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Vijay S. Madan and Pradeep Shukla Phase V Participants 2010-11
“Greater than all the armies of the world in an idea whose time has come”
There comes a time in the lives of nations as they progress economically and begin to modernize, when their Governments start allocating substantial portions of the national budgets for the health and wellbeing of the people and healthcare becomes a major national issue. This is a journey that all developed countries undertook at some point in time. In India the rationale and demand for such a paradigm shift in Governmental expenditure on healthcare is widely expressed. At present Indian public expenditure on healthcare is only about 1% of the GDP. This accounts for 26% of all healthcare expenditure in the country. Article 47 of the Directive Principles of the Constitution provides that “The State shall regard the raising of the level of nutrition and the standard of living of its people and the improvement of public health as among its primary duties.” The requirement of increasing the public component of healthcare in India is a duty of the Nation. The Planning Commission recognises the need and has included a demand to raise public healthcare expenditure in India to 2% of the GDP in the XIth Plan Document. It is reiterated in the National Health Policy. The NRHM Mission Statement repeats the demand and projects activities based upon it. India’s impressive economic growth and changing profile as an emerging superpower implies that the transition to a higher level of development and concomitant substantially increased level of Governmental involvement and healthcare is on the anvil and has to be considered actively as part of the modernization process of the country. The logic is irrefutable, the resources are available and the demand is from without as well as from within the Central Government itself. Everything is in place. All it needs is a small push which would be the tipping point for a major transition for the well being of the Indian people. We believe that this strategy paper and this interaction with the Performance Management Division is the push which will trigger a permanent transformation in the face of healthcare in India. We believe that comprehensive public healthcare in India is an idea whose time has come.
Vijay S. Madan and Pradeep Shukla Phase V Participants 2010-11
Contents Section I: Vision, Mission, Objectives and Functions Page No.
Section II: Assessment of the situation
Section III: Outline of the Strategy
Section IV: Implementation Plan
Section V: Linkage between Strategic Plan and RFD
Section VI: Cross departmental and cross functional issues
Section VII: Monitoring and Reviewing arrangements
DEPARTMENT OF HEALTH AND FAMILY WELFARE
Section 1: Vision, Mission, Objectives and Functions
VISION By 2025 India will have a stable balanced population, comprehensively covered by public health, having ready access to primary health care with effective linkages to secondary and tertiary health care.
DEPARTMENT OF HEALTH & FAMILY WELFARE MISSION 1. 2. 3. To ensure a stable population in India by 2025. To ensure gender balance in every segment of Indian society. To provide the people of India with a comprehensive coverage of public health extending to all aspects of regulated and state supported urban and rural life. To establish comprehensive primary healthcare delivery system and well functioning linkages with secondary and tertiary care health delivery system. To reduce Infant Mortality Rate to 28 per 1000 live births and Maternal Mortality Ratio to 1 per 1000 live births by end of 12 th Plan, i.e. year 2017. To reduce the incidence and burden of communicable and non-communicable diseases. To develop training capacity for providing human resources for health (medical, paramedical and managerial) with adequate skill mix at all levels. To regulate health service delivery and promote rational use of pharmaceuticals in the country.
----------------------------------------------------------------------------------------------------------DEPARTMENT OF HEALTH & FAMILY WELFARE OBJECTIVES 1. 2. Population stabilization in country. Universal access to Primary health care services for all sections of society with effective linkages to Secondary and Tertiary health care. Improving Maternal and Child health.
4. 5. 6. 7.
Developing comprehensive public health. Reducing overall disease burden of the society. Developing human resources for health to achieve health goals. Strengthening Secondary and Tertiary health care.
DEPARTMENT OF HEALTH & FAMILY WELFARE FUNCTIONS 1. 2. Policy formulation on issues relating to Health and Family Welfare sectors. Evolving and implementing national strategies on issues relating to Health and Family Welfare. Co-ordinating a “national consensus” on critical national priorities pertaining to the issues relating to health factors of Indian society. Co-ordinating with other Ministries and Departments on health issues and programmes which have an inter-departmental ambit. Extending support to states for strengthening their Health care and Family Welfare systems. Providing regulatory framework for matters in the Concurrent List of the Constitution viz. medical, nursing and paramedical education, pharmaceuticals, etc. Focusing on development of human resources through appropriate medical and public health education. Management of hospitals and other health institutions under the control of Department of Health and Family Welfare.
Section 2: Assessment of the situation
At the time of the creation of the World Health Organization (WHO), in 1948, health was defined as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity". This had a primary focus on the curative or “treatment of disease” issues. In 1979 the path breaking Lalonde Report of Canada suggested that with a curative approach the concept of healthcare should also include preventive measures usually labelled as public health, consisting of measures which prevent disease like sanitation and safe drinking water. It suggested that there are four general determinants of health including human biology, environment, lifestyle and healthcare services consisting of both curative and preventive activities. The WHO subsequently broadly accepted this modification. In India the Planning process has also acquiesced to this view and has extended the definition in the 11th Plan Document to state, “Achievement of health objectives involves much more than curative or even preventive medical care. We need a comprehensive approach which encompasses individual health care, public health, sanitation, clean drinking water, access to food and knowledge about hygiene and feeding practice. This is a difficult area because of our sociocultural complexities and also regional diversity. Policy interventions therefore have to be evidence based and responsive to area specific differences.”
In this context a survey of health parameters establishes that Healthcare delivery in India has essentially failed in its objective - to provide an acceptable minimum level of healthcare to the people of India. The prime reason for this shortcoming is the strategy adopted by the Central Government in the last three decades.
Though the 11th Plan Document records that, “health outcomes in India are adverse compared to bordering countries like Sri Lanka as well as countries of South East Asia like China and Vietnam” it does not directly address the primary causes and prefers to limit its observation to - “the targets on MMR & IMR have been missed. Accessibility remains a major issue especially in areas where habitations are scattered and women & children continue to die en route to hospitals. Rural health care in most states is marked by absenteeism of doctors/health providers, low levels of skills, shortage of medicines, inadequate supervision/monitoring and callous attitudes. There are neither rewards for service providers nor punishments for defaulters.” These are symptoms of the malady not the cause - the basic cause, as is explained below, is the strategy and approach of the Government of India.
SURVEY OF HEALTH PARAMETERS Despite impressive economic growth and attaining the status of an emerging superpower with a rightful place as a permanent member of the U.N. Security Council, India has some of the worst health indicators in the world. On many critical health parameters, over a third of the population of India is on par with some of the least developed nations on Earth. The position on some critical health indicators is :1. Malnutrition among children Globally the status of undernourished - underweight children (< 5 years) is as follows:(Source- World Health Statistics-2010) : S. No. Country Underweight 1. India 43.5 2. Afghanistan 32.9 3. Bhutan 12.0 4. Burundi 38.9 5. China 6.8 6. Congo 11.8 7. Egypt 6.8 8. Iraq 7.1 9. Rwanda 18.0 10. Sri Lanka 21.1 11. Tonga 20.5 12 Angola 27.5 13 Bangladesh 41.3 14 Cambodia 28.8 15 Chad 33.9 In India 52% children under 3 years are underweight and 18% are wasted (National family Health survey - NFHS-I, 1992-93). The level of Under-nutrition is much higher in rural areas than in urban areas. Under-nutrition is most serious among children ages 12 to 35 months. However, there is some improvement recently as per NFHS-III. The percentage of underweight children has come down to 46%. As per NFHS-III the percentage of underweight and anaemic children (children 0 - 59 months) in 8 backward States is shown in Table below:S. No. 1. 2. 3. 4. 5. 6. 7. 8. State Uttar Pradesh Uttarakhand Madhya Pradesh Chhattisgarh Bihar Jharkhand Rajasthan Orissa Average India Underweight 42.3 37.9 58.6 46.7 55.8 56.9 40.2 40.9 42.3 Anaemia (< 11 gm/dl) 73.9 61.4 74.1 71.2 78.0 70.3 69.7 65.0 69.3
2. Level of Universal Immunization: The status of complete immunization (measles) for children up to 1 year in some notdeveloped countries is as follows:
(Source: World Health Statistics- 2010)
% DPT III
% Measles Immunized
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
India Afghanistan Bhutan Burundi China Congo Egypt Indonesia Rwanda Sri Lanka Tonga Brazil Columbia Cuba Cambodia
66.0 85.0 96.0 92.0 97.0 89.0 97.0 77.0 97.0 98.0 99.0 99.0 92.0 99.0 89.0
70.0 75.0 99.0 84.0 94.0 79.0 92.0 83.0 92.0 98.0 99.0 97.0 92.0 99.0 91.0
The table shows that India is far behind even underdeveloped countries like Afghanistan, Burundi, Sri Lanka, Rwanda and Tonga in terms of immunization. In India the percentage of fully immunized children for the 4 most backward states in 2005-06 NFHS-III (National Family Health Survey) 2005-06 (NFHS-III) is given in the Table below. As per DLHS-III (2007-08, District Level Household Survey) the percentage of complete immunization has gone up – for example, in Uttar Pradesh it had reached 30.3%. It has further increased ( U.P. 41%) as per Coverage Evaluation Survey 2009 by UNICEF. However the fact of India being behind many of the poorest and most backward nations in the world is undisputed. Also the level of immunisation in Uttar Pradesh, Rajasthan and Madhya Pradesh remains significantly near the levels of the poorest and most backward nations of the world. The levels go down even further if only rural immunisation is considered. This implies that about 40% of the rural population of India has access to immunisation which is amongst the lowest in the world.
S. No. 1 2 3 4
State Uttar Pradesh Rajasthan Bihar Madhya Pradesh
Percentage 22.9 26.5 32.8 40.3
3..Availability of Primary Healthcare The basic Primary Healthcare is being covered through the infrastructure of Community Health Centres, Primary Health Centres and Health- Sub Centres. In India there are total 6500 Community Health Centres, 30000 Primary Health Centres and 1,75,000 Health-Sub Centres. There are over 5 lacs ASHAs in the country providing linkages to the community. For assessing the availability of Primary Healthcare there are no direct measures which factor in these resources in an international context. So a comparative position of availability of hospital beds per capita is examined as an indicator of access to Primary Healthcare in the world:- (Source:World Health Statistics 2010) S. No Country Hospital Beds/ 10,000 Pop. 9 17 30 16 21 13 16 31 24 17 20 18 24
1 India 2 Bhutan 3 China 4 Congo 5 Egypt 6 Iraq 7 Rwanda 8 Sri Lanka 9 Tonga 10 Algeria 11 Bahrain 12 Botswana 13 Brazil 4.Infant Mortality Rate (IMR)
IMR in India is very high in comparison to many not-developed countries in the world:
S. No Country IMR/1000 Live Births (L.B.) Under 5 mortality/1000L.B.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
India Bhutan China Egypt Sri Lanka Tonga Indonesia Philippines Oman Qatar Jamaica Fiji Morocco Iran Mongolia
55.0 45.0 23.0 29.3 11 18.6 26.6 23.1 12.3 8.2 13.6 19.5 30.6 30.6 39.8
78.6 64.8 29.4 33.8 12.9 21.9 31.8 27.2 13.8 10.2 17.2 24.3 36.3 35.5 53.8
(Source-World infant mortality rate 2008—CIA world fact book)
This parameter is one of the critical criteria for gauging the development of civilized societies. Reducing IMR is a Millennium Goal of the world and is a central objective of NRHM. Infant Mortality Rate was as high as 79 per thousand live birth in India as per NFHS-I which has come down to 57 per thousand live birth in NFHS-III, 2005-06. It has further comedown to 53 per thousand live births as per SRS-2008. In India the variations among states are large and the main reason for India’s slow progress is the distance which the backward states have to travel before the level of IMR in the country goes down to a level already achieved by Sri Lanka, i.e. 11 per 1000 live births. The status in the 4 most backward states is as follows S.N. 1. 2. 3. 4. State Madhya Pradesh Orissa Uttar Pradesh Rajasthan Average India IMR (SRS 2008) 70 69 67 63 53
5..Maternal Mortality Rate Maternal Mortality Ratio in various countries (as per World Health Statistics 2010) is as follows: S. No Country MMR Per Lac Live Birth 1 India 450 2 Bhutan 440 3 China 45 4 Egypt 130 5 Iraq 300 6 Sri Lanka 58 The figures for India appear to be erroneous as Maternal Mortality Rate in India was 408 per lac live birth in year 1997 (SRS Data) and this has come down to 254 as per SRS-2004-06. State wise data for the 4 most backward states is as follows: S.N. 1. 2. 3. 4. State Orissa Uttar Pradesh Madhya Pradesh Rajasthan MMR/lac Live Births 480 440 335 388
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Even with a figure of 254 India is far behind a country like Sri Lanka ( MMR 58 ). This parameter is also one of the critical criteria for gauging the development of nations. Reducing MMR is a Millennium Goal of the world and is a central objective of NRHM. 6..Life expectancy According to the population Reference Bureau 2000 world data sheet, life expectancy at birth for Indians is between 60 and 61 years. Only 4% of Indian population is over the age of 65 years. The life expectancy at birth for various countries of the world is as follows:
(Source:-WHO statistics. Health and Social Statistics 2008)
Sl 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Country India Iran Sri Lanka Qatar Pakistan China Malaysia Egypt Philippines Palau Thailand Jordon Kuwait Chile Oman World average
Life Expectancy at Birth 60.50 70.56 74.80 74.14 63.75 72.88 72.76 71.57 70.51 70.71 72.55 78.55 77.36 76.96 73.62 66 years
State wise data for 4 most backward states of India is as follows (source RGI-2003): this data is for the 1995-99 period.
