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DEPARTMENT OF HEALTH AND FAMILY WELFARE

___________________________

STRATEGY PAPER
___________________________

Vijay S. Madan and Pradeep Shukla


Phase V Participants 2010-11

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PREFACE
“Greater than all the armies of the world in an idea whose time has come”
(Victor Hugo).
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

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Index

Contents Page No.

Section I: Vision, Mission, Objectives and Functions

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

ANNEXURE I

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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. To ensure a stable population in India by 2025.

2. To ensure gender balance in every segment of Indian society.

3. 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.

4. To establish comprehensive primary healthcare delivery system and well functioning


linkages with secondary and tertiary care health delivery system.

5. 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.

6. To reduce the incidence and burden of communicable and non-communicable diseases.

7. To develop training capacity for providing human resources for health (medical,
paramedical and managerial) with adequate skill mix at all levels.

8. To regulate health service delivery and promote rational use of pharmaceuticals in the
country.

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DEPARTMENT OF HEALTH & FAMILY WELFARE

OBJECTIVES

1. Population stabilization in country.

2. Universal access to Primary health care services for all sections of society with effective
linkages to Secondary and Tertiary health care.

3. Improving Maternal and Child health.

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4. Developing comprehensive public health.

5. Reducing overall disease burden of the society.

6. Developing human resources for health to achieve health goals.

7. Strengthening Secondary and Tertiary health care.

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DEPARTMENT OF HEALTH & FAMILY WELFARE

FUNCTIONS

1. Policy formulation on issues relating to Health and Family Welfare sectors.

2. Evolving and implementing national strategies on issues relating to Health and Family
Welfare.

3. Co-ordinating a “national consensus” on critical national priorities pertaining to the issues


relating to health factors of Indian society.

4. Co-ordinating with other Ministries and Departments on health issues and programmes
which have an inter-departmental ambit.

5. Extending support to states for strengthening their Health care and Family Welfare
systems.

6. Providing regulatory framework for matters in the Concurrent List of the Constitution viz.
medical, nursing and paramedical education, pharmaceuticals, etc.

7. Focusing on development of human resources through appropriate medical and public


health education.

8. Management of hospitals and other health institutions under the control of Department of
Health and Family Welfare.

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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.

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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. State Underweight Anaemia (< 11 gm/dl)


1. Uttar Pradesh 42.3 73.9
2. Uttarakhand 37.9 61.4
3. Madhya Pradesh 58.6 74.1
4. Chhattisgarh 46.7 71.2
5. Bihar 55.8 78.0
6. Jharkhand 56.9 70.3
7. Rajasthan 40.2 69.7
8. Orissa 40.9 65.0
Average India 42.3 69.3

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2. Level of Universal Immunization:

The status of complete immunization (measles) for children up to 1 year in some not-
developed countries is as follows:

(Source: World Health Statistics- 2010)


S. No Country % DPT III % Measles
Immunized
1 India 66.0 70.0
2 Afghanistan 85.0 75.0
3 Bhutan 96.0 99.0
4 Burundi 92.0 84.0
5 China 97.0 94.0
6 Congo 89.0 79.0
7 Egypt 97.0 92.0
8 Indonesia 77.0 83.0
9 Rwanda 97.0 92.0
10 Sri Lanka 98.0 98.0
11 Tonga 99.0 99.0
12 Brazil 99.0 97.0
13 Columbia 92.0 92.0
14 Cuba 99.0 99.0
15 Cambodia 89.0 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.

(Source: NHFS-III)
S. No. State Percentage
1 Uttar Pradesh 22.9
2 Rajasthan 26.5
3 Bihar 32.8
4 Madhya Pradesh 40.3

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Average India 43.5

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.

