Twelfth Five Year Plan (2012-2017) Social Sectors
Item
- Title
-
Twelfth Five Year Plan
(2012-2017)
Social Sectors - extracted text
-
Twelfth Five Year Plan
(2012-2017)
Social Sectors
Volume III
Copyright © Planning Commission (Government of India) 2013
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First published in 2013 by
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ISBN: 978-81 -321 -1131-3 (PB)
The SAGE Team: Rudra Narayan, Archita Mandal, Rajib Chatterjee and Dally Verghcse
Twelfth Five Year Plan
(2012-2017)
Social Sectors
Volume III
Planning Commission
Government of India
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Contents
List of Figures
List of Tables
List of Boxes
List of Acronyms
List of Annexures
20.
Health
21.
Education
22.
Employment and Skill Development
23
Women’s Agency and Child Rights
24.
Social Inclusion
vii
viii
x
xi
xviii
1
47
124
164
221
Figures
20.1
20.2
20.3
20.4
21.1
21.2
21.3
21.4
21.5
22.1
22.2
23.1
23.2
23.3
23.4
Disease Burden of India, 2008 (Estimated number of deaths by cause)
Disability Adjusted Life Years in India, 2009 (Estimated percentage of DALY by cause)
Strategies to Prevent Pre-Term Births and Manage Pre-Term Babies
Projected HRH Capacity Expansion in the Twelfth Plan
GER for Secondary Education: By States/Select Countries
Improvements in Literacy Levels, 1981-2011 (%)
Strategic Framework
Enrolments in Higher Education (in lakh): 2006-07 to 2016-17
Gross Attendance Ratio, 2007-08
Trend in Unemployment Rate
Unemployment Rate among Youth
Child Sex Ratio 0-6 Years and Overall Sex Ratio India: 1961-2011
Nutrition Status of Children under 3 Years (%)
Inadequate Exclusive Breastfeeding in India (0-6 Months)
Children Aged 6-35 Months who Received a Vitamin A Dose During Last Six Months (%)
(AHS 2010-11)
2
2
30
37
69
87
91
97
102
126
133
182
197
198
199
Tables
Growth of Institutions in the Eleventh Plan
Growth of Central Institutions during the Eleventh Plan
Enrolment Targets by Level/Type for the Twelfth Plan
Funding Responsibility for Universities and Colleges
Gross Budgetary Support for the Twelfth Plan
LFPR and WFPR by Usual Principal and Subsidiary Status, 1993-94, 2004-05 and 2009-10
4
5
5
16
17
18
32
36
39
54
63
68
71
71
86
93
93
94
94
95
96
118
122
125
22.2
22.3
22.4
22.5
22.6
22.7
(%) Persons
Estimated Number of Persons in Millions
Unemployment, Wages and Consumption Expenditure, 1993-4 to 2009-10
Proportionate Share of Sectors in Employment
Formal and Informal Employment in Organized and Unorganised Sector (millions)
Number of Workers by Size of Enterprise in Industry and Services
Number of Workers According to Usual Status (PS+SS) Approach by Broad Employment
125
126
127
131
132
132
22.8
Status (Million Workers)
LFPR by Usual Principal and Subsidiary Status, 1993-04, 2004-05 and 2009-10 (%) by
133
22.9
Gender
WPR by Usual Principal and Subsidiary Status, 1993-04,2004-05 and 2009-10 (%) by
133
22.10
Gender
Child Workforce Participation Rate by UPSS (Percentage), 1993-04, 2004-05 and 2009-10
133
20.1
20.2
20.3
20.4
20.5
20.6
20.7
20.8
20.9
21.1
21.2
21.3
21.4
21.5
21.6
21.7
21.8
21.9
21.10
21.11
21.12
21.13
21.14
22.1
Eleventh Plan Monitorable Goals and Achievements
Allocation and Spending by Ministry of Health in Eleventh Plan
Funding for Health in Eleventh Plan: Core and Broad Health Components
State-Wise Targets on 1MR and MMR in Twelfth Plan
National Health Goals for Communicable Diseases
