. This excludes any prepayment for health services, for example in the form of taxes or specific insurance premiums or contributions and, where possible, net of any reimbursements to the individual who made the payments.
Output-based Aid (OBA): It is a form of RBF designed to deliver access to infrastructure and social services for the poor. Service delivery is contracted out to a third party—public or private—that receives a subsidy to complement or replace the required user contribution.
Pooling of funds: The accumulation of prepaid funds on behalf of some or all the population.
Portability: Portability enables beneficiaries to seek quality healthcare and treatment under PM-JAY outside their states/ anywhere in the country.
Public health: The science of protecting and improving the health of public through education, policy making, and research for disease and injury safety.
Purchasing of services: The payment or allocation of resources to health service providers.
Quality assurance: In health care delivery, QA focuses on ensuring and maintaining a high standard of the service provided in different health care systems. When the service delivered by the care provider is in accordance with what the recipients of health care expect, then quality in health care is considered to be present.
Quality of care: The extent to which health care services provided to individuals and patient populations improve desired health outcomes. In order to achieve this, health care must be safe, effective, timely, efficient, equitable and people-centered.
Results-based Financing (RBF): see Output-based Aid
Revenue raising: Sources of funds, including government budgets, compulsory or voluntary prepaid insurance schemes, direct out-of-pocket payments by users, and external aid.
Right to health: The right to health is a fundamental part of our human rights and of our understanding of a life in dignity. The right to the enjoyment of the highest attainable standard of physical and mental health, to give it its full name, is not new. Internationally, it was first articulated in the 1946 Constitution of the WHO, whose preamble defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”.
Sustainable Development Goals (SDGs) with special focus on SDG-3: The SDGs comprise 17 global goals for the year 2030 set by the United Nations General Assembly and designed to be a blueprint to achieve a better and more sustainable future for all. Goal 3 aims to ensure healthy lives and promote well-being for all at all ages. UHC is specifically addressed under the health target 3.8 : Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.
Socio-economic caste census (SECC): PM-JAY primarily targets the poor, deprived rural families and identified occupational categories of urban workers families as per the SECC (Socio-Economic Caste Census) 2011 database. In addition, Rastriya Swasthya Bima Yojana (RSBY) active card holders can also avail PM-JAY benefits.
Transaction Management System: It is an IT application which enables the empanelled hospitals to carry out paperless and cashless transactions for providing services to the beneficiaries of AB PM-JAY starting from registration of beneficiary till claim payment to the hospital.
Universal Health Coverage (UHC): means that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship. This definition of UHC embodies three related objectives:
- Equity in access to health services – everyone who needs services should get them, not only those who can pay for them
- The quality of health services should be good enough to improve the health of those receiving services
- People should be protected against financial-risk, ensuring that the cost of using services does not put people at risk of financial harm.
UHC is firmly based on the WHO constitution of 1948 declaring health a fundamental human right. UHC cuts across all of the health-related Sustainable Development Goals (SDGs) and brings hope of better health and protection for the world’s poorest.
Wellness: Wellness is the optimal state of health of individuals and groups. There are two focal concerns: the realization of the fullest potential of an individual physically, psychologically, socially, spiritually and economically, and the fulfilment of one’s role expectations in the family, community, place of worship, workplace and other settings.
Wellness Centers: see Health and Wellness Centers.