S. No. 1. 2. 3. 4.
State Assam Madhya Pradesh Orissa Uttar Pradesh India Average
Total LE 57.2 56.4 57.7 58.4 61.7
Male 57.1 56.5 57.6 58.9 60.8
Female 57.6 56.2 57.8 57.7 62.5
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7.Undernourishment of women Nutritional status of women is also a point of concern in India. The data is as follows: - Women (ages 15 - 49) with Body Mass Index below normal – 36.2% (NFHS-II, 1998-99) 33.0% (NFHS-III, 2005-06) 51.8% (NFHS-II, 1998-99) 56.2% (NFHS-III, 2005-06) Anaemia is a major cause of Maternal Mortality in India as per NFHS-III, the percentage of anaemic women aged 15-49 is as follows: S. No. 1. 2. 3. 4. 5. 6. State Andhra Pradesh Madhya Pradesh Bihar Rajasthan Orissa Haryana Average India % Anaemic Women 62.0 57.6 68.3 53.1 62.8 56.5 56.1 Women (ages 15 - 49) who are anaemic–
8..Total fertility rate (TFR) Total Fertility Rate (TFR) in some countries of the world is shown in the table below:- (CIA World Factbook 2009) – Figures for 2005-10 S. No 1 2 3 4 5 6 7 8 9 10 11 12 Country India Fiji Panama Guyna Qatar Bhutan Indonasia Kuwait Sri Lanka Vietnam Chile Iran Total Fertility Rate as per UN Ranking 2.81 2.75 2.56 2.33 2.66 2.19 2.18 2.18 1.88 2.14 1.94 2.04 Total Fertility Rate as per CIA Ranking * 2.68 2.65 2.53 2.48 2.45 2.38 2.31 2.76 1.99 1.98 1.92 1.71
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13 14 15
Cuba South Africa Morocco World Average
1.49 2.64 2.38 2.55
1.61 2.38 2.27 2.56
Total Fertility Rate (India average) was as high as 3.4 in NFHS-I and 2.85 in NFHS-II which has come down to 2.68 as per NFHS-III. State wise TFR data for the 4 most backward states is as follows:
S. No. 1. 3. 4. 5.
State Bihar Uttar Pradesh Jharkhand Rajasthan Average India
TFR 4.00 3.82 3.31 3.21 2.68
THE REASONS The Health parameters which graphically indicate the failure of the health care delivery system in India have arisen despite there being a full realisation of the gravity of the situation. The analysis and stated objectives of the National Planning process and the enunciated Policies of the Government of India have recorded the scenario and have clearly articulated the imperative need to address critical issues of health. However the actual implementation by the concerned Ministries has been at serious variance from stated policy and targets incorporated in the Policies have repeatedly not been achieved. This is illustrated subsequently.
THE FIRST BASIC REASON The most critical reason for the under achievement of Health indicators in India is clearly stated in the National Health Policy 2002 – “2.1 FINANCIAL RESOURCES 2.1.1 The public health investment in the country over the years has been comparatively low, and as a percentage of GDP has declined from 1.3 percent in 1990 to 0.9 percent in 1999. The aggregate expenditure in the Health sector is 5.2 percent of the GDP. Out of this, about 17 percent of the aggregate expenditure is public health spending, the balance being out-of-pocket
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expenditure. The central budgetary allocation for health over this period, as a percentage of the total Central Budget, has been stagnant at 1.3 percent, while that in the States has declined from 7.0 percent to 5.5 percent. The current annual per capita public health expenditure in the country is no more than Rs. 200. Given these statistics, it is no surprise that the reach and quality of public health services has been below the desirable standard. Under the constitutional structure, public health is the responsibility of the States. In this framework, it has been the expectation that the principal contribution for the funding of public health services will be from the resources of the States, with some supplementary input from Central resources. In this backdrop, the contribution of Central resources to the overall public health funding has been limited to about 15 percent. The fiscal resources of the State Governments are known to be very inelastic. This is reflected in the declining percentage of State resources allocated to the health sector out of the State Budget. If the decentralized pubic health services in the country are to improve significantly, there is a need for the injection of substantial resources into the health sector from the Central Government Budget. This approach is a necessity – despite the formal Constitutional provision in regard to public health, -- if the State public health services, which are a major component of the initiatives in the social sector, are not to become entirely moribund.” This is graphically illustrated by comparing India’s financial allocations for health with other countries. On the most important criteria of per capita government expenditure India at $11 in 2007 is the significantly the least in the countries listed (which excludes the developed and Arab nations ). An important point is that many countries which were on par with India in 2000 are much ahead in 2007 – Armenia from $7 to $63, Cameroon $6 to $14, Chad $4 to $18, Indonesia $6 to $23, Iraq $5 to $46, Kyrgyzstan $6 to $25, Mali $5 to $18, Rwanda $4 to $18, Sudan $3 to $15 and Tanzania $4 to $14. This emphasis is not visible in India in 2008 ($12), 2009 ($12) or 2010 ($13).
Member State Per capita government expenditure on health at average exchange rate (US$) General government expenditure on health as % of total expenditure on health 2007 26.2 41.2 81.6 80.3 50.8 47.3 26.8 51.0 80.3 69.2 74.6 41.6 25.9 56.3 58.7 44.7 84.2 General government expenditure on health as % of total government expenditure 2007 3.7 9.5 10.7 5.3 13.9 10.4 3.8 15.5 10.7 9.9 13.0 5.4 8.1 13.8 17.9 9.9 18.8
2000 India Albania Algeria Angola Argentina Armenia Azerbaijan Bahamas Bhutan Bolivia Botswana Brazil Cameroon Chad Chile China Colombia 5.0 27.0 46.0 12.0 382.0 7.0 6.0 510.0 30.0 37.0 88.0 107.0 6.0 4.0 169.0 17.0 1300
2007 11.0 101.0 141.0 69.0 336.0 63.0 38.0 783.0 60.0 47.0 278.0 252.0 14.0 18.0 361.0 49.0 239.0
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Congo Cubq Djibouti Dominica Dominican Republic Ecuador Equatorial Guinea
13.0 167.0 30.0 163.0 59.0 17.0 21.0
36.0 558.0 54.0 193.0 61.0 78.0 279.0
70.4 95.5 76.6 62.1 35.9 39.1 80.4
5.1 14.5 14.1 8.2 9.2 7.4 6.9
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Per capita government expenditure on health at average exchange rate (US$)
2000 India Fiji Gabon Georgia Guatemala Guyana Honduras India Indonesia Iran (Islamic Republic) Iraq Jamaica Jordan Kazakhstan Kenya Kiribati Kyrgyzstan Latvia Lebanon Lesotho Libyan Arab Jamahiriya Malaysia Maldives Mali Mauritania Mauritius Mexico Mongolia Montenegro Morocco Mozambique Namibia Nauru Nicaragua Panama Papua New Guinea Paraguay Rwanda Samoa Sao Tome and Principe Senegal Serbia Solomon islands South Arica Sri Lanka Sudan 5.0 68.0 126.0 8.0 38.0 43.0 35.0 5.0 6.0 107.0 5.0 100.0 84.0 26.0 9.0 61.0 6.0 107.0 145.0 14.0 147.0 67.0 113.0 5.0 8.0 76.0 153.0 18.0 72.0 16.0 10.0 90.0 273.0 29.0 208.0 21.0 49.0 4.0 52.0 20.0 8.0 56.0 39.0 101.0 16.0 3.0
2007 11.0 110.0 240.0 34.0 54.0 101.0 71.0 11.0 23.0 118.0 46.0 113.0 150.0 167.0 14.0 160.0 25.0 454.0 234.0 30.0 215.0 136.0 224.0 18.0 14.0 121.0 256.0 52.0 314.0 40.0 13.0 134.0 477.0 51.0 256.0 25.0 48.0 18.0 129.0 480 30.0 252.0 50.0 206.0 32.0 15.0
General government expenditure on health as % of total expenditure on health 2007 26.2 70.2 64.5 18.4 29.3 87.7 65.7 26.2 545 46.8 75.0 50.3 60.6 66.1 42.0 84.0 54.0 57.9 44.7 58.3 71.8 44.4 65.4 51.4 65.3 490 45.4 81.7 57.2 33.8 71.8 42.1 70.9 54.9 64.6 81.3 42.4 47.0 84.5 47.1 56.0 61.8 92.4 41.4 47.5 36.8
General government expenditure on health as % of total government expenditure 2007 3.7 9.5 14.0 4.2 14.1 14.8 19.0 3.7 6.2 11.5 3.1 5.2 11.4 11.2 7.8 10.3 9.8 10.0 11.7 7.9 5.4 6.9 10.5 11.8 5.3 9.3 15.5 9.1 26.4 6.2 12.6 11.1 32.1 16.3 11.6 7.3 11.9 19.5 12.8 13.2 12.1 13.8 15.4 10.8 8.5 6.1
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Per capita government expenditure on health at average exchange rate (US$)
2000 India Thailand Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvatu Ukraine United Republic of Tazania Uzbekistan Vanuatu Venezuela (Bolivarian Republic of) Viet Nam Yemen Zambia Zimbabwe India Median Maximum India African Region Region of the Americas South-East Asia Region European Region Eastern Mediterranean Region Western Pacific Region India Low income Lower middle income Upper middle income Global 5.0 38.0 63.0 104.0 67.0 122.0 36.0 160.0 19.0 4.0 14.0 35.0 113.0 6.0 13.0 9.0 35.0 5.0 62.0 2843 5.0 15.0 829.0 6.0 701.0 36.0 212.0 5.0 5.0 12.0 1577.0 279.0
2007 11.0 100.0 76.0 440.0 107.0 320.0 72.0 291.0 121.0 14.0 19.0 61.0 222.0 23.0 17.0 33.0 36.0 11.0 136.0 6763 11.0 34.0 1374.0 15.0 1546.0 74.0 282.0 11.0 11.0 34.0 2699.0 478.0
General government expenditure on health as % of total expenditure on health 2007 26.2 73.2 70.3 56.1 50.5 69.0 52.1 99.8 57.6 65.8 46.1 76.3 46.5 39.3 39.6 57.7 46.3 26.2 60.3 99.8 26.2 45.3 47.2 36.9 76.0 55.5 67.8 26.2 41.9 42.4 61.3 59.6
General government expenditure on health as % of total government expenditure 2007 3.7 13.1 9.7 9.4 9.1 10.3 10.3 16.3 9.2 18.4 7.9 11.4 7.1 8.7 4.5 14.5 8.9 3.7 10.8 32.1 3.7 9.6 17.1 5.3 15.3 7.5 15.1 3.7 8.7 7.8 17.2 15.4
This illustrates the fact that even after GOI’s proclamation of the Health Policy 2002 budgetary allocations have ignored the Policy’s central emphasis and “necessity” on substantial increase in allocations for health. It is to be noted that the Governmental spending on health in India went up from $5 in 2000 to $11 in 2007 – which was exactly the change ($5 to $11) for the average of the lowest income (least developed, including sub-Sahara Africa) countries in the world. The average increase for the lower middle income countries was from $12 to $34. In
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percentages the increase in per capita governmental health expenditure for lower middle income countries from 2000 to 2007 was 183% ($12 to $34) which was significantly higher than the above stated increase of 120%($5 to $11) for India. The trend has continued in 2008 (Source – WHO) with Indian government expenditure on health at $ 12 per capita while Indonesia spent $ 25, Sri Lanka $ 35, Rwanda $ 23, Nigeria $ 22, Egypt $ 48, Congo $ 34, Bhutan $ 60 and Zambia $ 42. For 2008 the Indian Government’s health allocation as percentage of the total budget (Source – WHO) was 4.1% as compared to 9.5% in Nepal, 7.6% in Sri Lanka, 8.7% in Bhutan, 7.3% in Bangladesh, 13.8% in Chad, 5.1% in Congo, 9.9% in China and 5.7% in Indonesia. This is the most basic reason for India’s backwardness on critical health parameters and an immediate course change in GOI strategy is imperative. THE SECOND BASIC REASON - THE CONSTITUTION OF INDIA The Constitution of India placed “Health” in the State List as entry No. 6 – “Public health and sanitation, hospitals and dispensaries”. There is no health related item in the Union List. In the Concurrent List there are six items relating to Health, namely entries 18. Adulteration of foodstuffs and other goods, 19. Drugs and poisons and 20A. Population control and family planning. Since Independence, the Union Government has not squarely addressed the issue of healthcare, specially preventive Public Health, as this is a State subject. It is again pertinent to quote the National Health Policy 2002 on this – “Under the constitutional structure, public health is the responsibility of the States. In this framework, it has been the expectation that the principal contribution for the funding of public health services will be from the resources of the States, with some supplementary input from Central resources. In this backdrop, the contribution of Central resources to the overall public health funding has been limited to about 15 percent. The fiscal resources of the State Governments are known to be very inelastic. This is reflected in the declining percentage of State resources allocated to the health sector out of the State Budgets”. The concern expressed in the National Health Policy 2002 needs redressal which has to be effected by the Government of India. Besides this the concern of the Planning Commission about the need to increase total Public expenditure on Healthcare as percentage of the GDP has also been ignored. As per the 11 th Plan document- “The Eleventh Plan will try to strengthen all aspects of the health care system - preventive, promotive, curative, palliative and rehabilitative....Public health spending will be raised to at least 2% of GDP during the Eleventh Plan period. However the actual Public health spending in India during the first four years of the XIth Plan has been far short of this target as shown below:-
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Actual Year wise Centre and States combined expenditure on Health and Family Welfare(Source- CRGA (2010, Union Budget 2010-11)) Year Centre’s Expenditure as % of GDP Total Expenditure (Centre + States)
2003-04 2004-05 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11
0.26 0.26 0.27 0.28 0.29 0.33 0.35 0.36
0.90 0.85 0.88 0.90 0.88 1.02 1.06
Public Health Expenditure by Country, 2007 (% of GDP) Highest percentage spent São Tomé Malawi Timor-Leste Iceland France Germany Norway Austria Occupied Palestinian Territories Sweden Luxembourg Denmark United Kingdom Portugal 9.9% Malta 9.6 United States 8.8 Belgium 8.3 Canada 8.2 Switzerland 8.2 Colombia 8.1 Slovenia 7.8 New Zealand 7.8 Italy Czech Republic Lowest percentage spent 7.0% Myanmar 6.9 Pakistan 6.9 Guinea 6.8 Burundi 6.7 Lao 6.7 India 6.6 Azerbaijan 6.5 Bangladesh 6.5 Côte d'Ivoire 0.3% Guinea-Bissau 0.4 Singapore 0.7 Armenia 0.8 Philippines 0.8 Nigeria 0.9 Trinidad and Tobago 1.3% 1.3 1.4 1.4 1.4 1.4 1.5 1.5 1.5
0.9 Sudan 0.9 Georgia 0.9 Angola Central African Republic
6.5 Tajikistan 6.5 Indonesia 6.3 Congo 6.3 Togo 6.1 6.1 Equatorial Guinea
1.5 1.5 1.5 1.5 1.5
7.2 Australia 7.1 Maldives 7.0 Japan 7.0 Israel Croatia
1.0 Chad 1.1 Cameroon 1.1 Nepal 1.2 Viet Nam
ALL OTHER COUNTRIES ARE ABOVE 1.5%
Source: Human Development Report, 2007, United Nations. Web: hdr.undp.org.