Budget Support for Departments of MoHFW in Twelfth Plan (2012-1 /)
Interventions to Combat Non-Communicable Diseases (NCDs)
Availability of HR during Eleventh Plan and Projections for Twelfth Plan
Illustrative List of Health Systems Strengthening in States
Cumulative Progress under SSA up to 2011-12
Civil Works under SSA in the Twelfth Plan
GER for Secondary Education by Social Groups (2009-10)
RMSA: Achievement in the Eleventh Plan
Centrally Sponsored Schemes for Secondary Education
Roles in System Improvement
Growth of Enrolment in the Eleventh Plan
Growth of Enrolment in DDL Programmes in the Eleventh Plan
Growth of Enrolment by Field of Study during the Eleventh Plan (in lakh)
Tables ix
Workforce Participation Rate by Usual Principal and Subsidiary Status, by Social Group,
1993-4, 2004-5 and 2009-10 (%)
22.12 Unemployment Rate by Usual Principal and Subsidiary Status, by Social Group, 2004-5 and
2009-10 (%)
22.13 Population and Labour Force Projections
22.14 Employment Elasticity from Past Data
22.15 Sectoral Growth Rates: Business-as-usual Scenario
22.16 Sectoral Employment (in million): Business-as-usual Scenario
22.17 Sectoral Growth Rates—Twelfth Plan Scenario
22.18 Sectoral EMPLOYMENTS (in million): Twelfth Plan Scenario
22.19 General Education Level of Labour Force (PS+SS) in the Age Group 15-59
22.20 Estimated Number of Workers (PS+SS in the age group of 15-59) by Level of Education by
Sector (millions), 2009-10
22.21 Distribution of Formally and Informally Vocationally Trained Workers (PS+SS in the age
group of 15-59) Within Primary, Secondary and Tertiary Sectors (%) in 2009-10
22.22 Apprentices in India (Under the Apprenticeship Training Act, 1961)
22.23 A Typology of Training Funds
Ministry-Wise Incorporation of Gender Concerns (under RFD)
23.1
Monitorable Targets of Eleventh Plan and Its Achievements
23.2
Existing Programmes/Schemes
23.3
Incidence of Poverty across Social Groups
24.1
Eleventh Plan Allocation and Expenditure for Special Schemes for SCs
24.2
Rural Population Living Below Poverty Line (1993-94,1999-2000 and 2004-05) (in %)
24.3
Literacy Rates of STs and Total Population (in %)
24.4
Female Literacy Rates of STs and Total Population (in %)
24.5
Mortality and Undernutrition
24.6
Eleventh Plan Allocation and Expenditure for Special Schemes for STs
24.7
Literacy Rate among Religious Communities, SCs and STs
24.8
Educational Levels among Different Communities
24.9
24.10 Percentage Distribution of Workers by Category
22.11
134
134
135
136
136
137
137
138
140
141
142
144
156
180
201
204
221
222
229
229
229
230
230
250
251
252
Boxes
20.1
20.2
20.3
20.4
20.5
20.6
20.7
21.1
21.2
21.3
21.4
21.5
21.6
21.7
21.8
21.9
21.10
21.11
22.1
22.2
22.3
22.4
22.5
22.6
22.7
23.1
23.2
23.3
23.4
23.5
24.1
24.2
24.3
24.4
24.5
Recommendations of High Level Expert Group on Universal Health Coverage
Illustrative List of Preventive and Public Health Interventions Funded and Provided by
Government
Public-Private Partnerships (PPP) in Health Sector
Institute of Liver and Biliary Sciences, Delhi: A Model of Autonomy and Sustainable
Financing
Flexibility and Decentralised Planning: Key Elements of National Health Mission
Suggested Items in Model HR Guidelines
Convergence: Village Health and Nutrition Day in North Tripura
Targets for the Twelfth Plan
Twelfth Plan Strategy for Elementary Education
School Excellence Programme—Mumbai
