Ayushman Arogya Mandir: a revolutionary primary healthcare approach shaping India’s path to universal health coverage

Introduction

India's commitment to Universal Health Coverage (UHC) has been a longstanding and progressively evolving initiative, marked by a series of strategic policies and programmatic interventions. The nation has consistently demonstrated its sustained commitment by being a signatory to the Alma Ata Declaration¹ in 1978, and more recently, signing the Astana declaration [1] in 2018. India alike other similarly placed countries, had limited focus on only reproductive and child health related services in primary health care. The selective approach was adopted in taking the geography specific health challenges.

The saturation approach was felt as need of the time. This background paved the way for integration of UHC principles into the National Health Policy 2017² which demonstrated a fundamental shift in India's healthcare strategy, addressing evolving health system priorities after a 15-year gap. The policy advocated for comprehensive primary healthcare, integrating services beyond Reproductive and child health to include chronic and non-communicable diseases, with referral linkages to higher facilities and ensuring continuum of care. By emphasizing higher resource allocation to primary care, the policy aimed to strengthen primary health with a focus on the vulnerable population in both rural and urban areas. For converting the vision into action, Government of India’s flagship program, Ayushman Bharat was launched in 2018.

Ayushman Bharat has four main components:

1. Ayushman Arogya Mandir (AAM)³, erstwhile Ayushman Bharat Health and Wellness Centre, to deliver comprehensive primary healthcare through strengthening and upgradation of existing primary healthcare facilities i.e. Sub Health Centre (SHC) and Primary Health Centre (PHC) in rural and urban areas;
2. Ayushman Bharat Pradhan Mantri Jan Arogya Yojana⁴to provide financial protection to cover poor and most vulnerable individuals in the country for secondary and tertiary care;
3. Ayushman Bharat Digital Mission (ABDM)⁵to ensure access, equity and continuum of care while leveraging information technology and supporting existing health systems in a ‘citizen-centric’ approach; and
4. Pradhan Mantri Health Infrastructure Mission⁶, the country’s largest pan India infrastructure scheme to develop capacity across all levels of care.

India’s health care system is three-tiered with primary health care as the first level of care, typically the first point of contact between citizens and healthcare system, catering to most of the preventive and basic curative health care needs such as SHCs & PHCs. Second tier comprises of the first referral centres providing specialist care, operative services, emergency and critical care, blood transfusion services etc. such as District Hospital (DH) & Community Health Centre, followed by tertiary level of health care for complex diagnostic procedures and treatment modalities acting as institutions for imparting education and research such as medical colleges. As per established norms⁷, a PHC and SHC in rural areas is to be established for a population of 30,000 in plains (20,000 in hilly and tribal areas) and 5,000 in plains (3000 in hilly and tribal area) respectively. Similarly, PHC in urban areas are established for every 50,000 population with SHC for every 15,000 to 20,000 population in close proximity to urban slums.

The AAM initiative was announced with the aim to revolutionize primary healthcare delivery in India by transforming existing healthcare facilities i.e. SHC and PHC into AAM-SHC and AAM-PHC to address critical systemic challenges adversely affecting the Indian health system since decades. As an attempt to move from a selective to a comprehensive approach, the AAM delivers an expanded range of services spanning preventive, promotive, curative, rehabilitative and palliative care across diverse demographic and geographic landscapes, free of cost. Since its launch in April 2018, a total of 176,887 AAM have been operationalized as of March 2025 delivering primary healthcare services across the country, particularly in underserved areas (fig. 1)⁸.

This article focuses on comprehensive overview of the AAM initiative, detailing its key reforms, achievements, challenges, and future directions. It will specifically elucidate India's efforts in fortifying the primary healthcare system and advancing UHC, highlighting the impact and evolution of these initiatives in improving health outcomes and achieving health equity.

Key reforms under Ayushman Arogya Mandir

Infrastructure development

The AAM initiative prioritizes the enhancement of existing SHC and PHC across the nation ensuring that the upgraded facilities, i.e. the AAM-SHC and AAM-PHC are well-equipped to deliver a comprehensive range of services. These enhancements encompass the construction of new buildings, renovation of existing structures, and provision of essential equipment and supplies in accordance with Indian Public Health Standard guidelines⁹. Since the announcement of the scheme, the upgradation of infrastructure coupled with quality certification, adequate sanitization and hygiene practices has been instrumental in the effective implementation of the initiative.