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India is thus fifth from the bottom of all countries in the world in terms of public expenditure on health as percentage of GDP.
As per Planning Commission’s 11th Plan Document- “Good health is both an end in itself and also contributes to economic growth. Meeting the health needs of the population requires a comprehensive and sustained approach. Our health services should be affordable and of reasonable quality. The Eleventh Plan will try to strengthen all aspects of the health care system. Public health spending will be raised to at least 2% of GDP during the Eleventh Plan period. Year wise Centre and States combined expenditure on Health and Family WelfareCentre’s Expenditure as % of GDP 2003-04 0.26 2004-05 0.26 2005-06 0.27 2006-07 0.28 2007-08 0.29 2008-09 0.33 2009-10 0.35 2010-11 0.36 (Source- CRGA (2010, Union Budget 2010-11)) For Consideration The actions taken by Government of India in the Health Sector over the years appear to have been largely a response to the demands of the international community, notably the UN and its agencies. 1. The Primary Health Care Model : Year Total Expenditure (Centre + States) 0.90 0.85 0.88 0.90 0.88 1.02 1.06 -
The Alma Ata declaration on Health (WHO/UNICEF 1978) – (based partly on experiments of some Indian States) brought in the concept of “Health for All” through access to Primary Health Care (PHC) approach worldwide. This declaration formed the basis of the first ever National Health Policy 1983 which targeted ‘Health for All’ for India by 2000. The Primary Health Centre model – which embodies the essence of this approach - still remains the most realistic and viable strategy for providing ‘Health for All’ in rural India but has serious performance shortcomings in many States due to lack of Government action, as has been delineated subsequently. 2. Polio Eradication :-
The largest healthcare drive of GOI in the last 15 years is espoused by the WHO. This has been so intense and so repeated (up to 12 rounds per year – with each round witnessing the
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involvement of almost the entire district preventive health machinery and substantive portions of CHC/PHC infrastructure in the states for 5-7 days) that it has diluted the focus on Routine Immunization in states like Uttar Pradesh or Bihar. So while the system has had notable measures of success against polio (now reduced to 41 cases in India in 2010) there are an estimated 300000 deaths in 2009 due to diseases covered by RI which has no similar focus. 3. Millennium Goals of UN and NRHM:
The identification of reduction of Infant Mortality Rate and Maternal Mortality Rate as Millennium Development Goals No. 4 and 5 respectively (enunciated in Millennium Development Goals which have arisen out of the UN Millennium Summit of 2000 that all 192 United Nations Member States have agreed to achieve by the year 2015) has evoked the response of NRHM – National Rural Health Mission - focussed, initially, largely on RCH – Reproductive and Child Health - issues. 4. National Programmes on Tuberculosis and Malaria:
Malaria and Tuberculosis have been under international focus for a considerable period (and are now part of the Millennium Goal No.6) and the Indian response includes active ingredients of external guidance and expectations . The National Vector Borne Disease Control Programme (NVBDCP) definitely includes a range of vector borne diseases besides malaria but the focus on malaria, including setting up of Malaria Research Centre (MRC) by the Indian Council of Medical Research (ICMR) in 1977, was amidst international attention. 5. Aids Control :
The international clamour over AIDS and the inclusion of combating it as Millennium Goal No. 6 has resulted in the creation of a separate Department – NACO, National Aids Control Organisation. However, for an equally, if not more, important national priority of population stabilisation on which the National Population Policy 2000 has been pronounced – a Mission for Family Welfare has not been set up. This had been affirmed in Para 43, Page 15 of the National Population Policy as - “To enhance performance, particularly in states with currently below average socio-demographic indices that need focused attention, a Technology Mission in the Department of Family Welfare will be established to provide technology support in respect of design and monitoring of projects and programmes for reproductive and child health, as well as for IEC campaigns.”
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In their paper, “The Political Economy of State Health Expenditure in India” Sonia Bhalotra and Juan Pedro Schmid have investigated the impact of between and within-state variation in indicators of the quality of democracy on state health spending and infant mortality in India, contributing to a rapidly growing literature on the effects of political institutions on social expenditure and welfare outcomes. State-level panel data including political variables, health expenditure, net domestic product, inequality and rainfall is matched to individual cohort data on almost 200000 births in 1970-1998 across the fifteen major Indian states. They have first investigated whether the level of health expenditure in a state reacts to innovations in infant morality (a direct effect), and whether the size of this reaction is greater when the political marketplace functions better (an interaction effect). They also allow for direct effects of the political variables on health expenditure. Infant mortality is instrumented with rainfall shocks, and the model includes state and year fixed effects and state-specific trends. In this way, under some restrictions, they avoid the problem that changes in the political landscape are determined simultaneously with (conditional) changes in health expenditure. They find that the political variables have no significant effect on health expenditure, whether or in interaction with mortality shocks. In the second leg of the analysis, the dependent variable is infant mortality and they find no political effects again. The results suggest that either the median voter does not care sufficiently about infant mortality or relating infant mortality to political performance has no measurable significance. They observe that, “If salience issues are not key, then the results suggest that the incentives facing political actors are not such as to favour the regular provision of broad-based health services. This is consistent with political actors reacting to big isolated shocks like floods that claim media attention, with public investment in infrastructure projects that favour targeted groups of voters, or with identity-based voting which leads to its own form of targeting”. The authors extracted the estimated state dummy coefficients from the model and regressed these upon averages over the period of the political variables. In this simple crosssectional regression, they find large and significant effects of the political variables on both health expenditure and infant mortality. They conclude that, “It seems therefore that longstanding differences in political culture across the Indian states are pertinent to health outcomes, even if within state periodical variations in political functioning are not”.
OTHER CRITICAL REASONS 1. ISSUE OF “PUBLIC HEALTH” : The 11th Plan Document states – “We need comprehensive approach which encompasses individual health care, public health, sanitation, clean drinking water, access to food and knowledge about hygiene and feeding practice”. The preventive side of healthcare in India is essentially focused on the “vertical” model of controlling specific diseases. In this a structure is created from the field to the top in the State and Central Directorates for some specific disease, like Aids or Tuberculosis or Malaria. This has resulted in notable successes in regards to diseases like Polio and Small Pox.
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However preventive healthcare in the current stage of development in India needs the strategy outlined in the 11th Plan Document which has not been implemented by GOI. A COMPREHENSIVE APPROACH ON PUBLIC HEALTH – which translates into a Multi-Departmental thrust on Public Health as an integral part of the Healthcare Strategy of India clearly including (1) Actions for direct preventive measures against specific diseases by state Medical Departments, Urban bodies and Rural Institutions. These have to be closely coordinated and monitored. (2) Solid Waste Disposal - uniform policies and implementation. (3) Sanitation - uniform policies and implementation. (4) Hospital Waste Disposal - uniform policies and implementation. (5) Clean Drinking Water (6) Dissemination of knowledge about hygiene and feeding practices - uniform policies and implementation. (7) Food and Drug Control - uniform policies and implementation.
2. ISSUE OF POPULATION CONTROL The National Population Policy (NPP) 2000 has laid down short-term, medium-term and long-term targets for stabilisation of population by 2045. One of the important medium term goals in NPP-2000 is bringing down the Total Fertility Rate (TFR - the average number of children a woman bears in her lifetime) at replacement level of 2.1 by 2010. The immediate objective is to address unmet need. It has been emphasised in the NPP-2000 that the achievements in the backward states of UP, MP, Bihar, Rajasthan and Orissa will determine the time and the year in which the country is likely to achieve population stabilisation. An ICMR study by Padam Singh has analysed the magnitude of population problem in backward states vis-a-vis the rest. Table : Total Fertility Rate - States TFR (Figures of 2005) All India Bihar MP Rajasthan U.P. 2.9 3.9 3.6 3.7 4.2
The government informed the Lok Sabha on December 10, 2010 that the Total Fertility Rate (TFR) across the country had declined to 2.6 in 2008 from 2.9 in 2005. While 14 states or Union Territories out of 35 states have achieved the replacement level of TFR of 2.1, four states, viz Daman and Diu, Orissa, Jammu and Kashmir and Tripura have TFR of 2.2-2.5 and seven states have TFR between
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2.6-3.0. Ten states (Bihar, Uttar Pradesh, Madhya Pradesh, Rajasthan, Jharkhand, Chhattisgarh, Meghalaya, Arunachal Pradesh, Nagaland and Dadra and Nagar Haveli) have TFR between 3.0 and 3.9.
The TFR for the group of backward States (combined) was 3.7 in 2005 and on projection would be 3.3 in 2008 which is much higher than what would have enabled the desired TFR of 2.1 by 2010. These States account for 45% of India’s population and their contribution to the shortfall in reaching the targeted level of TFR is about 75%. Their contribution in terms of total births in the country is more than 55%. The infant mortality in these States as well as the under 5 mortality rate continue to be high and account for about 2/3 of infant and child deaths. These states together account for as high as over 75% of unmet need of Family Planning and immunisation of children. The experience of states like Goa, Kerala, Tamil Nadu and Andhra Pradesh where TFR = 2.1 has been achieved, has demonstrated that different approaches have to be adopted in different situations but there is a common denominator of political commitment, administrative support and continuous efforts over a period of time. The figures for unmet Family Planning measures is also the highest in the backward States. NHFS surveys have brought out that the demand for limiting measures is much higher than that for spacing methods. Also the percentage demand satisfied is very low for spacing as compared to limiting methods. It is particularly lower for the states with high TFR, ie, Bihar, Rajasthan, Madhya Pradesh, Uttar Pradesh, Orissa, Meghalaya and Nagaland. Concerted efforts have to be made therefore both for increasing the demand for spacing methods as well as for taking care of the unmet need for the same. Serious, consistent steps focussing on all the various components constituting Family Planning measures with regional characteristics factored in are required urgently. ICMR has identified that there are 133 districts with TFR more than 3.5 which could be termed as demographically weak districts which are required to be specially targeted for faster gains. These districts together account for about 25% of India’s population and over 45% of TFR gap. These districts are mainly from the States of Uttar Pradesh (51), Bihar (24), North Eastern states (28), Rajasthan (9), Jharkhand (9), J&K (6), Madhya Pradesh (3), Uttaranchal(1) and Haryana (1). On the basis of the 2001 Census and the decardal growth rate 1991-2001 North Eastern states, J&K and Haryana are also required to be focused and included in the group of backward states. Table: States with Decardal Growth Rate >25.6 i.e. more 20 % higher than the All India growth rate of 21.34 % (1991-2001) Jammu & Kashmir 29.04 Haryana 28.06 Rajasthan 28.33 Uttar Pradesh 25.80 Bihar 28.43 Sikkim 32.98 Arunachal Pradesh 26.21 Nagaland 64.41 Manipur 30.02 Mizoram 29.18 Meghalaya 29.94
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The Registrar General of India has projected, based on current trends of population growth, that the population of India will be 117 crores in 2010, 125 crores in 2015, 132 crores in 2020 and 138 crores in 2025. The Working Group on Population Stabilization for the Eleventh Five-Year Plan (20072012) has estimated that “the population of India would grow by 1.4 percent during the Eleventh Five-Year Plan period (more precisely during 2006-11). Even by 2021-26, the population is expected to have a growth rate of 0.9 percent. An important assumption underlying this projection is that the total fertility rate would reach replacement level (approximately 2.1) only by 2021. The reason behind this gloomy expectation is the slow pace of fertility transition in several large, north Indian states. In fact, according the Technical Group, TFR would not reach the replacement level in some of these states even by 2031. Although the Technical Group did not carry forward the projection till the date of stabilization, the projected delay in reaching the replacement-level fertility would imply that India’s population would not stabilize before 2060, and until population size nears 1.7 billion.” This indicates that, besides all the Recommendations of the Working Group and the current level of State intervention, there is an imperative need to take up Family Planning in a ‘Mission Mode’ in the nation, specially for the backward States. The Technology Mission for Family Welfare postulated to be set up in the National Population Policy 2002 should be put in place with immediate effect.