Secondary Education: Twelfth Plan Goals
CBSE Examination Reforms
Pilot Project on Vocational Education under NVEQF
Enrolment Target for the Twelfth Plan
TISS: A Multi-Location Networked University
Strategic Shift in Central Funding for State Higher Education
Concept and Framework for Establishing Community Colleges
Student Financial Aid Programme (SFAP)
Conceptual Framework of Key Employment and Unemployment Indicators
Skill Policy for Promoting India’s Competitiveness in the Global Market
Priority Sectors Identified in the Twelfth Plan
Strategies for Expanding and Scaling up the Skill Development in Twelfth Plan
Major Functions of Proposed National Skill Development Authority
Good Performers in Financing—Chile, Australia, South Africa, Singapore
Equity Implications of LJser Fees
Women Friendly Infrastructure Development in Kerala
Declining Child Sex Ratio—A Call for Urgent Action
Making the Difference—ICDS Restructuring
Learning by Doing—SNEHA SHIVIRs
Early Joyful Learning-Chilli Pilli
Eleventh Five Year Plan Schemes
Vision for the Twelfth Five Year Plan
Specific Interventions under PM’s 15 PP
The Jaipur Foot Story
Possible Actions by Central Government Ministries to Benefit Those with Disabilities
12
14
20
24
28
35
45
51
56
62
72
75
79
91
99
100
101
104
127
143
148
151
151
157
158
171
183
189
190
193
253
255
256
264
269
Acronyms
Antodaya Anna Yojana
Activity-Based Learning
Adult Education & Skill
Development Centres
Annual Health Survey
AHS
All India Council for Technical
AICTE
Education
Acquired Immuno Deficiency
AIDS
Syndrome
All India Entrance Exam for
AIEEE
Engineering
All India Trade Test
AITT
AllMS like Institutions
A Lis
Anganwadi Level Monitoring and
ALMSC
Support Committee
Auxiliary Nurse & Midwife
ANM
Ass ciation of Rehabilitation
ARUNIM
under National Trust Initiative of
Marketing
Academic Ranking of World
ARWU
Universities
Academic Staff College
A SC
Annual Status of Education Report
ASER
Accredited Social Health Activist
ASHA
ASSOCHAM Associated Chambers of Commerce
& Industry
Apprenticeship Training Scheme
ATS
Accredited Vocational Institutes
AVI
Anganwadi Training Centre
AWTC
Anganwadi Worker
AWW
Bengal Engineering and Science
BESU
University
Babu Jagjivan Ram Chatarvas Yojana
BJRCY
Body Mass Index
BMI
Below Poverty Line
BPL
Business Process Outsourcing
BPO
Block Resource Centre
BRC
AAY
ABE
AESDCs
BRGF
CABE
CAGR
CAL
CAT
CBM
CBSE
CBUs
CCD
CCE
CDS
CES
CFR
CGHS
CHC
CHEB
CIHEC
CII
CLAT
CMB
COBSE
CoE
CPI
CPE
CPMT
CPPE
CRC
CSC
CSIR
CSO
Backward Regions Grant Fund
Central Advisory Board of Education
Compounded Annual Growth Rate
Computer Aided Learning
Common Admission Test
Community Based Monitoring
Central Board of Secondary
Education
Community Based Organisations
Conservation cum Development
Continuous and Comprehensive
Evaluation
Current Daily Status
Coverage Evaluation Survey
Community Forest Rights
Central Government Health Scheme
Community Health Centre
Central Health Education Bureau
Council for Industry and Higher
Education Collaboration
Confederation of Indian Industries
Common Law Admission Test
Conditional Maternity Benefit
Scheme
Counci l of Boards of School
Education
Centre of Excellence
Consumer Price Index
Commercial Pilot Licence
Combined Pre Medical Entrace Test
Council for People’s Participation in
Education
Cluster Resource Centre
Common Service Centre
Council of Scientific and Industrial
Research