Expanded service delivery

The upgraded facilities now offer an expanded range of 12 services in addition to maternal and child health, addressing the increasing burden of non-communicable diseases such as diabetes, hypertension, cardiovascular diseases, and three common cancers (oral, breast, and cervical) which require long-term management. Currently, 681 million patients are enrolled under the NCD programme of the country and it is progressing well. Historically neglected mental health services are now integrated into primary care, ensuring early detection and start of treatment. In the year 2022, toll free tele mental health assistance (Tele Mental Health Assistance and Networking Across State – Tele MANAS) initiative has been rolled out pan India with more than 2.1 million calls made till date. Additionally, AAM provide services related to ENT care, eye care, oral health, trauma care, geriatric and palliative care, catering to diverse healthcare needs within the community.

Expanded human resources

The introduction of Community Health Officer represents a strategic move to strengthen the healthcare workforce in the primary healthcare system [2]. Community Health Officers (CHOs) are trained professionals managing the AAM-SHCs as the leader of the primary healthcare team, providing clinical and public health services. In addition to managerial responsibilities, the CHOs conduct screenings, manage chronic conditions, provide preventive care, and offer health education. Furthermore, the AAM initiative encourages efforts to keep all types of vacancies filled regularly at the primary level to ensure sufficient healthcare providers to meet the growing service demand. Adequate mix of offline and online training, both classroom and on the job capacity-building programs, enhance healthcare professionals' skills and knowledge, enabling them to deliver high-quality care.

Free medicines and diagnostics

Previously the selective care for Maternal and Child care enlisted limited medicines (57 at SHC) and diagnostics (7 at SHC & 19 at PHC) at primary health care facilities. Under Ayushman Bharat initiative, the list has been expanded and reorganized to 106 essential medicines at SHC, 172 essential medicines at PHC and 14 diagnostics at SHC, 63 diagnostics at PHC required for 12 packages of services at AAM.

Ensuring the availability of essential medicines and diagnostic services is instrumental for the successful implementation of the AAM initiative. These drugs and diagnostics are provided free of cost resulting into significant reduction of Out-Of-Pocket Expenditure (OOPE), making healthcare more affordable and accessible to the population. This approach also enhances treatment regimen, ensures timely and appropriate patient care, reducing the need for referrals to higher-level facilities. Moreover, the country has a robust web/app based portal (Drugs & Vaccine Distribution Management System) for indent, procurement and distribution of medicines and diagnostics consumables ensuring efficient supply chain and warehousing with quality assurance features such as Prescription audit, grievance redressal etc. for monitoring the real-time status of procurement and availability of essential medicines.

Community mobilization

Community mobilization is foundational to the AAM initiative. Engaging the community ensures effective utilization of healthcare services and promotes active individual participation in health maintenance. Health promotion activities include educational campaigns, workshops, and community meetings to raise awareness about preventive measures, healthy lifestyles, and service availability at AAMs. This is bolstered through constitution of Jan Arogya Samiti, Mahila Arogya Samitis, and Village Health Sanitation and Nutrition Committee with representation from community as well as public representatives, overseeing the performance of health facilities and health workers.

Accredited Social Health Activists (ASHAs) and other community health workers play indispensable roles in mobilizing the community, conducting door-to-door visits, organizing health camps, and facilitating access to care in hard-to-reach areas. Their efforts help build trust between healthcare providers and the community, leading to improved health outcomes. Currently, there are more than one million ASHAs in-position in the country with the general norm of one ASHA per 1000 population and one ASHA per habitation in scheduled tribe areas.

Health promotion

Similar to community mobilization, health promotion and disease prevention are central to the AAM initiative with a focus on ‘Illness to Wellness’. AAM facilities are equipped to conduct universal screenings for NCDs, such as diabetes and hypertension, enabling early detection and timely intervention. Additionally, AAMs promote healthy lifestyles through nutritional counselling, physical activity programs, and smoking cessation support. Wellness activities, including yoga sessions and mental health workshops, foster holistic well-being. By prioritizing preventive measures and health promotion, the initiative is resulting in reduced disease incidence and improved overall health outcomes.

Continuum of care

AAM facilities serve as the first contact point for beneficiaries, ensuring timely access to care. This approach minimizes delays in diagnosis and treatment, leading to improved and equitable health outcomes. AAM facilities are integrated into a broader healthcare network, facilitating seamless referrals to secondary and tertiary healthcare facilities when specialized care is required. With the implementation of AAM, approach to healthcare has transitioned from fragmented care to continuum of care. Robust referral systems are ensuring that the patients receive care at the appropriate level, reducing the burden on higher-level facilities and optimizing resource utilization.