3. HEALTH FOR ALL – PRIMARY HEALTH CARE APPROACH The National Health Policy 1983 postulated the target of ‘Health for All’ by 2000 which was broadly based on the 1978 Alma Ata Declaration on Health (WHO/UNICEF 1978) and the pledge made to achieve ‘Health for All’ through the Primary Health Care (PHC) Approach. The principles of the PHC Approach are as relevant today as they were nearly 30 years ago and provide a guide not just for the organization of health care systems, but also for how health care systems should act as an engine for promoting health and development. The Alma Ata Declaration, sponsored by WHO and UNICEF, arose from the observation of failings in health care systems, as well as the positive results from health programmes in countries such as India, Nicaragua, Costa Rica, Guatemala, Honduras, Mexico, Cuba, Bangladesh, the Philippines and China (Commission on the Social Determinants of Health 2005). The term ‘Primary Health Care Approach’ came to be associated with the health care elements of the Declaration and can be summarised as follows : First, it stresses a comprehensive approach to health by emphasizing ‘upstream interventions’ aimed at promoting and protecting health such as improving household food security, promoting women’s literacy and increasing access to clean water. This places a greater emphasis on preventive interventions and counters the biomedical and curative bias of many health care systems, and promotes a multi-sect oral approach to health. Second, it promotes integration – of different clinical services within health facilities, of health programmes and of different levels of the health care system. This recommendation was partially in response to the limitation of ‘vertical’, stand-alone disease control
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programmes and to the observation that hospitals in many countries were not adequately involved in strengthening primary-level health care. Third, it emphasizes equity. This recommendation would, for example, aim to correct the neglect of rural populations, as well as socially and economically marginalized groups, within many health care systems. Fourth, it advocates the use of ‘appropriate’ health technology, and health care that is socially and culturally acceptable. Fifth, it emphasizes appropriate and effective community involvement within the health care system. And sixth, it adopts a strong human rights perspective on health by affirming the fundamental human right to health and the responsibility of governments to formulate the required policies, strategies and plans of action.
India had aggressively expanded the Primary Health Centre and the District Health System (DHS) as an organizational framework to deliver the PHC Approach. After the Alma Ata declaration, for many countries in the world, the PHC Approach and DHS model formed the conceptual and organizational pillars respectively for the attainment of Health for All. However, in India, in a number of States, the DHC/PHC model failed to deliver the objective of Health for All In essence the failure of the Indian Healthcare system delivery is the failure of the PHC/DHC model. Any program for real extension of healthcare to the people of India has to ensure strengthening and effective functioning of the PHCs. In India the following features have impaired the functioning of the PHC model, especially in the Backward States. Continuous shortfall in real public health expenditure. (The United Nations Commission on Macroeconomics and Health 2001 had estimated that low and lower middle-income countries need to spend at least US$ 30-40 (2002 prices) each year per person it they are to provide their populations with ‘essential’ health care through the DHC/PHC model. The figures for India are substantially lower) Chronic shortages in availability of doctors and in actual presence of physicians in PHCs. A catastrophic loss of morale and motivation of subsidiary public health workers as the absence of doctors and of effective monitoring reduced the perceived value of their work and undermined their ability to perform. Selective health care and Verticalization. Deterioration of health facilities and equipment; Shortages of drugs and other supplies; Minimal patient attendance at PHCs as the quality of care available did not attract patients.
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The first reason has been discussed earlier. The second and third reasons arising from a shortage in supply of doctors and the fourth reason of “Vertical Healthcare” merit separate attention as these are critical reasons which do not have a genesis in paucity of funds. 4. SHORTAGE OF DOCTORS The capability of health programmes to effectively reach the vast majority of the rural masses depends on the quality, distribution and utilization of health manpower. The evolution of the health manpower policy in Indian since 1947 has been characterized by two different models of health manpower development. One model is based on primacy of “quality considerations” in design of health care programmes which saw the exclusive dependence on allopathic MBBS doctors for delivery of not only primary curative functions but also public health programmes in the first two decades after independence. Since the 1970s there has been recognition of the need to usher in rural health schemes based on utilization of indigenous medical practitioners and paramedical personnel besides MBBS doctors. The Community Health Volunteer (CHV) scheme was launched in 1977. It has been extended by the system of ANMs and, more recently, of ASHAs and AYUSH doctors at primary health centres. The evolution of this second model has definitely modified the perception of medical and health delivery over the last mile in rural areas. However the need for MBBS doctors remains critical even in this process. The National Health Policies of 1983 and 2002, the Plan Documents and the various strategy papers and budget speeches of the Department of Health and Family Welfare continually repeat the need for developing adequate human resources. However Government of India has never stated or implemented, as an objective, the task of actively increasing the production of quality trained MBBS and post graduate Allopathic doctors. This task has been left to the Medical Council of India (MCI) with no effective monitoring, despite the fact that this is has adversely affected the adequate availability of a critical national human resource. The uneven functioning of the MCI is reflected in both the limited capacity of existing allopathic medical education in India as well as the skewed distribution of medical colleges in the country. State Name AP BIHAR KARNATAKA KERALA MAHARASTRA MP ORISSA PUNJAB RAJASTHAN TAMILNADU UP Total in India Total intake in India Number 36 9 39 21 41 8 6 8 10 37 21 300 11192
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Source - As per MCI Website data sheet. Distribution of Medical Colleges in India Distribution of Nursi Colleges in India
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The skewed distribution of doctors is reflected in the vacancies in the state PMS Cadres as given in the Table below: Strength of PMS Doctors /Vacancies in States Total No of Sanctioned In % in Dist. Posts of Vacancy Position Position Hospitals doctors in the State 71 50 32 33 14 27 13789 5809 4727 5767 2465 4213 8278 4094 2961 4580 2769 3610 60.03 70.48 62.64 79.42 112.33 85.69 5511 1715 1766 1187 -304 603
1 2 3 4 5 6
U.P. M.P. Orissa Rajasthan Kerala Tamil Nadu
39.97 29.52 37.36 20.58 -12.33 14.31
Source - RHS Bulletin GOI 2008 and individual Directorate officials.
States like U.P., M.P., Orissa and Rajasthan have a problem in ensuring the basic presence of doctors at PHCs because the vacancies are essentially in the lowest pay scales which normally serve in the Primary Health Centres.
In Uttar Pradesh in 2009, as many as 5500 vacancies were advertised by UPPSC. 2800 doctors applied, 1600 turned up for the interview and were selected of which finally 1100 joined. On being asked by the Directorate fresh MBBS graduates stated that the pay scale and facilities do not suffice for them to reside in the rural PHCs. They stated that they have aspirations like other young graduates and would not exchange the lifestyle offered by district headquarters or towns in exchange for a rural residence on the packages being offered.
5. SELECTIVE HEALTH CARE AND VERTICALISATION ‘Selective health care’ refers to a limited focus on certain health care interventions, as distinct from comprehensive or holistic health care. The most common argument in favour of selective health care is that, until health care systems are adequately resourced and organized, it is better to deliver a few proven interventions of high efficacy at high levels of coverage, aimed at diseases responsible for the greatest mortality (Walsh and Warren 1979). Selective health care tends to be associated with ‘vertical programmes’- generally meaning separate health structures with strong central management dedicated to the planning, management and implementation of selected interventions – partly because of a lack of adequate health care infrastructure, but also because it often reflects a scientific and biomedical orientation that emphasizes the delivery or ‘medical technologies’ amenable to vertical programmes. Just as smallpox was eradicated through a concerted global effort, for instance, it is argued that diarrhoeal disease, malaria and other common diseases can be tackled in a similar way.
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By the early 1980s, WHO, UNICEF and major bilateral donors, notably USAID, had endorsed this approach, the focus of MOHFW has shifted to “vertical” programmes leaving the PHC to the states. Complex health problems with underlying social and economic determinants were recast as problems to be treated or prevented through the delivery of effective technologies. The participatory and bottom-up orientation of the PHC Approach has been downgraded, and the socio-political orientation of Alma Ata, with its emphasis on community empowerment and socio-economic equity, replaced by an approach that treated poorer communities more as passive recipients of health care than as active participants. Although selective health care was advocated on the grounds that basic health care infrastructure is inadequate, it was not implemented in conjunction with a plan to strengthen such infrastructure at the same time. As a result, the selective and vertical programmes on Kala Azar, Small Pox and Polio have had results only in targeted sectors because they have not been followed by the establishment of permanent health services to sustain the on-going control and prevention of other diseases. Worse still, because of their demands on the time and resources of the entire system, they have actually undermined the development of routine health care systems. For example, the Polio campaign has often been prioritized to such an extent that other services have been disrupted and the long-term development of sustainable routine immunization services hindered, especially in Uttar Pradesh and Bihar. 6. THE NATIONAL RURAL HEALTH MISSION.
The National Rural Health Mission ( 2005-2012 ) is the most ambitious undertaking of GOI with a preamble that “Recognizing the importance of Health in the process of economic and social development and improving the quality of life of our citizens, the Government of India has resolved to launch the National Rural Health Mission to carry out necessary architectural correction in the basic health care delivery system. The Mission adopts a synergistic approach by relating health to determinants of good health viz. segments of nutrition, sanitation, hygiene and safe drinking water.” It begins by recording the State Of Public Health in India as follows:Public health expenditure in India has declined from 1.3% of GDP in 1990 to 0.9% of GDP in 1999. The Union Budgetary allocation for health is 1.3% while the State’s Budgetary allocation is 5.5%. Union Government contribution to public health expenditure is 15% while States contribution about 85% Vertical Health and Family Welfare Programmes have limited synergisation at operational levels. Lack of integration of sanitation, hygiene, nutrition and drinking water issues. There are striking regional inequalities. Population Stabilization is still a challenge, especially in States with weak demographic indicators.
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The Vision Statement records the following:• The Mission is an articulation of the commitment of the Government to raise public spending on Health from 0.9% of GDP to 2-3% of GDP. • It aims at effective integration of health concerns with determinants of health like sanitation & hygiene, nutrition, and safe drinking water through a District Plan for Health. • It seeks to address the inter-State and inter-district disparities, especially among the 18 high focus States, including unmet needs for public health infrastructure. The Goals include:-Reduction in Infant Mortality Rate (IMR) and Maternal Mortality Ratio (MMR) -Universal access to public health services such as Women’s health, child health, water, sanitation & hygiene, immunization, and Nutrition. -Access to integrated comprehensive primary healthcare -Population stabilization, gender and demographic balance. The underlined parts illustrate that the issues being outlined in this Strategy Paper have again been reiterated by GOI (MoHFW). However, in a repetition of a recurrent theme, the Strategies, Action Plan and actual implementation of NRHM do not address the issues which are at the core of the problems in the Indian Healthcare delivery system. This point is so significant that the entire Strategies and Action Plan from the NRHM Mission Statement are re-capitulated here as Annexure-1. The Strategies and Action Plan of NRHM again do not adequately address the core issues which are underlined in the Preamble, the Vision Statement and the Goals of NRHM. The Preamble postulates “The Mission adopts a synergistic approach by relating health to determinants of good health viz. segments of nutrition, sanitation, hygiene and safe drinking water.” This critical point of preventive Healthcare which should be actively assimilated in the Healthcare delivery mechanism of India as integral component – right from the Level of the Planning Process, the Ministries/Departments, the State Government Departments/Organisations/Directorates to the field has just been included as a Sanitation/Hygine co-ordination and monitoring effort at the district level. The INSTITUTIONAL MECHANISMS envisaged in the Mission Statement have only an additional provision for a National Mission Steering Group chaired by Union Minister for Health & Family Welfare with Deputy Chairman Planning Commission, Ministers of Panchayat Raj, Rural Development and Human Resource Development and public health professionals as members, to provide policy support and guidance to the Mission. This essentially dilutes the entire thrust on an integral National approach to Preventive Healthcare. Even the programmes and functioning of the Women and Child Development Department are not effective integrated vertically with the MoHFW despite the fact that the Integrated Child Development Services Scheme (ICDS), a flagship scheme of GOI with an allocation of Rs. 8,700 crore in 2010-11 seeks) “to provide an integrated package of health, nutrition and educational services to children up to six years of age, pregnant women and nursing mothers. The package
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includes supplementary nutrition, immunization, health checkup, referral services, nutrition & health education and non-formal pre-school education” (to quote the Expenditure Budget Document 2010-11). In order to universalize the scheme, the Government has, in 2010-11, approved additional 792 Projects and nearly 3 lacs Aganwadi Centres, taking the total number of projects to 7076 and Anganwadi Centres/Mini-Anganwadi Centres to 14 lacs, including 20,000 Anganwadi on demand. Uttar Pradesh has, for example, 3 lac female Aganwadi workers (as compared to 1.2 lac ASHAs) which are not working in tandem on common issues. Only recently, in 2010, have the MoWCD and MoHFW come out with a joint GO signed by the two Secretaries. Effective close co-ordination and monitoring are not yet on the anvil. The State of Public Health in India and the Vision Statement postulate “Public health expenditure in India has declined from 1.3% of GDP in 1990 to 0.9% of GDP in 1999” and “The Mission is an articulation of the commitment of the Government to raise public spending on Health from 0.9% of GDP to 2-3% of GDP.” For implementation the Mission Statement records, “The Outlay of the NRHM for 2005-06 is in the range of Rs.6700 crores.The Mission envisages an additionality of 30% over existing Annual Budgetary Outlays, every year, to fulfill the mandate of the National Common Minimum Programme to raise the Outlays for Public Health from 0.9% of GDP to 2-3% of GDP.” The year wise estimated versus actual allocation under NRHM displayed below is quite at testimony to the shortfalls in financial allocations which often impair and distort the original concept. The Ministry of Health and Family Welfare, of course, passes on the shortfalls to the state governments without much of an explanation or indication as to how the state governments are expected to cope with such shortfalls.
Year YEAR WISE ESTIMATED Vs ACTUAL ALLOCATON UNDER NRHM. Estimated Allocation - GOI ( SourceActual Allocation Made (Source - NRHM -5 NRHM framework for implementaion yr of implementation - the journey so far 2005-12, MOHFW, New Delhi-Page 93) 2005-10, MOHFW, GOI)
2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12
6500 9500 12350 17290 24206 33884 47439
5703 7486.6 10890 11930 14050 15440 To be decided in Feb-mar 11
The Mission Document of NRHM contains “MAINSTREAMING AYUSH” as a major component of the strategy. While the contribution of AYUSH doctors is welcome, the attempt in NRHM to address the issue of non-availability of MBBS doctors at Primary Health Centres by
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substituting AYUSH doctors for MBBS doctors is not in the interest of providing modern medicine to the rural population. NRHM document does not contain any provision or proposal for providing incentives to MBBS doctors to increase their availability at PHCs. Central Government employees in the North East and “hard areas” are entitled to special incentives such as hard areas allowances, retention of residential accommodation in previous place of posting, shorter tenures and children education allowance etc. in the context on the significance and importance of healthcare and availability of doctors such incentives should be made available for Allopathic doctors in rural areas to compensate for the “hard life” in isolated conditions.