Civil Society Organisations
xii
Acronyms
CSR
CSS
CTA
CTC
CTE
CTET
CUE
CVD
CWSN
DALY
DAPCU
DEC
DEI
DES
DGET
DHR
DIG
DIET
DISE
DLHS
DNB
DNT
DONER
DOTS
DPC
DPEP
DRG
DSLL
DTH
DWS
EAG
EBB
ECCE
EESC
EGS
EHP
ELM
EMR
EPC
Corporate Social Responsibility
Centrally Sponsored Scheme
Criminal Tribes Act
Central Tripatite Committee
College of Teacher Education
Central Teacher Eligibility Test
Centre for Universal Education
Cardio-Vascular Diseases
Children With Special Needs
Disability Life Adjusted Year
District AIDS Prevention & Control
Unit
Distance Education Council
Distance Education Institution
Double Fortified Salt
Directorate General of Employment
& Training
Department of Health Research
Design Innovation Centre
District Institute of Education and
Training
District Information System of
Education
District Level Health Survey
Diplomats of National Board
De-notified Tribes
Department of North Eastern Region
Directly Observed Treatment - Short
Course
District Planning Committees
District Primary Education
Programme
Diagnostic Related Group
Department of Skills and Lifelong
Learning
Direct-to-Home
Drinking Water Supply
Empowered Action Group
Educationally Backward Blocks
Early Childhood Care and Education
Essential and Emergency Surgical
Care
Education Guarantee Scheme
Essential Health Package
Elementary (Classes I-VIII)
Electronic Medical Record
Engineering, Procurement and
Construction
ER
ERP
EDO
FICCI
FRA
FRU
FSSA
FSSAI
GAR
GBPS
GBS
GDP
GER
GNM
GP
GPI
GPS
GS
GVA
HCR
HEI
HFW
HH
HIS
HIV
HLEG
HMIS
IAP
IASE
IAY
IB A
I CAI
I CDS
ICMR
ICT
IDD
IDMI
IEC
E1 ec ted Represen ta tives
Enterprise Resource Planning
Fixed Dose Combination
Federation of Indian Chamber of
Commerce & Industry
Forest Rights Act
First Referral Unit
Food Safety and Standards Act
Food Safety and Standards Authority
of India
Gross Attendance Ratio
Gigabit Per Second
Gross Budgetary Support
Gross Domestic Product
Gross Enrolment Ratio
General Nursing and Midwifery
Gram Panchayats
Gender Parity Index
Global Positioning System
Gram Sabhas
Gross Value Added
Head Count Ratio
Higher Education Institution
Health and Family Welfare
House Holds
Health Information System
Human Immunodeficiency Virus
High Level Expert Group
Health Management Information
Systems
Indian Academy of Pediatrics/
Integrated Action Plan
Institute of Advanced Studies in
Education
Indira Awas Yojana
Indian Banks’ Association
Institute of Cost Accounts of India
Integrated Child Development
Services
Indian Council of Medical Research
Information and Communication
Technology
Iron Deficiency Disorder
Infrastructure Development in
Minority Institutions
Information, Education and
Communication
Acronyms
IEDSS
IFA
IFR
IGMSY
IGNOU
IIC
hit
UM
USER
IIT
IMCs
1MNCI
IMR
IMRB
IMS Act
IMS
INC
INN
INT
IPC
TPERPO
1PHS
IPOP
IPR
IRCAs
ISCED
ISM
IT
ITCs
ITIs
ITPA
IUC
IVRS
IYCF
JE
JEE
Inclusive Education for the Disabled
at Secondary Stage
Iron Folic Acid
Individual Forest Rights
Indira Gandhi Matritva Sahyog
Yojana
Indira Gandhi National Open
University
Inter Institutional Centre
International Institute of
Information Technology
Indian Institute of Management
Indian Institute of Science Education
and Research
Indian Institute of Technology
Institute Management Committees
Integrated Management of Neonatal
and Childhood Illness
Infant Mortality Rate
International Marketing and
Research Bureau
Infant Milk Substitutes Act
Infant Milk Substitute