1 India 9
2 Bhutan 17
3 China 30
4 Congo 16
5 Egypt 21
6 Iraq 13
7 Rwanda 16
8 Sri Lanka 31
9 Tonga 24
10 Algeria 17
11 Bahrain 20
12 Botswana 18
13 Brazil 24
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 Under 5


(L.B.) mortality/1000L.B.
1 India 55.0 78.6
2 Bhutan 45.0 64.8
3 China 23.0 29.4
4 Egypt 29.3 33.8
5 Sri Lanka 11 12.9
6 Tonga 18.6 21.9
7 Indonesia 26.6 31.8
8 Philippines 23.1 27.2
9 Oman 12.3 13.8
10 Qatar 8.2 10.2
11 Jamaica 13.6 17.2
12 Fiji 19.5 24.3
13 Morocco 30.6 36.3
14 Iran 30.6 35.5
15 Mongolia 39.8 53.8

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(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. State IMR (SRS 2008)

1. Madhya Pradesh 70

2. Orissa 69

3. Uttar Pradesh 67

4. Rajasthan 63

Average India 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. State MMR/lac Live


Births
1. Orissa 480
2. Uttar Pradesh 440
3. Madhya Pradesh 335
4. Rajasthan 388

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Average India 254

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 Country Life Expectancy at Birth

1 India 60.50
2 Iran 70.56
3 Sri Lanka 74.80
4 Qatar 74.14
5 Pakistan 63.75
6 China 72.88
7 Malaysia 72.76
8 Egypt 71.57
9 Philippines 70.51
10 Palau 70.71
11 Thailand 72.55
12 Jordon 78.55
13 Kuwait 77.36
14 Chile 76.96
15 Oman 73.62
World average 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. State Total LE Male Female


1. Assam 57.2 57.1 57.6
2. Madhya Pradesh 56.4 56.5 56.2
3. Orissa 57.7 57.6 57.8
4. Uttar Pradesh 58.4 58.9 57.7
India Average 61.7 60.8 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)

- Women (ages 15 - 49) who are anaemic– 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. State % Anaemic Women


1. Andhra Pradesh 62.0
2. Madhya Pradesh 57.6
3. Bihar 68.3
4. Rajasthan 53.1
5. Orissa 62.8
6. Haryana 56.5
Average India 56.1

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 Country Total Fertility Rate Total Fertility Rate as per


as per UN Ranking CIA Ranking *
1 India 2.81 2.68
2 Fiji 2.75 2.65
3 Panama 2.56 2.53
4 Guyna 2.33 2.48
5 Qatar 2.66 2.45
6 Bhutan 2.19 2.38
7 Indonasia 2.18 2.31
8 Kuwait 2.18 2.76
9 Sri Lanka 1.88 1.99
10 Vietnam 2.14 1.98
11 Chile 1.94 1.92
12 Iran 2.04 1.71

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13 Cuba 1.49 1.61
14 South Africa 2.64 2.38
15 Morocco 2.38 2.27
World Average 2.55 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. State TFR


1. Bihar 4.00
3. Uttar Pradesh 3.82
4. Jharkhand 3.31
5. Rajasthan 3.21
Average India 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 Per capita government General General


State expenditure on health at government government
average exchange rate (US$) expenditure expenditure on
on health as health as % of
% of total total
expenditure government
on health expenditure
2000 2007 2007 2007

India 5.0 11.0 26.2 3.7


Albania 27.0 101.0 41.2 9.5
Algeria 46.0 141.0 81.6 10.7
Angola 12.0 69.0 80.3 5.3
Argentina 382.0 336.0 50.8 13.9
Armenia 7.0 63.0 47.3 10.4
Azerbaijan 6.0 38.0 26.8 3.8
Bahamas 510.0 783.0 51.0 15.5
Bhutan 30.0 60.0 80.3 10.7
Bolivia 37.0 47.0 69.2 9.9
Botswana 88.0 278.0 74.6 13.0
Brazil 107.0 252.0 41.6 5.4
Cameroon 6.0 14.0 25.9 8.1
Chad 4.0 18.0 56.3 13.8
Chile 169.0 361.0 58.7 17.9
China 17.0 49.0 44.7 9.9
Colombia 1300 239.0 84.2 18.8