During the past 5 years of implementation, the Mission has made a substantial impact in creating greater awareness about antenatal care with the help of ASHAs who have been appointed for every 1000 population. This has resulted in an increase in the number of institutional deliveries, post-natal care and child immunization as well as the number of outpatients being provided with healthcare services in the health facilities at various levels. With less than 15 months remaining before the completion of its tenure of 7 years, it is of paramount importance that the Government declares its intention to continue with the initiative in the manners envisaged. In dealing with the State Governments for implementation of the NRHM, the corner stone of the relationship is the ‘flexibility’ permitted in determination of measures as well as the mode of carrying them out, particularly as ‘one size fits all’ dictum does not work in the diverse situations that may exist in different States. Substantial progress has been made in providing untied funds at all levels of facilities, and permitting the much needed flexibility for outreach of services and so on. While some of these achievements are commendable, a lot more needs to be done and indeed, the scale of the challenge that remains is immense. In this connection, signing of Memorandums of Understanding (MoUs) between the state governments and the central government is important in order to bind the states through the benchmarking of performance. Also, in addition to the funding of inputs, it is important, and perhaps more effective to link the payments/ allocation to agreed outputs. The basic intervention on demand side made in implementation of NRHM has quite clearly worked in creating a much higher level of demand for public health services. For example, the total outdoor patients in Government hospitals in Uttar Pradesh went up from 3 crores to 6 crores in the period of NRHM implementation. The challenge now, more than ever before, is to make the systems and processes to function better in order to meet this surging demand through a set of corrective measures, such as: 1) to address financing issues, and to increase public health spendings in general, and for NRHM in particular; 2) to improve the recruitment procedures, carry out comprehensive training, ensure effective control and monitoring, and make timely and adequate payments for the ASHAs; 3) to appoint public health managers and ensure an effective and efficient management structure for the health facilities at the village, block and district levels; 4) to put in place a well-defined and implementable role of the Panchayati Raj Institutions (PRIs) and to establish a comprehensive and on-going training program for the panchayat members; 5) to ensure that commensurate physical infrastructure and human resources exist in the sub-
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centers and the Primary Health Centres that respond to the growing needs of the regions; and 6) ASHAs and ANMs to work hand-in-hand with the Aanganwadi workers of the Integrated Child Development Scheme. It is necessary to incorporate easily accessible advances in technology in addressing the chronic gaps in rural healthcare delivery. Special efforts however we need to be made to ensure that be technologies adapted in such a way that they become rugged and can be used in the prevailing skill-sets and constraints in the rural areas. For example, a specific recommendation for reduction of IMR can be to tackle hypothermia.(One of the major causes of IMR is the birth of premature and low-birth-weight babies who are at high risk of death or disability because of hypothermia) A potential solution to the problem of hypothermia in neonates is a low-cost infant warmer (traditional incubators are expensive both in terms of purchase price and running costs). In 2007, a number of design and business students at Stanford University, developed the Embrace infant warmer, which uses an innovative phase-change material to regulate a baby’s temperature, and is likely to cost a little over Rs. 1000. The infant warmer does not require electricity for its operation, has no moving parts, is portable, and is safe and intuitive to use. The clinical trials for the equipment are likely to be completed shortly. Inclusion of this item in ANM kit (and ASHA kit over time) could really be a valuable add-on, particularly as the equipment is re-usable and amenable to sterilization. A specific intervention for upgrading the access available at PHCs and sub-centres can be Tele-medicine. Initially, the Tele-medicine can be introduced through Mobile Medical Units (MMUs) that have been deployed in majority of the Districts (an a country wide deployment is expected to be completed by 2012). The Tele-medicine module carry its own satellite connection and would be powered by the Mobile Van, or auxiliary battery carried by it. This would permit a visual inspection and a voice contact between the doctor and the patient in real time, besides the assistance that can be provided by the paramedic or the nurse. In cases where an MBBS doctor is deployed with MMU, these module can be utilized for consulting specialist at CHC, district hospitals or even medical colleges (nationally or internationally). Over a period of time, diagnostic equipment can be redesigned to provide the results, in real time, through data transfer. Enough trials have already been done to indicate that these are all within the realm of immediate possibility, provided funding support is given. FOR THE ASSESSMENT: 2A - External factors which will have an impact: Political: At the political level Health is not a critical parameter. However major positive initiatives in the Health sector have a relevance for publicity and delivery to the poor and should be welcome at the political level. Socio Cultural: Health interventions are largely welcome across all sections of society. However the issue of family planning has been sensitive in India with various religious and political groups opposed to any kind of coercion in family planning. Technological: Technological advances affect strategies in Healthcare. Currently the reach and impact of rural schemes can be multiplied by use of communication technologies, mobile medical units and GPS fitted emergency ambulance services.
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2B-Stakeholders : The stakeholders in the Health sector are 1. Government of India 2.State Governments – have to implement the programmes. Demand resources. 3.People of India – expect delivery. 4.Political Parties and Press/Media – expects delivery with a critical evaluation of performance. On Issues of family planning political response can be reactive and biased. 5.Medical and Paramedical cadres in the Central and State Governments – is the cutting edge for delivery. Expect better service conditions and remuneration. 6. Private Sector in Medicine – expects support and minimum regulation. Delivers the major portion of Healthcare in the country. 7.UN Agencies and International Donors – Active participants in Governmental and NGO schemes and activities. 2C- Strengths and Weaknesses : India’s strengths in Healthcare are a strong economy with high rates of growth which permits increase in the level of financial intervention. An educated, competent reservoir of qualified medical and paramedical personnel. An elaborate delivery system existing from existing down to the Nyay Panchayat level. Availability of “best in class” curative services. An extensive technological knowledge base with concomitant technological systems, like communication, in place. A strong pharmaceutical and medical equipment industry. Growing medical tourism. India’s weaknesses in Healthcare are political apathy towards Healthcare and a low level of public expenditure on Healthcare. A chaotic unorganised private sector providing 76% of Healthcare nationally and over 75% of Healthcare in rural areas. Skewed distribution of doctors/specialists/nurses focused on certain regions of the country and largely urban based in backward states. A huge number of unqualified/unlicensed private medical practitioners specially in the rural areas. A demoralised state delivery cadre at the PHC/Sub centre level in many parts of backward states. Serious shortage of doctors in state medical cadres in backward states. Public apathy compounded by a lack of basic hygiene, sanitation and even of safe drinking water and nutrition in significant parts of the country. The main reasons for the poor health parameters in the country have been given in detail in the analysis above. 2D- Learning Agenda: The learning agenda from six decades of independent India’s tryst with healthcare is that piecemeal efforts and changing strategies have resulted in abysmal health parameters despite some islands of success and excellence. What is needed is not to do different things but to do things differently. More of the same is not going to generate any basic transformation. India needs a paradigm shift in the entire sector of public healthcare delivery to effect substantive and urgently needed improvement.
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Section 3: Outline of the Strategy
“Greater than all the armies of the world is an idea whose time has come” (Victor Hugo) The idea of a comprehensive healthcare delivery system for the citizens of India is an idea whose time has come. 3A- Background and possible strategies: India is now “on the surge” and with consistent high levels of economic growth and is emerging as a major power in the world. The people of India, the political system and socioeconomic realities demand a better deal for the citizens and healthcare is a vital need of all human beings. It is for the Ministry of Health and Family Welfare to aggressively assert the requirements which would transform healthcare in India permanently. The strategy has to be bold and incorporate radical departures from the past because more-of-the-same or mere modifications are not going to result in the quantum jumps needed for the required metamorphosis. The assessment of Healthcare delivery system in Section 2 establishes that restructuring of the Centre Government’s role to increase the dimensions of Public Healthcare in India as well as more attention to regional disparities and requirements is imperative if India is to move out of the category of nations with the poorest health parameters. There is really no alternative to a much larger financial commitment by the Government of India, urgent realisation of the pronouncements incorporated in the Plans and Policies and directly focusing on the issues and weaknesses of the backward states. Strategy Initiatives: The strategy outlined here consists of addressing the core causes which have resulted in the shortcomings of the Indian Healthcare services discussed above. Essentially it consists of affirming that Government should do what it is saying it should do. That is, that the Ministry of Health and Family Welfare has to ensure implementation of what the Plan Document, the National Health Policy, the National Population Policy and the Mission Statement of HRHM are stating are essential Goals for the nation. This implies that, at the initial stage, the Ministry of Health and Family Welfare has to assert the Central Government’s commitment to a more comprehensive healthcare delivery in the country than has ever been undertaken before. (There has been no pronouncement of extension or announcement regarding the future of the flagship programme of MoHFW-NRHM which is supposed to end on 31-03-2012. This should immediately be clarified by Government of India.)
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As an essential part of the commitment of the Central Government there has to be an acknowledgement that Healthcare is a requirement of the citizens of India for which the Union and State Governments are both responsible. For this it is necessary to AMEND THE CONSTITUTION to include Healthcare and Public Health in the Concurrent List. The second component of the strategy is to acknowledge that in modern societies, for the health and well being of the citizens, preventive measures are as relevant as curative measures and in India also Public Health has to be an integral part of Government Healthcare strategy. For effective reduction of the overall disease burden of the society direct preventive action against specific diseases has to be accompanied by the convergence of Health and Family Planning with Public Health, Sanitation, Hygiene, Drinking Water and Nutrition postulated by the Planning Commission in the Xth Plan Document. An Intra-Ministerial Committee on National Health under the chairmanship of the Prime Minister is the only viable alternative that can result in the required co-ordination among the Ministries/Departments. The third component is to have a clearly stated commitment to increase the resource allocation for the Health sector in the Union Budget to fructify the assertions made in the Plan Document and National Health Policy 2002. This should be announced specifically for the XIIth Plan Period and should form a signal feature of the XIIth Plan. The fourth component is to address the issue of population stabilization squarely. This issue has not been a central theme of the activities of MoHFW despite proclamations in the Mission Document. There has to be a re-assertion of the Nation’s commitment to voluntary Family Planning. Family Planning has to be implemented in a mission mode. This has to be accompanied by reasserting the value of the girl child. The fifth component is to reaffirm the commitment to ‘Health for All’ and to reassert the importance of Universal access to Primary Health Care services for all sections of society with effective linkage to secondary and tertiary health care. It has to be ensured that the Primary Health Centre in the country are functioning properly. This has two sub components. Firstly, is the availability of human resources. “Funds without doctors and doctors without funds both cannot deliver”. The healthcare systems of the more backward states have to function on full strength especially in the rural areas. Keeping in view the fact that “the resource of the States are inelastic” and that the Union Government should put Healthcare on the Concurrent List – medical and paramedical services have to be incentivised sufficiently with Central support to ensure the presence of allopathic doctors and trained paramedical staff at each PHC. Secondly is the long term production of doctors. The issues relating to the functioning of the “Medical Council of India” need a drastic transformation by a Central Act (possible because Medical Education is in the Concurrent List) to ensure that the system of opening and functioning of Medical colleges is rationalized without any compromises on quality. The concomitant position of nursing education and other paramedical professionals has also to be addressed simultaneously.
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This sixth component of the strategy is to re-structure the formulation of projects and schemes in the Healthcare sector to enable state specific and region specific features to be addressed directly. It also incorporates the use of technology to assist in the monitoring and implementation of healthcare schemes. There has to be separate focus on improving the performance of the backward States in each area of action.
3B- Stakeholders engagement: This strategy engages all the stakeholders positively because it implies additional funds and facilities for all. Government gains as this is a necessary step on the road to India’s modernisation and the people of India are benefited permanently. The bold steps of the strategy outlined above would be a positive message for each Indian, especially the poor. The State Governments would welcome direct support in the Health sector because, as the Xth Plan Document points out, the finances of the States are “inelastic”. High focus on backward States can result in additional resource allocations for these States which can raise counter demands by States which are more developed. These States need to be compensated in other areas. The delivery mechanism of the cadres of doctors and paramedical staff would be benefited by any incentives for the services. As was noted above in the assessment of the Primary Health Care system, the absence of doctors and of insufficient resources at the PHC level has led to a serious demoralisation of the staff at PHCs. The proposed strategy would refocus on the PHC as an institution and lead to higher motivation for PHC staff. The political system and the media/press should welcome the focus on healthcare which is a defining feature of a modern developing nation. The WHO, UNICEF and international health agencies should welcome this paradigm shift as long overdue and, in the effect on numbers of humans, likely to influence global parameters significantly. There can be resistance by the Medical Council of India but this can be countered by with drafting the legislation to restructure Medical Education with care so that it passes the scrutiny of the Courts. There can also be a criticism from political and religious groups if the Family Planning initiative is perceived to incorporate any element of coercion. This has to be strictly voluntary and essentially focusing on making the option available for every eligible couple in the country, accompanied by a public campaign on the ease of adopting Family Planning measures and the benefits arising out of smaller families. If possible, a fresh “National consensus on voluntary Family Planning” should be passed by Parliament. Weaknesses: The main weakness is the general lack of confidence in the Governmental Healthcare system as is expressed by the Planning Commission in the approach to the XIIth Plan which has identified “Better preventive and curative healthcare” as a challenge because, “India’s health
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indicators are not improving as fast as other socio-economic indicators. Good healthcare is perceived to be either unavailable or unaffordable” and has raised the query on out to improve healthcare conditions, both curative and preventive, especially relating to women and children. This is especially true for the backward States where, in some cases, Primary Health Care is effectively non-existent and there are significant shortcomings in secondary and tertiary sectors. The strategy outlined here would result in a separate focus on health indicators of the backward States which is missing in the current strategy of MoHFW. (Even for the Objective of “Improving Maternal and Child Health” which is central to NRHM there is no separate weightage of the performance of the 18 high-focus States mentioned in the NRHM Mission Document). The strategy would also assert the commitment of Government of India to healthcare in the nation and would improve the confidence in the Governmental Healthcare system as well as improve healthcare conditions both curative and preventive. This lack of belief in the efficacy of the Governmental Healthcare system is reflected even in the flagship policy of NRHM where there is a de-facto “surrender” to the difficulty of providing doctors at PHCs. NRHM has included AYUSH doctors as an alternative to MBBS doctors for manning PHCs. This position of Government expressing its inability to provide essential primary modern healthcare to its rural citizens is unacceptable. The answer can only be to provide sufficient incentives to MBBS doctors so that no PHC in the country is bereft of an allopathic physician. AYUSH doctors are a welcome additionality but cannot replace the modern system of medicine. The challenge of ensuring sufficient incentives to MBBS doctors in State Cadres through Central support is an unchartered area with acute regional disparities and the programme to buttress the State Cadres has to be evolved carefully Another weakness can be the reluctance to provide the additional financial outlays which are critical to any proposed expansion of the health services. It is to be noted that the National Urban Health Mission is proposed to be launched only in the XIIth Plan and lack of financial resources can be an unsaid reasons. However, Government of India has repeatedly reiterated its commitment to raising public expenditure to 2% of the GDP and this weakness should not really be a barrier if MoHFW presents its case with full logic. An area of possible weakness can be the contentious issue of Family Planning which has yet to shed the stigmas that had come to be associated with it. However, the thrust in the strategy is on purely voluntary Family Planning. The reality of economic benefits, including education of children, with smaller families is widely understood and, if a formal “national consensus” for voluntary Family Planning is taken from the Parliament then it is likely that voluntary Family Planning will also emerge as an idea whose time has come. Ensuring a restructuring of Medical Education to provide for more medical colleges and increase the numbers of MBBS doctors being produced in the country is likely to be resisted and challenged by the entrenched Medical Council of India (MCI) but there is really no alternative if allopathic doctors have to be made available to all Indians everywhere in the country. 3C- Learning process: The learning process for this strategy is, firstly, the example of the other not-developed nations which are spending much larger proportions of their budgets on Healthcare and have achieved substantially better levels of healthcare parameters than India. Secondly, within the
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country, the processes and methodologies of the best performing states provide a crucible of learning for the backward states whose performances have to drastically improve if India is to achieve significant levels of progress.