Indian Nursing Council
International Non-proprietary Name
Indian Institute oflnfbrmation
Technology
Indian Penal Code
Intellectual Property Education,
Research and Public Outreach
Indian Public Health Standard
Integrated Programme for Older
Persons
Intellectual Property Rights
Integrated Rehabilitation Centre for
Addicts
International Standard Classification
of Education
Indian School of Mines
Information Technology
Industrial Training Centres
Industrial Training Institutes
Immoral Trafficking Prevention Act
Inter University Centre
Interactive Voice Response System
Infant and Young Child Feeding
Japanese Encephalitis
Joint Entrance Exam
JIPME.R
JKGBV
JNNURM
JNV
JPC
JRF
JSS
JSY
KGBV
KV
KVKs
KVY
LEP
LFPR
LLIN
LMIS
LMS
LWE
MAEF
MCDs
MCS
MDG
MDM
MDMS
MES
MFP
MGHN
MGNREGA
MGNREGS
MHFW
MH RD
MIB
MIS
MITI
MLA
MMER
MMP
MMR
MMU
xiii
Jawaharlal Institute of Post Graduate
Medical Education and Research
Kasturba Gandhi Balika Vidyalay
Jawaharlal Nehru National Urban
Renewal Mission
Jawahar Navodaya Vidyalaya
Joint Parliamentary Committee
Junior Research Fellowship
Jan Shiksha Sansthans
Janani Suraksha Yojana
Kasturba Gandhi Balika Vidyalaya
Kendriya Vidyalaya
Krishi Vigyan Kendras
Kaushal Vikas Yojana
Learning Enhancement Programme
Labour Force Participation Rate
Long Lasting Insecticide Net
Labour Market Information System
Learning Management System
Left Wing Extremism
Maulana Azad Education
Foundation
Minority Concentration Districts
Model Cluster Schools
Millennium Development Goal
Mid-Day Meal
Mid-Day Meals in Schools
Modular Employable Skills
Minor Forest Produce
Merry Gold Health Network
Mahatma Gandhi National Rural
Employment Guarantee Act
Mahatma Gandhi National Rural
Employment Guarantee Scheme
Ministry of Health and Family
Welfare
Ministry of Human Resource
Development
Ministry of Information and
Broadcasting
Management Information System
Model Industrial Training Institute
Member of Legislative Assembly
Management, Monitoring,
Evaluation and Research
Mission Mode Project
Maternal Mortality Ratio
Mobile Medical Unit
xiv Acronyms
MoHFW
MoLE
MoMA
MOOC
MoSJE
MoTA
MoU
MoWCD
MP
MPCE
M.Phil
MPLADS
MPR
MS
MSDP
MSDP
MSJE
MSME
MTP
MVA
MYA
MYA&S
NAAC
NAC
NACP
NAS
NBA
NBCFDC
NBHE
NBT
NBTTC
NCD
NCERT
NCF
NCFTE
Ministry of Health & Family Welfare
Ministry of Labour & Employment
Ministry of Minority Affairs
Massive Open Online Course
Ministry of Social Justice and
Empowerment
Ministry of Tribal Affairs
Memorandum of Understanding
Ministry of Woman & Child
Development
Madhya Pradesh
Monthly Per-capita Consumption
Expenditure
Master of Philosophy
Member of Parliament Local Area
Development Scheme
Ministry of Panchayati Raj
Manila Samakhya
Multi Sectoral Development Plan
Multi Sectoral Development
Programme
Ministry of Social Justice and
Empowerment
Ministry of Micro, Small and
Medium Enterprises
Medical Termination of Pregnancy
Manual Vacuum Aspiration
Ministry of Youth Affairs
Ministry of Youth Affairs & Sports
National Assessment and
Accreditation Council
National Advisory Council
National AIDS Control Programme
National Assessment Survey
National Board of Accreditation
National Backward Classes Finance
and Development Corporation
National Board for Health Education
National Book Trust
National Board for Trade Testing
and Certification
Non Communicable Disease
National Council of Educational
Research & Training
National Curriculum Framework