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Congo 13.0 36.0 70.4 5.1
Cubq 167.0 558.0 95.5 14.5
Djibouti 30.0 54.0 76.6 14.1
Dominica 163.0 193.0 62.1 8.2
Dominican Republic 59.0 61.0 35.9 9.2
Ecuador 17.0 78.0 39.1 7.4
Equatorial Guinea 21.0 279.0 80.4 6.9

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Member Per capita government General General
State expenditure on health at government government
average exchange rate (US$) expenditure expenditure on
on health as health as % of
% of total total
expenditure government
on health expenditure
2000 2007 2007 2007

India 5.0 11.0 26.2 3.7


Fiji 68.0 110.0 70.2 9.5
Gabon 126.0 240.0 64.5 14.0
Georgia 8.0 34.0 18.4 4.2
Guatemala 38.0 54.0 29.3 14.1
Guyana 43.0 101.0 87.7 14.8
Honduras 35.0 71.0 65.7 19.0
India 5.0 11.0 26.2 3.7
Indonesia 6.0 23.0 545 6.2
Iran (Islamic Republic) 107.0 118.0 46.8 11.5
Iraq 5.0 46.0 75.0 3.1
Jamaica 100.0 113.0 50.3 5.2
Jordan 84.0 150.0 60.6 11.4
Kazakhstan 26.0 167.0 66.1 11.2
Kenya 9.0 14.0 42.0 7.8
Kiribati 61.0 160.0 84.0 10.3
Kyrgyzstan 6.0 25.0 54.0 9.8
Latvia 107.0 454.0 57.9 10.0
Lebanon 145.0 234.0 44.7 11.7
Lesotho 14.0 30.0 58.3 7.9
Libyan Arab Jamahiriya 147.0 215.0 71.8 5.4
Malaysia 67.0 136.0 44.4 6.9
Maldives 113.0 224.0 65.4 10.5
Mali 5.0 18.0 51.4 11.8
Mauritania 8.0 14.0 65.3 5.3
Mauritius 76.0 121.0 490 9.3
Mexico 153.0 256.0 45.4 15.5
Mongolia 18.0 52.0 81.7 9.1
Montenegro 72.0 314.0 57.2 26.4
Morocco 16.0 40.0 33.8 6.2
Mozambique 10.0 13.0 71.8 12.6
Namibia 90.0 134.0 42.1 11.1
Nauru 273.0 477.0 70.9 32.1
Nicaragua 29.0 51.0 54.9 16.3
Panama 208.0 256.0 64.6 11.6
Papua New Guinea 21.0 25.0 81.3 7.3
Paraguay 49.0 48.0 42.4 11.9
Rwanda 4.0 18.0 47.0 19.5
Samoa 52.0 129.0 84.5 12.8
Sao Tome and Principe 20.0 480 47.1 13.2
Senegal 8.0 30.0 56.0 12.1
Serbia 56.0 252.0 61.8 13.8
Solomon islands 39.0 50.0 92.4 15.4
South Arica 101.0 206.0 41.4 10.8
Sri Lanka 16.0 32.0 47.5 8.5
Sudan 3.0 15.0 36.8 6.1

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Member Per capita government General General
State expenditure on health at government government
average exchange rate (US$) expenditure expenditure on
on health as health as % of
% of total total
expenditure government
on health expenditure
2000 2007 2007 2007