3D- Priorities: The priorities amongst the strategic initiatives would be having weights/priorities as below : Weights Strategic Initiative 1: 10: Affirming the commitment to an extended healthcare delivery regime, extending NRHM beyond 2012 and amending the Constitution. Including preventive measures of Public Health in healthcare, reducing the diseases burden in society with convergence of Health and Family Planning with Public Health, Sanitation, Hygiene, Drinking Water and Nutrition and setting up a interministerial committee under the Prime Minister. Increasing Governmental financial resources for healthcare. Renewed focus on family planning. Renewed focus on “Health for All” including Universal access to Primary Health Care services for all sections of society with effective linkage to secondary and tertiary health care, incentivisation of doctors to serve in rural areas and restructuring of Medical Education. Restructure programmes to enable state specific features to be addressed directly. Use of technology.
Strategic Initiative 2: 20:
Strategic Initiative 3: 15: Strategic Initiative 4: 20: Strategic Initiative 5: 25:
Strategic Initiative 6: 10:
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Section 4: Implementation Plan
4(i)- Strategic Initiatives: 1. Amendment to the Constitution of India to include Health in the Concurrent List. This incorporates a recasting of the language of Item No. 6 of the State List so that it covers the entire scope of healthcare in the current scenario. Announce extension of NRHM. Enunciate, announce and implement a commitment to increase Governmental spending on Health from $12 per capita in 2008 to $24 per capita (2008 prices) in 2012 budget to $30 per capita (2008 prices) in 2015. Healthcare should stabilise at about 12-15% of the Central Budget. A renewed focus on Family Planning with major inputs in creating public awareness and providing access to family planning measures. This has to have a separate component for backward States. This also includes setting up of a Technology Mission within the Department of Health and Family Welfare to facilitate the adoption and use of better technologies of family planning in the States and Union territories. Evolving a “national consensus” in Parliament on the benefits of and need for voluntary family planning. An extensive national campaign on the value of the girl child co-ordinated with a rigorous implementation of legal enactments. Enunciation of a comprehensive policy of preventive measures of Public Health – as an integral part of Healthcare in India - accompanied by a well defined strategy and implementation program. Set up an inter-ministerial Committee for National Health under the chairmanship of the Prime Minister. This committee will coordinate all issues relating to public healthcare delivery to ensure convergence of preventive healthcare measures being taken in different ministries, especially Health and Family Planning with Public Health, Sanitation, Hygiene, Drinking Water and Nutrition. The Ministries of Health and Family Welfare, Women and Child Development, Panchayat Raj, Rural Development, Urban Development, Labour, Finance and Planning would be included in the Committee. The Health Department has to take the lead in ensuring co-ordination on all issues of preventive healthcare. In the major initiative of MoHFW launched in 2010-11 on Tracking of Pregnant Women and Infants immediate active close co-operation is necessary with the Aaganwadi setup of Women and Child Welfare Department.
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To reduce Infant Mortality Rate to 28 per 1000 live births and Maternal Mortality Ratio to 1 per 1000 live births by end of 12th Plan, i.e. year 2017. To incentivise the carders of allopathic doctors and paramedical staff sufficiently so as to ensure full presence of allopathic physicians and paramedical staff at each PHC of the country. For this the States shall be supported financially by GoI. (A solution is to take into account the issues raised in the Uttar Pradesh example given above and have a rural allowance for doctors and staff at PHCs, permit residence for doctors at district headquarters, provide transport and ensure presence in the PHCs from 9-5 every working day. The other staff can be incentivised sufficiently to maintain 24X7 minimal availability with back-up emergency ambulance transport support throughout the country. Basically it has been a paucity of funds that has precluded aggressive state action and evolution of solutions in the primary healthcare scenario in backward States. As an initial fillip the age of retirement of allopathic doctors can also be raised to 65 years.) The strengths of State Carders of doctors and paramedical staff should be finalised in consultation with GoI to ensure effective performance of PHCs, CHCs and District Hospitals. To enact legislation to modify the role of Medical Council of India and rationalise the procedures and system of establishing Medical Colleges and providing Medical Education to effectively double the number of MBBS doctors being produced in the country by 2020 and triple the number by 2025. To develop concurrently the training capacity for other human resources for health/medical, paramedical and managerial for ensuring availability of an adequate skill mix. To ensure comprehensive primary healthcare delivery system with strengthening of PHC infrastructure supplemented by Mobile Medical Units with well functioning linkages with Secondary and Tertiary care health delivery system. This implies availability of emergency ambulance services and technology supported communication links uniformly across the country. Strengthening of Secondary and Tertiary care health delivery systems. A critical component is addressing the problems of backward States to bring their facilities up to the national standards. Reducing overall disease burden of the society by continuing the focus on communicable diseases like Malaria, Tuberculosis, Filariasis, Kala-azar and Leprosy. Additional diseases like Japanese Encephalitis and Acute Encephalitis should be included. Address the issue of non-communicable disease by continuing the focus on Blindness, Cancer and Mental Health with inclusion of other diseases like Diabetes. To regulate health service delivery. Promote rational use of pharmaceuticals in the country. This has to be accompanied by rigourous regimes of food and drug control in all States of the country.
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Jointly develop five year and annual State Health Plans in conjunction with the national priorities and meet the resource gap to ensure availability of essential finances to enable achievement of State targets. A major and continuous public awareness campaign on Healthcare emphasising the increased commitment of the Government and the potential benefits to each citizen of the country. In the perspective of the substantive transformation of the role of MoHFW it would be necessary to reformulate the Citizen’s/Client’s Charter. The Department should also implement the accepted recommendations of the Administrative Reforms Commissions.
4(ii)- Stakeholders Engagement: In this strategy the major initiative is be taken by the Government of India and all other stakeholders, accept Medical Council of India, stand to benefit from the strategy. In the development of modern nations there has been a transition to aggressive Governmental expenditure either gradually or at some defined stage in all cases. The time for India is now. If this major shift in policy by the Central Government is announced and implemented with an aggressive public campaign it will influence the public perception of Government activity in a significantly positive manner. The rural public in backward States will welcome the presence of allopathic doctors in PHCs lying moribund for decades. The political system and the media/press should welcome the focus on healthcare which is a defining feature of a modern developing nation. The WHO, UNICEF and international health agencies should welcome this paradigm shift as long overdue and, in the effect on numbers of humans, likely to influence global parameters significantly. The States should welcome a Central Government commitment to Health with increased financial support. High focus on backward States can result in additional resource allocations for these States which can raise counter demands by States which are more developed. These States need to be compensated in other areas. The medical and paramedical personnel across the country should welcome the incentives being proposed and the focus on medical professions.
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There can be resistance by the Medical Council of India but this can be countered by with drafting the legislation to restructure Medical Education with care so that it passes the scrutiny of the Courts. There can also be a criticism from political and religious groups if the Family Planning initiative is perceived to incorporate any element of coercion. This has to be strictly voluntary and essentially focusing on making the option available for every eligible couple in the country, accompanied by a public campaign on the ease of adopting Family Planning measures and the benefits arising out of smaller families. If possible, a fresh “National consensus on voluntary Family Planning” should be passed by Parliament. 4(iii)- Learning Agenda: The Strategy envisages a paradigm transformation in Governmental approach to Healthcare and has to be accompanied by a wide ranging Learning Agenda. Government of India has to build up a repertoire of “best practices” worldwide and especially of the not-developed nations, like Sri Lanka, which have significantly better health parameters than India. Government of India should also have a pool of experts familiar with different State realities so that the healthcare programmes of different States can be finalised with inputs from those who can get into details of the State’s scenario. There is need for an increased inter-State interaction on methodologies and schemes so that knowledge of the detailed functioning of “best practices” is available to the Directorates and State Resource Centres in all the States. State Resource Centre should be setup in all States in 2011-12. The policy formulators in the States should be encouraged to travel, interact and see the programmes being implemented in other States. The State Health Plans should be circulated in routine to all States so that knowledge of initiatives, schemes, successes and shortfalls in other States should be uniformly available to all States. The Strategy includes a public publicity campaign to substantially increase the awareness of Healthcare, the necessity of preventive measures and the role of the Government and private sector. The Learning Agenda has to include a system of close co-operation and co-ordination with other Ministries/Departments dealing with preventive Public Healthcare. Since a convergence of Healthcare schemes is being proposed for the first time, MoHFW will have to take the lead in developing a working relationship and co-ordination with other Ministries/Departments to ensure best synergy and outcomes. 4(iv)- Resources Required: The heart of the Strategy is the issue of financial resources. As has been illustrated in detail, Government of India has to stand by the promise in the Xth Plan, the National Health Policy and the NRHM Mission Document to raise public expenditure on Healthcare in India to 2% of the GDP. It has also to bring Healthcare in the Concurrent List of the Constitution of India. This can be ensured by sizeable increase for the Healthcare in the Central Budget from 2011-12 onwards and definitely for the XIIth Plan period 2012-2017.
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The second requirement is for policy planners and policy developers in the Centre and the States who are conversant with relevant “best practices” because, the substantially increased financial allocations, the paradigm shift in Governmental approach to Healthcare in the country will have to be carefully defined. The third requirement is for doctors, nurses and paramedical staff in appropriate ratios and numbers in all the States. This critical human resource is central to the revamping of the Healthcare system in the country in which the Primary Health Care system has to especially deliver in the backward States. 4(v)- Tracking and Measuring The Strategy has to have a 5 year perspective or the XIIth Plan period till 2017. However, most of the essential components can be put in place in 2012-13, the first year of XIIth Plan. The measurable and observables for the 21 Strategic Initiatives is proposed as follows:
(Table on next page)
INITIATIVE 1. Amendment to the Constitution of India to include Health in the Concurrent List. This incorporates a recasting of the language of Item No. 6 of the State List so that it covers the entire scope of healthcare in the current scenario. Announce extension of NRHM
Measurable and Observables, Reviews Specific action of Constitutional Amendment by December, 2011. Review by Cabinet Secretariat. Specific action of Announcement by February, 2011. Review by Cabinet Secretariat. Policy Decision and Proclamation by May, 2011 (Preferably for budget 201112) Review by Cabinet Secretariat. Incorporate in State NRHM PIPs from 2011-12 onwards i.e. by May, 2011. Review by MoHFW. Technology Mission by December, 2011 Review by Cabinet Secretariat.
Enunciate, announce and implement a commitment to increase Governmental spending on Health from $12 per capita in 2008 to $24 per capita (2008 prices) in 2012 budget to $30 per capita (2008 prices) in 2015. Healthcare should stabilise at about 12-15% of the Central Budget. A renewed focus on Family Planning with major inputs in creating public awareness and providing access to family planning measures. This has to have a separate component for backward States. This also includes setting up of a Technology Mission within the Department of Health and Family Welfare to facilitate the adoption and use of better technologies of family planning in the States and Union territories.