Teleconsultation

Teleconsultation is expanding the reach to specialist care directly from rural and underserved areas. Integrating teleconsultation services into AAM facilities enables patients to connect with medical officers and specialists from remote locations, overcoming geographical barriers. Teleconsultation platforms such as eSanjeevani and Tele MANAS facilitate real-time communication between patients and healthcare providers, allowing accurate and timely diagnosis, treatment planning, and follow-up care. This approach enhances the reach and quality of healthcare services, reduces OOPE for patients with the need of long-distance travel in remote areas, and ensures timely consultations. Additionally, teleconsultation supports capacity building among primary care providers particularly the CHOs and Auxiliary Nurse and Midwife (ANM) at the AAM-SHC by enabling them to seek guidance from specialists for handling the patients independently in future.

Provider payment reforms

Provider payment reforms and team-based incentives are essential for the sustainability and efficiency of any health care system. The web/app based online systems to report & verify claims, followed by timely & transparent disbursal of payments & incentives in most the parts of country is helping the country to keep the health workforce motivated to deliver high-quality care. Performance-based payments are linked to specific health outcomes and quality indicators, encouraging adherence to best practices and guidelines among the primary health workforce. Moreover, these reforms align healthcare providers' financial incentives with the initiative's goals, fostering a culture of accountability and continuous improvement in healthcare delivery.

Financial support

The National Health Policy of Government of India envisions increase in public health expenditure to 2.5% of Gross Domestic Product by the year 2025 and strives to allocate two-third of total health expenditure to primary health care. National Health Mission is the one of the largest Centrally Sponsored Schemes of health supported by Government of India, with annual budget of approx. 4 Billion USD for ensuring universal access to quality health care in India. To further build a resilient health system, there is an additional central funding of 8.3 Billion USD through Finance Commission directly to local government (rural & urban) to strengthen primary healthcare system as per local needs.

To further accelerate the process, Pradhan Mantri-Ayushman Bharat Health Infrastructure Mission (PM-ABHIM) has been launched with an outlay of 7.62 billion USD to develop the capacities of primary, secondary, and tertiary care health systems, strengthen existing national institutions, and create new institutions to detect and cure new and emerging diseases.

Achievements so far

Improved access and population coverage

The AAM initiative has markedly increased access to primary healthcare services, especially in rural and underserved regions. By establishing the AAM-SHCs and AAM-PHCs, the initiative has effectively decentralized healthcare delivery, thereby reducing time to care. This decentralization approach aligns with global health strategies emphasizing the importance of accessible and equitable healthcare services. The widespread network of healthcare facilities has significantly improved population coverage. Since its implementation, the cumulative number footfall in the AAM-SHCs and AAM-PHCs have increased from 134.9 million in 2019-20 to 4.04 billion in 2024-25¹⁰ (fig. 2).

Reduced out-of-pocket expenditure

AAM has effectively reduced OOPE for individuals availing essential primary healthcare services at the AAM-SHCs and AAM-PHCs by offering services free of cost. This reduction in OOPE has facilitated improved access to essential healthcare, particularly benefiting economically disadvantaged populations. Patients referred to higher level facilities have the provision to avail services under Pradhan Mantri Jan Arogya Yojna (PM JAY) which provides a health insurance coverage of ~ 6000 USD per family per year for secondary and tertiary care hospitalization the bottom 40% of the Indian population (approx. 550 millions of beneficiaries). According to the recently published National Health Account (NHA) estimates, OOPE had accounted for 64.2% of Total Health Expenditure in 2013-14 and reduced to 39.4% in 2021-22¹¹.

Decongestion of secondary and tertiary healthcare facilities

The AAM initiative has contributed to the decongestion of secondary and tertiary healthcare facilities in the country by strengthening the primary healthcare infrastructure and enhancing access to essential services at the community level¹² [3]. By addressing healthcare needs at the primary level, this program has reduced the patient load on higher-level facilities, allowing them to focus on more complex and specialized treatments. This decentralization of healthcare delivery has improved the overall efficiency and effectiveness of the healthcare system, ensuring that secondary and tertiary institutions are not overwhelmed and can provide better quality care.

Improved population health outcomes

AAM has made a substantial impact towards improved population health outcomes in India by enhancing access to comprehensive healthcare services, particularly for economically disadvantaged groups [4]. The program's extensive coverage of essential health care services and preventive care has led to early diagnosis and timely intervention, thereby reducing morbidity and mortality rates. Maternal Mortality Rate has reduced from 122 in 2015-17 to 97 in 2018-20, Infant Mortality Rate has declined from 37 in 2015 to 28 in 2020 and Under-5 Mortality Rate has reduced from 43 in 2015 to 32 in 2020¹³. Moreover, the financial protection offered has also alleviated economic barriers to healthcare, fostering greater utilization of health services and promoting better overall health within the population.