India 5.0 11.0 26.2 3.7


Thailand 38.0 100.0 73.2 13.1
Tonga 63.0 76.0 70.3 9.7
Trinidad and Tobago 104.0 440.0 56.1 9.4
Tunisia 67.0 107.0 50.5 9.1
Turkey 122.0 320.0 69.0 10.3
Turkmenistan 36.0 72.0 52.1 10.3
Tuvatu 160.0 291.0 99.8 16.3
Ukraine 19.0 121.0 57.6 9.2
United Republic of 4.0 14.0 65.8 18.4
Tazania
Uzbekistan 14.0 19.0 46.1 7.9
Vanuatu 35.0 61.0 76.3 11.4
Venezuela (Bolivarian 113.0 222.0 46.5 7.1
Republic of)
Viet Nam 6.0 23.0 39.3 8.7
Yemen 13.0 17.0 39.6 4.5
Zambia 9.0 33.0 57.7 14.5
Zimbabwe 35.0 36.0 46.3 8.9
India 5.0 11.0 26.2 3.7
Median 62.0 136.0 60.3 10.8
Maximum 2843 6763 99.8 32.1
India 5.0 11.0 26.2 3.7
African Region 15.0 34.0 45.3 9.6
Region of the Americas 829.0 1374.0 47.2 17.1
South-East Asia Region 6.0 15.0 36.9 5.3
European Region 701.0 1546.0 76.0 15.3
Eastern Mediterranean 36.0 74.0 55.5 7.5
Region
Western Pacific Region 212.0 282.0 67.8 15.1
India 5.0 11.0 26.2 3.7
Low income 5.0 11.0 41.9 8.7
Lower middle income 12.0 34.0 42.4 7.8
Upper middle income 1577.0 2699.0 61.3 17.2
Global 279.0 478.0 59.6 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 Total Expenditure


as % of GDP (Centre + States)
2003-04 0.26 0.90
2004-05 0.26 0.85
2005-06 0.27 0.88
2006-07 0.28 0.90
2007-08 0.29 0.88
2008-09 0.33 1.02
2009-10 0.35 1.06
2010-11 0.36

Public Health Expenditure by Country, 2007 (% of GDP)


Highest percentage spent Lowest percentage spent
São Tomé 9.9% Malta 7.0% Myanmar 0.3% Guinea-Bissau 1.3%

Malawi 9.6 United States 6.9 Pakistan 0.4 Singapore 1.3

Timor-Leste 8.8 Belgium 6.9 Guinea 0.7 Armenia 1.4

Iceland 8.3 Canada 6.8 Burundi 0.8 Philippines 1.4

France 8.2 Switzerland 6.7 Lao 0.8 Nigeria 1.4

Trinidad and
Germany 8.2 Colombia 6.7 India 0.9 1.4
Tobago

Norway 8.1 Slovenia 6.6 Azerbaijan 0.9 Sudan 1.5

Austria 7.8 New Zealand 6.5 Bangladesh 0.9 Georgia 1.5

Occupied Palestinian
7.8 Italy 6.5 Côte d'Ivoire 0.9 Angola 1.5
Territories

Czech Central African


Sweden 7.7 6.5 Tajikistan 1.0 1.5
Republic Republic

Luxembourg 7.2 Australia 6.5 Indonesia 1.0 Chad 1.5

Denmark 7.1 Maldives 6.3 Congo 1.1 Cameroon 1.5

United Kingdom 7.0 Japan 6.3 Togo 1.1 Nepal 1.5

Equatorial
Portugal 7.0 Israel 6.1 1.2 Viet Nam 1.5
Guinea

Croatia 6.1 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 Welfare-

Year Centre’s Expenditure Total Expenditure


as % of GDP (Centre + States)
2003-04 0.26 0.90
2004-05 0.26 0.85
2005-06 0.27 0.88
2006-07 0.28 0.90
2007-08 0.29 0.88
2008-09 0.33 1.02
2009-10 0.35 1.06
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 :

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.”

21 | P a g e
Without Comment

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 long-
standing 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.

22 | P a g e
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 co-
ordinated 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 2.9


Bihar 3.9
MP 3.6
Rajasthan 3.7
U.P. 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

23 | P a g e
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 (2007-
2012) 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

25 | P a g e
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.