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Evolving a “national consensus” in Parliament on the By the Monsoon Session of benefits of and need for voluntary family planning. the Parliament. Review by Cabinet Secretariat. An extensive national campaign on the value of the girl Incorporate in State NRHM child co-ordinated with a rigorous implementation of legal PIPs from 2011-12 onwards enactments. i.e. by May, 2011 Review by MoHFW Enunciation of a comprehensive policy of preventive By December, 2011. measures of Public Health – as an integral part of Review by Cabinet Healthcare in India - accompanied by a well defined Secretariat. strategy and implementation program. Set up an inter-ministerial Committee for National Health 1. Setting of the Committee by under the chairmanship of the Prime Minister. This the Monsoon Session of the committee will coordinate all issues relating to public Parliament. healthcare delivery to ensure convergence of preventive 2. Convergence from 2012-13 healthcare measures being taken in different ministries, onwards (XIIth Plan Period). especially Health and Family Planning with Public Review by Cabinet Health, Sanitation, Hygiene, Drinking Water and Secretariat. Nutrition Yearly targets for each State Review by MoHFW. 1. Evolution of possible incentives-September 2011-12. 2. Inclusion in budget of 2012-13. 3. Implementation for States – from 2012 onward (XIIth Plan Period). Review by Cabinet Secretariat. 1. Enacting legislation by Monsoon Session of Parliament, 2011. 2. Increasing Capacity and new Medical Colleges by 2015. 3. Doubling number of MBBS doctors being produced per year- by 2020. Review of proposed Legislation by Cabinet Secretariat. 1. Statewise Road map by December 2011. 2. Achievement by 2015. Review by MoHFW 1. Availability of Doctors at PHCs-Defining incentivesSeptember 2011.
10. To reduce Infant Mortality Rate to 28 per 1000 live births and Maternal Mortality Ratio to 1 per 1000 live births by end of 12th Plan, i.e. year 2017. 11. To incentivise the carders of allopathic doctors and paramedical staff sufficiently so as to ensure full presence of allopathic physicians and paramedical staff at each PHC of the country. For this the States shall be supported financially by GoI. The strengths of State Carders of doctors and paramedical staff should be finalised in consultation with GoI to ensure effective performance of PHCs, CHCs and District Hospitals.
12. To enact legislation to modify the role of Medical Council of India and rationalise the procedures and system of establishing Medical Colleges and providing Medical Education to effectively double the number of MBBS doctors being produced in the country by 2020 and triple the number by 2025.
13. To develop concurrently the training capacity for other human resources for health/medical, paramedical and managerial for ensuring availability of an adequate skill mix. 14. To ensure comprehensive primary healthcare delivery system with strengthening of PHC infrastructure supplemented by Mobile Medical Units with well
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functioning linkages with Secondary and Tertiary care 2. Inclusion in budget 2012health delivery system. This implies availability of 13. emergency ambulance services and technology supported 3. Additional recruitment of communication links uniformly across the country. doctors in States- 2012-14. 4. Strengthening other PHC infrastructure 2012-14. 5. Mobile Medical Units in all backward districts of the country 2012-13. 6. Emergency Ambulance services uniformly in all States 2012-13. 7. Technology supported communication links from sub-centres to PHCs to Secondary and Tertiary Healthcare Centres-20122014. Review by MoHFW/ Cabinet Secretariat.
15. Strengthening of Secondary and Tertiary care health 1. Setting up of 6 AIIMS like delivery systems. A critical component is addressing the institutions by 2013. problems of backward States to bring their facilities up to 2. Upgrading all State the national standards. Medical Colleges-by 2014. 3. Uniformly upgrading all District Hospitals-by 2015. Review by MoHFW 16. Reducing overall disease burden of the society by 2011-2012 and onwards. continuing the focus on communicable diseases like Review by MoHFW Malaria, Tuberculosis, Filariasis, Kala-azar and Leprosy. Additional diseases like Japanese Encephalitis and Acute Encephalitis should be included.
17. Address the issue of non-communicable disease by 2011-2012 and onwards. continuing the focus on Blindness, Cancer and Mental Review by MoHFW Health with inclusion of other diseases like Diabetes. 18. To regulate health service delivery. After the Constitutional Amendment ensure a uniform regulation of the private sector in Healthcare in the country by 2014. Review by Cabinet Secretariat. 19. Promote rational use of pharmaceuticals in the country. 2011-2012 and onwards. This has to be accompanied by rigourous regimes of food Review by MoHFW and drug control in all States of the country. 20. Jointly develop five year and annual State Health Plans in 1.Complete Statewise exercise
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conjunction with the national priorities and meet the for XIIth Plan by September, resource gap to ensure availability of essential finances to 2011. enable achievement of State targets. 2.Submit Demands to Planning Commission and Finance Ministry by October, 2011. 3.Implement from 2012-2013 and onwards. Review by Planning Commission. 21. A major and continuous public awareness campaign on 2011-2012 and onwards. Healthcare emphasising the increased commitment of the Review by Cabinet Government and the potential benefits to each citizen of Secretariat. the country. 22. Reformulation of the Citizen’s/Client’s Charter. The By March, 2012 Department should also implement the accepted Review by Cabinet recommendations of the Administrative Reforms Secretariat. Commissions.
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4(vi)- Overall Plan and Milestones: The overall Plan and Milestones can be listed as follows:INITIATIVE 1. Amendment to the Constitution of India to include Health in the Concurrent List. This incorporates a recasting of the language of Item No. 6 of the State List so that it covers the entire scope of healthcare in the current scenario. 2. Announce extension of NRHM
Milestones 1. Bill for Amendment by April, 2011 2.. Constitutional Amendment by December, 2011. 1.Consultation with Finance Ministry 15 February, 2011 2.Announcement by 28th February, 2011. 1.Consultation with Planning Commission and Finance Ministry by March, 2011 2.Cabinet Proposal by April, 2011. 3.Policy by May, 2011 Incorporate in State NRHM PIPs from 2011-12 onwards i.e. by May, 2011 1.Finalising proposal for Technology Mission by May, 2011 2.Setting up of Mission by December, 2011. 1.Finalising draft of National Consensus by April, 2011. 2.Placing before ParliamentMonsoon Session Incorporate in State NRHM PIPs from 2011-12 onwards i.e. by May, 2011 By December, 2011.
Enunciate, announce and implement a commitment to increase Governmental spending on Health from $12 per capita in 2008 to $24 per capita (2008 prices) in 2012 budget to $30 per capita (2008 prices) in 2015. Healthcare should stabilise at about 12-15% of the Central Budget. A renewed focus on Family Planning with major inputs in creating public awareness and providing access to family planning measures. This has to have a separate component for backward States. This also includes setting up of a Technology Mission within the Department of Health and Family Welfare to facilitate the adoption and use of better technologies of family planning in the States and Union territories. Evolving a “national consensus” in Parliament on the benefits of and need for voluntary family planning.
An extensive national campaign on the value of the girl child co-ordinated with a rigorous implementation of legal enactments. Enunciation of a comprehensive policy of preventive measures of Public Health – as an integral part of Healthcare in India - accompanied by a well defined strategy and implementation program. Set up an inter-ministerial Committee for National Health under the chairmanship of the Prime Minister. This committee will coordinate all issues relating to public healthcare delivery to ensure convergence of preventive healthcare measures being taken in different ministries, especially Health and Family Planning with Public Health, Sanitation, Hygiene, Drinking Water and Nutrition To reduce Infant Mortality Rate to 28 per 1000 live births and Maternal Mortality Ratio to 1 per 1000 live births by end of 12th Plan, i.e. year 2017.
1. Setting of the Committee by the Monsoon Session of the Parliament. 2. Convergence from 2012-13 onwards (XIIth Plan Period).
1.Fix yearly targets for each State separately-by March, 2011.
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To incentivise the carders of allopathic doctors and paramedical staff sufficiently so as to ensure full presence of allopathic physicians and paramedical staff at each PHC of the country. For this the States shall be supported financially by GoI. The strengths of State Carders of doctors and paramedical staff should be finalised in consultation with GoI to ensure effective performance of PHCs, CHCs and District Hospitals.
2. Ensure State wise monitoring 1.Evolution of possible incentives-September 201112. 2.Inclusion in budget of 201213. 3.Implementation for States – from 2012 onward (XIIth Plan Period).
To enact legislation to modify the role of Medical Council of India and rationalise the procedures and system of establishing Medical Colleges and providing Medical Education to effectively double the number of MBBS doctors being produced in the country by 2020 and triple the number by 2025.
1.Finalising draft of legislation-by June, 2011 2.Enacting legislation by Monsoon Session of Parliament, 2011. 3.Fix yearly targetsStatewise- for increasing capacity and new Medical Colleges for period 2012-15. 4.Doubling number of MBBS doctors being produced per year- by 2020.
To develop concurrently the training capacity for other human resources for health/medical, paramedical and managerial for ensuring availability of an adequate skill mix. To ensure comprehensive primary healthcare delivery system with strengthening of PHC infrastructure supplemented by Mobile Medical Units with well functioning linkages with Secondary and Tertiary care health delivery system. This implies availability of emergency ambulance services and technology supported communication links uniformly across the country.
1.Road map by December 2011 detailing actions for each State separately from 2012-15. 2.Achievement by 2015. 1.Availability of Doctors at PHCs-Defining incentivesSeptember 2011. 2.Inclusion in budget 2012-13. 3.Additional recruitment of doctors in States- 2012-14. 4.Strengthening other PHC infrastructure 2012-14. 5.Mobile Medical Units in all backward districts of the country 2012-13. 6.Emergency Ambulance services uniformly in all States 2012-13.
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Strengthening of Secondary and Tertiary care health delivery systems. A critical component is addressing the problems of backward States to bring their facilities up to the national standards.
Reducing overall disease burden of the society by continuing the focus on communicable diseases like Malaria, Tuberculosis, Filariasis, Kala-azar and Leprosy. Additional diseases like Japanese Encephalitis and Acute Encephalitis should be included.
7.Technology supported communication links from sub-centres to PHCs to Secondary and Tertiary Healthcare Centres-2012-14. 1.Setting up of 6 AIIMS like institutions by 2013. 2.Finalising the Road map for each State separately for upgrading all State Medical Colleges-by December 2011. 3.Ungradation of State Medical Colleges from 201213 to 2013-15 with yearly targets. 4. Finalising the Road map for each State separately for upgrading all State District Hospitals-by December 2011. 5. Uniformly upgrading all District Hospitals-by 2015 with yearly targets. 1.Existing programme intensified for 2011-12. 2.Finalisation of programme for Additional Diseases by December, 2011. 3.Inclusion of Additional Diseases 2012-13.
Address the issue of non-communicable disease by 1.Existing programme continuing the focus on Blindness, Cancer and Mental intensified for 2011-12. Health with inclusion of other diseases like Diabetes. 2.Finalisation of programme for Additional Diseases by December, 2011. 3.Inclusion of Additional Diseases 2012-13. To regulate health service delivery. After the Constitutional Amendment ensure a uniform regulation of the private sector in Healthcare in the country by 2014. Promote rational use of pharmaceuticals in the country. 1.Existing programme This has to be accompanied by rigorous regimes of food intensified for 2011-12. and drug control in all States of the country. 2.Finalisation of programme with each State for Additional action by December, 2011. 3. Rigorous and largely uniform regimes of food and drug control in all States of the country. 2012-13.
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Jointly develop five year and annual State Health Plans in conjunction with the national priorities and meet the resource gap to ensure availability of essential finances to enable achievement of State targets.
1.Complete Statewise exercise for XIIth Plan by September, 2011. 2.Submit Demands to Planning Commission and Finance Ministry by October, 2011. 3.Implement from 2012-2013 and onwards. A major and continuous public awareness campaign on 2011-2012 and onwards. Healthcare emphasising the increased commitment of the Government and the potential benefits to each citizen of the country. Reformulation of the Citizen’s/Client’s Charter. The 1. Reformulation of the Department should also implement the accepted Citizen’s/Client’s Charter by recommendations of the Administrative Reforms September, 2011 Commissions. 2.Implementation of accepted recommendations of the Administrative Reforms Commissions by March, 2012.
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Section 5: Linkage between Strategic Plan and RFD
The Results Framework Document for the Department of Health and Family Welfare 2010-2011 displays the skewed priorities of the Department. In Section 2 the Objective of “Focusing on population stabilization in the country” has been given a Weight of 6.00. That is, the entire gamut of Family Planning for the people of India has a weight of 6.00 which is half the weight assigned to “Commencement and completion of 30-40% work in 6 AIIMS Medical Colleges and Hospitals and upgrading facilities at 13 Government Medical Colleges” which has been assigned a weight of 12.00. The low priority of Family Planning in India is also illustrated by is weight of 6.00 being less than the weights assigned to the combine of “Efficient Functioning of the RFD System”-weight 5.00 and “Improving Internal Efficiency of the Department” weight 6.00. The core activity of “Improving Maternal and Child Health” in the country has a weight of only 8.00 whereas the supplementary activity of training of ASHAs, doctors and NSSK has a weight of 8.50. In actuality the LSAS and EMoC training for the year have targets of only 220 and 125 doctors respectively for the entire country. There is no weight assigned to improving the conditions in 18 Backward States which is a prime focus of NRHM. For all targets in the RFD all-India figures have been bundled together and targets would be largely achieved in States which are not focus States. The fact that there is no Objective, Weight or Success Indicator linked to reduction of regional disparities is indicative of the reduced priority which the Department has assigned to this target. The RFD of the Department of Health and Family Welfare has to reflect the priorities of the Government and the strategy of the Department. Population stabilization is a significant Objective which merits higher Weightage and a clear sub-target for the Backward States. Similarly “Improving Maternal and Child Health” is a core programme of the Government and again merits higher Weightage with clear sub-targets for the 18 special focus States identified in the National Rural Health Mission. Future RFDs have to carefully emphasise and focus on Success Indicators which would reflect significant factors in the delivery of Healthcare in India. (The current RFD, for example, has a weight of 2.00 for “Institutional Deliveries as a percentage of total deliveries” and a similar weight of 2.00 for “Full Immunization of Children” against a weight of 5.04 for “No. of Medical Colleges approved for upgradation” with a target of approval for 50.) So for future RFDs-Firstly, Objectives have to be defined in terms of the Plan, Policies and Missions of the Department. There has to be a clear linkage between the priority of strategies and the priority of Objectives. Major thrust areas like population control, Improving Maternal and Child Health and delivery of primary health care have to be the Objectives with maximum weightage.
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Within the Objectives the Actions and Success Indicators have also to be prioritised to reflect the effectiveness of actual implementation and impact. (For example, establishment of 75 Special New Born Care Units in the country or Preparation of 24 District Health Action Plans cannot have significant weights within “Strengthening of Health Infrastructure” or “Strengthening of Community Involvement”). The Success Indicators in each category of the priority programmes where high focus States or Districts have been defined have to include a specific component and weightage for the performance of these high focus States and Districts.