Improved screening for common NCDs

Historically, primary healthcare systems in India have been predominantly focused on maternal and child health services. The AAM initiative, however, adopts a more holistic approach, incorporating services for NCDs, mental health, and other specialized healthcare needs. This transition is critical in a country where NCDs account for a significant proportion of morbidity and mortality [5]. Emphasizing health promotion and disease prevention is a cornerstone of the AAM initiative. Universal screenings for NCDs such as diabetes and hypertension are conducted at the AAM-SHCs and AAM-PHCs, enabling early detection and timely intervention. From 2019-20 to 2024-25 cumulative number of screenings for hypertension increased from 38 million to more than 1.1 billion and for diabetes, increased from 32 million to 978 million (fig. 3A & 3B). Similarly, screening for three common cancers (oral, breast and cervical) has also improved¹⁴.

Enhanced health wellness activities

Health education campaigns and wellness activities, including yoga sessions and nutritional counselling, are integral components of the AAM initiative. These measures not only foster awareness but also empower individuals to take proactive steps towards maintaining their health. As a result of the initiative, the cumulative number of wellness sessions increased from 1 million in 2019-20 to more than 52 million in 2024-25¹⁴ (fig. 4). Evidence suggests that such integrated health promotion activities can lead to substantial improvements in community health outcomes.

Institutional reform and agent of effective implementation of all health programmes

These AAMs as against the old version of SHC have now become the example of unique experiment of institutional reform comprising all the tenets of the primary health care. As it is evident that these have become trustworthy partners in the implementation of all the health programmes of national importance, they have instilled a confidence in the policymakers to decide ambitious timelines of various health programme roll out or saturation coverage. India has launched the UWIN portal for immunisation drive to keep record of each vaccination dose, eliminate the vector borne diseases such as Kala-azar, Lymphatic Filariasis, Malaria and tuberculosis wholly realising the fact that these SHCs are now the reliable and dependable institutions for ensuring comprehensive primary health care for citizens living in rural and difficult to reach areas of country.

Way forward

While the progress towards citizen-friendly health care has been impressive, taking government health care services till the last mile is an area for improvement. The awareness among masses about health services, health seeking behavior and utilization of health care services in India is dynamic and dependent on multiple factors such as gender, stages of illness, literacy, socio-economic conditions, social beliefs, ease of accessibility, availability of services, time to care and quality of care etc. The efforts for provision of comprehensive care closer to the homes of people keeping along the community approach, intervened with dependable digital technologies will go a long way in reaching the unreached. The ongoing efforts for quality assurance certification (National Quality Assurance Standards issued by Ministry of Health and Family Welfare) of public health care facilities need further strengthening to enhance the trust of citizens in government health systems.

Availability of skilled healthcare workforce is critical to meet the increasing need for health care services. Innovative remuneration policies such as ‘you quote we pay’ for hiring the doctors to work in rural areas, skill based training, career progression through Public Health Management Cadres guidelines, residential facilities near workplace, Incentive mechanism are few sectors which will be focused in coming times.

India’s ambitious initiative ABDM, is a digital ecosystem with health facility and health care provider registry, to maintain the digital health records through the unique Health ID for every individual i.e. Ayushman Bharat Health Account (ABHA ID). It will play a crucial and central role in maintaining the longitudinal electronic health records of patient enabling seamless movement of patient across the health facilities, government or private. The efforts shall have to be energised to use of this feature by maximum patients.

Additionally, impact assessments, monitoring health outcomes, and gathering feedback from beneficiaries and healthcare providers are essential to identify best practices, address challenges, and informed policy decisions.

Moreover, adequate funding on health sector as per expected norms, efficient resource utilization through inter and intra sectoral coordination will be required to sustain the initiative's gains and achieve the overall Sustainable development Goals.

Conclusion

The AAM initiative represents a paradigm shift in India's progression towards UHC, addressing systemic deficiencies within the primary healthcare infrastructure. By decentralizing service delivery and augmenting access to essential services, particularly in rural and underserved regions, the initiative has markedly improved health outcomes and reduced OOPE. Its comprehensive framework, which encompasses preventive, promotive, curative, rehabilitative, and palliative care, has alleviated the burden on secondary and tertiary care facilities, thereby enhancing the overall efficiency and efficacy of the healthcare system. Notwithstanding challenges such as infrastructural inadequacies and workforce shortages, the successful implementation of the AAM initiative has the potential to further advance healthcare equity and improve the quality of healthcare services in the country. Future initiatives must prioritize infrastructure enhancement, adequate human resource deployment, and the integration of technological innovations to consolidate and extend the progress achieved, ultimately furthering the nation’s trajectory towards UHC.