26 | P a g e
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 Number


AP 36
BIHAR 9
KARNATAKA 39
KERALA 21
MAHARASTRA 41
MP 8
ORISSA 6
PUNJAB 8
RAJASTHAN 10
TAMILNADU 37
UP 21
Total in India 300
Total intake in India 11192

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Source - As per MCI Website data sheet.
Distribution of Medical Colleges in India Distribution of Nursi Colleges in India

28 | P a g e
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
Sl.No State Dist. Posts of Vacancy % Vacancy
Position Position
Hospitals doctors in
the State
1 U.P. 71 13789 8278 60.03 5511 39.97
2 M.P. 50 5809 4094 70.48 1715 29.52
3 Orissa 32 4727 2961 62.64 1766 37.36
4 Rajasthan 33 5767 4580 79.42 1187 20.58
5 Kerala 14 2465 2769 112.33 -304 -12.33
6 Tamil Nadu 27 4213 3610 85.69 603 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.

29 | P a g e
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 WISE ESTIMATED Vs ACTUAL ALLOCATON UNDER NRHM.
Year Estimated Allocation - GOI ( Source- Actual 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 6500 5703

2006-07 9500 7486.6

2007-08 12350 10890

2008-09 17290 11930

2009-10 24206 14050

2010-11 33884 15440

2011-12 47439 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 un-
tied 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 re-
focus 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

38 | P a g e
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.
Strategic Initiative 2: 20: 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 inter-
ministerial committee under the Prime Minister.

Strategic Initiative 3: 15: Increasing Governmental financial resources for healthcare.

Strategic Initiative 4: 20: Renewed focus on family planning.

Strategic Initiative 5: 25: 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.

Strategic Initiative 6: 10: Restructure programmes to enable state specific features to be


addressed directly. Use of technology.

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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.

2. Announce extension of NRHM.

3. 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.

4. 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.

5. 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.

6. Evolving a “national consensus” in Parliament on the benefits of and need for voluntary
family planning.

7. An extensive national campaign on the value of the girl child co-ordinated with a rigorous
implementation of legal enactments.

8. 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.

9. 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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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. (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.

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 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.

15. 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.

16. 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.

17. Address the issue of non-communicable disease by continuing the focus on Blindness,
Cancer and Mental Health with inclusion of other diseases like Diabetes.

18. To regulate health service delivery.

19. 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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20. 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.

21. 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.

22. 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.

43 | P a g e
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.

44 | P a g e
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 Measurable and


Observables, Reviews
1. Amendment to the Constitution of India to include Specific action of
Health in the Concurrent List. This incorporates a Constitutional Amendment by
recasting of the language of Item No. 6 of the State List so December, 2011.
that it covers the entire scope of healthcare in the current Review by Cabinet
scenario. Secretariat.

2. Announce extension of NRHM Specific action of


Announcement by February,
2011.
Review by Cabinet
Secretariat.
3. Enunciate, announce and implement a commitment to Policy Decision and
increase Governmental spending on Health from $12 per Proclamation by May, 2011
capita in 2008 to $24 per capita (2008 prices) in 2012 (Preferably for budget 2011-
budget to $30 per capita (2008 prices) in 2015. Healthcare 12)
should stabilise at about 12-15% of the Central Budget. Review by Cabinet
Secretariat.
4. A renewed focus on Family Planning with major inputs in Incorporate in State NRHM
creating public awareness and providing access to family PIPs from 2011-12 onwards
planning measures. This has to have a separate component i.e. by May, 2011.
for backward States. Review by MoHFW.
5. This also includes setting up of a Technology Mission Technology Mission by
within the Department of Health and Family Welfare to December, 2011
facilitate the adoption and use of better technologies of Review by Cabinet
family planning in the States and Union territories. Secretariat.