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Section 6: Cross departmental and cross functional issues
6A- Linkage with Potential Challenges likely to be addressed in the XIIth Plan: A potential challenge which would be addressed in the XIIth Plan is Healthcare. It has been spelled out as: “Better preventive and curative healthcare: India’s health indicators are not improving as fast as other socio-economic indicators. Good healthcare is perceived to be either unavailable or unaffordable. How can we improve healthcare conditions, both curative and preventive, especially relating to women and children?” The MoHFW has to be the major implementing and co-ordinating Department for Healthcare. The role of co-ordination would be critical in the XIIth Plan because for the first time preventive measures like Public Health including Sanitation, Hygiene, Safe Drinking Water and Nutrition are proposed to be included with Curative Healthcare. The proposal to have a committee under the chairmanship of the Prime Minister would include the Ministries of Urban Development, Women and Child Development, Panchayati Raj, Rural Development and Labour besides Planning and Finance. MoHFW will have to co-ordinate and ensure effective convergence of all Healthcare measures. 6B- Identification and management of cross departmental issues including resource allocation and capacity building issues: Effective co-ordination with the Department of Women and Child Development is immediately necessary as the major initiative of MoHFW of “Tracking of Pregnant Women and Infants” launched in 2010-11 needs the active contribution of the Aganwadi Workers in the backward States. The job profile of Aganwadi Workers includes healthcare components as a central activity. However, in a number of States, there is little or no co-ordination between the ICDS setup and the District Health Department. MoHFW has to developed a system of close co-operation and co-ordination with other Ministries/Departments dealing with preventive Public Healthcare. Since a convergence of Healthcare schemes is being proposed for the first time, MoHFW will have to take the lead in developing a working relationship and co-ordination with other Ministries/Departments to ensure best synergy and outcomes. MoHFW also has to ensure co-ordination between the Departments, for example, on issues of Sanitation between the Zila Parishads and Urban Bodies. 6C- Cross functional linkages within departments/offices: The Strategy for Department of Health and Family Welfare has been developed for the “whole of organisation”. There is no predomination or emphasis of any Divisional nature. 6D- Organizational Review and Role of agencies and wider public service: The Strategy includes a paradigm transformation in the approach and areas of activity of the Department. As such it includes reformulation of the Citizen’s/Client’s Charter as part of the Strategy Initiatives. It also includes implementing the accepted recommendations of the
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Administrative Reforms Commissions. (A table showing areas of co-ordination with various central
ministries is given on the next page)
Cross Departmental Issues Ministry Common Issues ICDS (Integrated Child Development Services) (Anganwadi worker, in actual practice, is largely a public health worker) Women and Child Development Tracking System (Pregnant Women & Infants/Children) Creches (for children 6 month to 2 years children of working mother) Urban Development Labour & Employment Human Resource Development Rural Development Women Empowerment Water/Supply/Treatment Sanitation/Sewerage Waste Management Maternity Benefits Working Conditions (particularly for women) Rasthiya Swastya Bima Yojna (RSBY) ESI etc. Rogi Kalyan Samiti (RKS) Village Health and Sanitation Committee (VHSC) Education & Literacy (particularly for Girls) Mid-Day-Meal Programme Poverty/Employment NREGA
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Section 7: Monitoring and Reviewing arrangements
Regarding institutional arrangement for internal monitoring and reviews for successful implementation of strategy, besides the periodic reviews and evaluation done at the level of Secretary of the department, it is proposed that the Department should constitute a Special Evaluation Team led by a senior officer of the rank of Additional Secretary in the Department of Health and Family Welfare assisted by a suitable number of experts/professionals from various disciplines including finance. This Additional Secretary should not be the Mission Director of NRHM. The special evaluation team should report regularly to the Secretary of the Department. For evaluation of the implementation of strategy and its component programmes in the field it is proposed that concurrent external evaluation should be an integral part of the schemes in the Health sector. There should be a defined budget allocation for external evaluation (it can be a fix percentage of the total allocation). Competent evaluators should be selected by a competitive bid process. This evaluation should extend to each state of the country and should cover a significant sample in each state.
“There is a tide in the affairs of men, Which, taken at a flood, leads on to fortune..”
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NRHM – STRATEGIES AND ACTION PLAN “4. STRATEGIES (a) Core Strategies: • Train and enhance capacity of Panchayati Raj Institutions (PRIs) to own, control and manage public health services. • Promote access to improved healthcare at household level through the female health activist (ASHA). • Health Plan for each village through Village Health Committee of the Panchayat. • Strengthening sub-centre through an untied fund to enable local planning and action and more Multi Purpose Workers (MPWs). • Strengthening existing PHCs and CHCs, and provision of 30-50 bedded CHC per lakh population for improved curative care to a normative standard (Indian Public Health Standards defining personnel, equipment and management standards). • Preparation and Implementation of an inter-sectoral District Health Plan prepared by the District Health Mission, including drinking water, sanitation & hygiene and nutrition. • Integrating vertical Health and Family Welfare programmes at National, State, Block, and District levels. • Technical Support to National, State and District Health Missions, for Public Health Management. • Strengthening capacities for data collection, assessment and review for evidence based planning, monitoring and supervision. • Formulation of transparent policies for deployment and career development of Human Resources for health. • Developing capacities for preventive health care at all levels for promoting healthy life styles, reduction in consumption of tobacco and alcohol etc. • Promoting non-profit sector particularly in under served areas. (b) Supplementary Strategies: • Regulation of Private Sector including the informal rural practitioners to ensure availability of quality service to citizens at reasonable cost. • Promotion of Public Private Partnerships for achieving public health goals.66 • Mainstreaming AYUSH – revitalizing local health traditions. • Reorienting medical education to support rural health issues including regulation of Medical care and Medical Ethics. • Effective and viable risk pooling and social health insurance to provide health security to the poor by ensuring accessible, affordable, accountable and good quality hospital care. 5. PLAN OF ACTION COMPONENT (A): ACCREDITED SOCIAL HEALTH ACTIVISTS • Every village/large habitat will have a female Accredited Social Health Activist (ASHA) chosen by and accountable to the panchayat- to act as the interface between the community and the public health system. States to choose State specific models. • ASHA would act as a bridge between the ANM and the village and be accountable to the Panchayat.
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• She will be an honorary volunteer, receiving performance-based compensation for promoting universal immunization, referral and escort services for RCH, construction of household toilets, and other healthcare delivery programmes. • She will be trained on a pedagogy of public health developed and mentored through a Standing Mentoring Group at National level incorporating best practices and implemented through active involvement of community health resource organizations. • She will facilitate preparation and implementation of the Village Health Plan along with Anganwadi worker, ANM, functionaries of other Departments, and Self Help Group members, under the leadership of the Village Health Committee of the Panchayat. • She will be promoted all over the country, with special emphasis on the 18 high focus States. The Government of India will bear the cost of training, incentives and medical kits. The remaining components will be funded under Financial Envelope given to the States under the programme. • She will be given a Drug Kit containing generic AYUSH and allopathic formulations for common ailments. The drug kit would be replenished from time to time. • Induction training of ASHA to be of 23 days in all, spread over 12 months. On the job training would continue throughout the year. • Prototype training material to be developed at National level subject to State level modifications. • Cascade model of training proposed through Training of Trainers including contract plus distance learning model • Training would require partnership with NGOs/ICDS Training Centres and State Health Institutes. COMPONENT (B): STRENGTHENING SUB-CENTRES • Each sub-centre will have an Untied Fund for local action @ Rs. 10,000 per annum. This Fund will be deposited in a joint Bank Account of the ANM & Sarpanch and operated by the ANM, in consultation with the Village Health Committee. • Supply of essential drugs, both allopathic and AYUSH, to the Sub-centres. • In case of additional Outlays, Multipurpose Workers (Male)/Additional ANMs wherever needed, sanction of new Sub-centres as per 2001 population norm, and upgrading existing Subcentres, including buildings for Sub-centres functioning in rented premises will be considered. COMPONENT (C): STRENGTHENING PRIMARY HEALTH CENTRES Mission aims at Strengthening PHC for quality preventive, promotive, curative, supervisory and Outreach services, through: • Adequate and regular supply of essential quality drugs and equipment (including Supply of Auto Disabled Syringes for immunization) to PHCs • Provision of 24 hour service in 50% PHCs by addressing shortage of doctors, especially in high focus States, through mainstreaming AYUSH manpower. • Observance of Standard treatment guidelines & protocols. • In case of additional Outlays, intensification of ongoing communicable disease control programmes, new programmes for control of noncommunicable diseases, upgradation of 100% PHCs for 24 hours referral service, and provision of 2nd doctor at PHC level (I male, 1 female) would be undertaken on the basis of felt need. COMPONENT (D): STRENGTHENING CHCs FOR FIRST REFERRAL CARE A key strategy of the Mission is: • Operationalizing 3222 existing Community Health Centres (30-50 beds) as 24 Hour First Referral Units, including posting of anaesthetists. • Codification of new Indian Public Health Standards, setting norms for infrastructure, staff, equipment, management etc. for CHCs. • Promotion of Stakeholder Committees (Rogi Kalyan Samitis) for hospital management.
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• Developing standards of services and costs in hospital care. • Develop, display and ensure compliance to Citizen’s Charter at CHC/PHC level. • In case of additional Outlays, creation of new Community Health Centres (30-50 beds) to meet the population norm as per Census 2001, and bearing their recurring costs for the Mission period could be considered. COMPONENT (E): DISTRICT HEALTH PLAN • District Health Plan would be an amalgamation of field responses through Village Health Plans, State and National priorities for Health, Water Supply, Sanitation and Nutrition. • Health Plans would form the core unit of action proposed in areas like water supply, sanitation, hygiene and nutrition. Implementing Departments would integrate into District Health Mission for monitoring. • District becomes core unit of planning, budgeting and implementation. • Centrally Sponsored Schemes could be rationalized/modified accordingly in consultation with States. • Concept of “funneling” funds to district for effective integration of programmes • All vertical Health and Family Welfare Programmes at District and state level merge into one common “District Health Mission” at the District level and the “State Health Mission” at the state level • Provision of Project Management Unit for all districts, through contractual engagement of MBA, Inter Charter/Inter Cost and Data Entry Operator, for improved programme management COMPONENT (F): CONVERGING SANITATION AND HYGIENE UNDER NRHM • Total Sanitation Campaign (TSC) is presently implemented in 350 districts, and is proposed to cover all districts in 10th Plan. • Components of TSC include IEC activities, rural sanitary marts, individual household toilets, women sanitary complex, and School Sanitation Programme. • Similar to the DHM, the TSC is also implemented through Panchayati Raj Institutions (PRIs). • The District Health Mission would therefore guide activities of sanitation at district level, and promote joint IEC for public health, sanitation and hygiene, through Village Health & Sanitation Committee, and promote household toilets and School Sanitation Programme. ASHA would be incentivized for promoting household toilets by the Mission. COMPONENT (G): STRENGTHENING DISEASE CONTROL PROGRAMMES • National Disease Control Programmes for Malari a, TB, Kala Azar, Filaria, Blindness & Iodine Deficiency and Integrated Disease Surveillance Programme shall be integrated under the Mission, for improved programme delivery. • New Initiatives would be launched for control of Non Communicable Diseases. • Disease surveillance system at village level would be strengthened. • Supply of generic drugs (both AYUSH & Allopathic) for common ailments at village, SC, PHC/CHC level. • Provision of a mobile medical unit at District level for improved Outreach services. COMPONENT (H): PUBLIC-PRIVATE PARTNERSHIP FOR PUBLIC HEALTH GOALS, INCLUDING REGULATION OF PRIVATE SECTOR • Since almost 75% of health services are being currently provided by the private sector, there is a need to refine regulation • Regulation to be transparent and accountable • Reform of regulatory bodies/creation where necessary • District Institutional Mechanism for Mission must have representation of private sector • Need to develop guidelines for Public-Private Partnership (PPP) in health sector. Identifying areas of partnership, which are need based, thematic and geographic. • Public sector to play the lead role in defining the framework and sustaining the partnership
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• Management plan for PPP initiatives: at District/State and National levels COMPONENT (I): NEW HEALTH FINANCING MECHANISMS A Task Group to examine new health financing mechanisms, including Risk Pooling for Hospital Care as follows: • Progressively the District Health Missions to move towards paying hospitals for services by way of reimbursement, on the principle of “money follows the patient.” • Standardization of services – outpatient, in-patient, laboratory, surgical interventions- and costs will be done periodically by a committee of experts in each state. • A National Expert Group to monitor these standards and give suitable advice and guidance on protocols and cost comparisons. • All existing CHCs to have wage component paid on monthly basis. Other recurrent costs may be reimbursed for services rendered from District Health Fund. Over the Mission period, the CHC may move towards all costs, including wages reimbursed for services rendered. • A district health accounting system, and an ombudsman to be created to monitor the District Health Fund Management , and take corrective action. • Adequate technical managerial and accounting support to be provided to DHM in managing risk-pooling and health security. • Where credible Community Based Health Insurance Schemes (CBHI) exist/are launched, they will be encouraged as part of the Mission. • The Central government will provide subsidies to cover a part of the premiums for the poor, and monitor the schemes. • The IRDA will be approached to promote such CBHIs, which will be periodically evaluated for effective delivery. COMPONENT (J): REORIENTING HEALTH/MEDICAL EDUCATION TO SUPPORT RURAL HEALTH ISSUES • While district and tertiary hospitals are necessarily located in urban centres, they form an integral part of the referral care chain serving the needs of the rural people. • Medical and para-medical education facilities need to be created in states, based on need assessment. • Suggestion for Commission for Excellence in Health Care (Medical Grants Commission), National Institution for Public Health Management etc. • Task Group to improve guidelines/details.
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