45 | P a g e
6. 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.
7. 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
8. 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.
9. 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

10. To reduce Infant Mortality Rate to 28 per 1000 live births Yearly targets for each State
and Maternal Mortality Ratio to 1 per 1000 live births by Review by MoHFW.
end of 12th Plan, i.e. year 2017.
11. To incentivise the carders of allopathic doctors and 1. Evolution of possible
paramedical staff sufficiently so as to ensure full presence incentives-September
of allopathic physicians and paramedical staff at each 2011-12.
PHC of the country. For this the States shall be supported 2. Inclusion in budget of
financially by GoI. The strengths of State Carders of 2012-13.
doctors and paramedical staff should be finalised in 3. Implementation for States –
consultation with GoI to ensure effective performance of from 2012 onward (XIIth
PHCs, CHCs and District Hospitals. Plan Period).
Review by Cabinet
Secretariat.
12. To enact legislation to modify the role of Medical Council 1. Enacting legislation by
of India and rationalise the procedures and system of Monsoon Session of
establishing Medical Colleges and providing Medical Parliament, 2011.
Education to effectively double the number of MBBS 2. Increasing Capacity and
doctors being produced in the country by 2020 and triple new Medical Colleges by
the number by 2025. 2015.
3. Doubling number of MBBS
doctors being produced per
year- by 2020.
Review of proposed
Legislation by Cabinet
Secretariat.
13. To develop concurrently the training capacity for other 1. Statewise Road map by
human resources for health/medical, paramedical and December 2011.
managerial for ensuring availability of an adequate skill 2. Achievement by 2015.
mix. Review by MoHFW
14. To ensure comprehensive primary healthcare delivery 1. Availability of Doctors at
system with strengthening of PHC infrastructure PHCs-Defining incentives-
supplemented by Mobile Medical Units with well September 2011.

46 | P a g e
functioning linkages with Secondary and Tertiary care 2. Inclusion in budget 2012-
health 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-2012-
2014.
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

47 | P a g e
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.

48 | P a g e
4(vi)- Overall Plan and Milestones:

The overall Plan and Milestones can be listed as follows:-


INITIATIVE Milestones
1. Amendment to the Constitution of India to include 1. Bill for Amendment by
Health in the Concurrent List. This incorporates a April, 2011
recasting of the language of Item No. 6 of the State List so 2.. Constitutional Amendment
that it covers the entire scope of healthcare in the current by December, 2011.
scenario.
2. Announce extension of NRHM 1.Consultation with Finance
Ministry 15 February, 2011
2.Announcement by 28th
February, 2011.
3. Enunciate, announce and implement a commitment to 1.Consultation with Planning
increase Governmental spending on Health from $12 per Commission and Finance
capita in 2008 to $24 per capita (2008 prices) in 2012 Ministry by March, 2011
budget to $30 per capita (2008 prices) in 2015. Healthcare 2.Cabinet Proposal by April,
should stabilise at about 12-15% of the Central Budget. 2011.
3.Policy by May, 2011
4. A renewed focus on Family Planning with major inputs in Incorporate in State NRHM
creating public awareness and providing access to family PIPs from 2011-12 onwards
planning measures. This has to have a separate component i.e. by May, 2011
for backward States.
5. This also includes setting up of a Technology Mission 1.Finalising proposal for
within the Department of Health and Family Welfare to Technology Mission by May,
facilitate the adoption and use of better technologies of 2011
family planning in the States and Union territories. 2.Setting up of Mission by
December, 2011.
6. Evolving a “national consensus” in Parliament on the 1.Finalising draft of National
benefits of and need for voluntary family planning. Consensus by April, 2011.
2.Placing before Parliament-
Monsoon Session
7. 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
8. Enunciation of a comprehensive policy of preventive By December, 2011.
measures of Public Health – as an integral part of
Healthcare in India - accompanied by a well defined
strategy and implementation program.
9. 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
Health, Sanitation, Hygiene, Drinking Water and
Nutrition
10. To reduce Infant Mortality Rate to 28 per 1000 live births 1.Fix yearly targets for each
and Maternal Mortality Ratio to 1 per 1000 live births by State separately-by March,
end of 12th Plan, i.e. year 2017. 2011.

49 | P a g e
2. Ensure State wise
monitoring
11. To incentivise the carders of allopathic doctors and 1.Evolution of possible
paramedical staff sufficiently so as to ensure full presence incentives-September 2011-
of allopathic physicians and paramedical staff at each 12.
PHC of the country. For this the States shall be supported 2.Inclusion in budget of 2012-
financially by GoI. The strengths of State Carders of 13.
doctors and paramedical staff should be finalised in 3.Implementation for States –
consultation with GoI to ensure effective performance of from 2012 onward (XIIth Plan
PHCs, CHCs and District Hospitals. Period).

12. To enact legislation to modify the role of Medical Council 1.Finalising draft of
of India and rationalise the procedures and system of legislation-by June, 2011
establishing Medical Colleges and providing Medical 2.Enacting legislation by
Education to effectively double the number of MBBS Monsoon Session of
doctors being produced in the country by 2020 and triple Parliament, 2011.
the number by 2025. 3.Fix yearly targets-
Statewise- for increasing
capacity and new Medical
Colleges for period 2012-15.
4.Doubling number of MBBS
doctors being produced per
year- by 2020.

13. To develop concurrently the training capacity for other 1.Road map by December
human resources for health/medical, paramedical and 2011 detailing actions for each
managerial for ensuring availability of an adequate skill State separately from 2012-15.
mix. 2.Achievement by 2015.
14. To ensure comprehensive primary healthcare delivery 1.Availability of Doctors at
system with strengthening of PHC infrastructure PHCs-Defining incentives-
supplemented by Mobile Medical Units with well September 2011.
functioning linkages with Secondary and Tertiary care 2.Inclusion in budget 2012-13.
health delivery system. This implies availability of 3.Additional recruitment of
emergency ambulance services and technology supported doctors in States- 2012-14.
communication links uniformly across the country.
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.

50 | P a g e
7.Technology supported
communication links from
sub-centres to PHCs to
Secondary and Tertiary
Healthcare Centres-2012-14.
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.Finalising the Road map for
the national standards. each State separately for
upgrading all State Medical
Colleges-by December 2011.
3.Ungradation of State
Medical Colleges from 2012-
13 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.
16. Reducing overall disease burden of the society by 1.Existing programme
continuing the focus on communicable diseases like intensified for 2011-12.
Malaria, Tuberculosis, Filariasis, Kala-azar and Leprosy. 2.Finalisation of programme
Additional diseases like Japanese Encephalitis and Acute for Additional Diseases by
Encephalitis should be included. December, 2011.
3.Inclusion of Additional
Diseases 2012-13.

17. 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.
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.
19. 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.

51 | P a g e
20. Jointly develop five year and annual State Health Plans in
1.Complete Statewise exercise
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.
21. 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.
22. 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.

52 | P a g e
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.

53 | P a g e
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.

54 | P a g e
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

55 | P a g e
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  Tracking System (Pregnant Women & Infants/Children)
Development  Creches (for children 6 month to 2 years children of working
mother)
 Women Empowerment

 Water/Supply/Treatment
Urban Development  Sanitation/Sewerage
 Waste Management

 Maternity Benefits
 Working Conditions (particularly for women)
Labour & Employment
 Rasthiya Swastya Bima Yojna (RSBY)
 ESI etc.

 Rogi Kalyan Samiti (RKS)


Panchayati Raj
 Village Health and Sanitation Committee (VHSC)

Human Resource  Education & Literacy (particularly for Girls)


Development  Mid-Day-Meal Programme

Rural Development  Poverty/Employment NREGA

56 | P a g e
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..”

(Shakespeare-Julius Caesar)

57 | P a g e
ANNEXURE- 1
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.

58 | P a g e
• 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 Sub-
centres, 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.

59 | P a g e
• 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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