National Curriculum Framework for
Teacher Education
NCHER
NCHRH
NCHS
NCLSE
NCRB
NCSC
NCST
NCTE
NCVT
NDDB
NDIN
NDRDA
NE
NEAC
NEGP
NER
NFHS
NFIDA
NFSB
NGO
Ni l A
NHFDC
NHM
NHPPT
NHRDA
NHSRC
NICE
NIDDCP
NIFFT
National Commission for Higher
Education and Research
National Commission for Human
Resources in Health
National Centre for Health Statistics
National Centre for Leadership in
School Education
National Crime Records Bureau
National Commission for Scheduled
Castes
National Commission for Scheduled
Tribes
National Council for Teacher
Education
National Council of Vocational
Training
National Dairy Development Board
National Design Innovation Network
National Drug Regulatory and
Development Authority
North East
National Evaluation and Assessment
Committee
National e-Governance Plan
North Eastern Region
National Family Health Survey
National Fund for Innovative
Development Activities
National Food Security Bill
Non-Governmental Organisation
National Health Accounts
National Handicapped Finance
Develop m e n t Corpo ratio n
National Health Mission
National Health Promotion and
Protection Trust
National Health Regulatory and
Development Authority
National Health System Resource
Centre
National Institute of Clinical
Excellence
National Iodine Deficiency Disorders
Control Programme
National Institute of Foundry and
Forge Technology
Acronyms
NIHFW
NIN
NIOS
N1PPCD
NJRD
NISD
NIT
NKC
NLM
NMDFC
NME-1CT
NMMS
NNMB
NNP
NOSS
NPAN
NPCC
NPCDCS
NPEGEL
NP-NSPE
NRDWP
NREGA
NRHM
NRLM
NSDC
NSDCB
National Institute of Health arid
Family Welfare
National Institute of Nutrition
National Institute of Open Schooling
National Institute of Public
Cooperation and Child
Development
National Institute for Rural
Development
National Institute of Social Defence
National Institute of Technology
National Knowledge Commission
National Literacy Mission
National Minorities Finance and
Development Corporation
National Mission on Education
through Information and
Communication Technology
National Merit-cum-Means
Scholarships
National Nutrition Monitoring
Bureau
National Nutrition Plan
National Overseas Scholarship
Scheme
National Plan of Action on Nutrition
National Programme Coordination
Committee
National Programme for the
Prevention and Control of Cancer,
Diabetes, Cardiovascular Diseases
and Stroke
National Programme for Education
of Girls at Elementary Level
National Programme for Nutritional
Support to Primary Education
National Rural Drinking Water
Programme
National Rural Employment
Guarantee Act
National Rural Health Mission
National Rural Livelihoods Mission
National Skill Development
Corporation
National Skill Development
Coordination Board
NSFDC
NSIGSE
NSKFDC
NSQF
NSS
NSSO
NSTFDC
NT
NTFs
NTFP
NUEPA
NV
NVEQF
OBCs
ODL
ODS
OECD
OOP
OoSC
ORS
PCR Act
PDS
PEC
PESA Act
PET
PG
PGIMER
PHC
Ph.D
PIP
PISA
PLHA
PMAGY
xv
National Scheduled Castes Finance
and Development Corporation
National Scheme of Incentive to
Girls for Secondary Education
National Safai Karamcharis Finance
and Development Corporation
National Skills Qualification
Framework
National Sample Survey/Nutrition
Surveillance System
National Sample Survey
Organisation
National Scheduled Tribes Finance
and Development Corporation
Nomadic Tribe
National Training Funds
Non Timber Forest Product
National University of Educational
Planning and Administration
Navodaya Vidyalaya
National Vocational Education
Qualifications Framework
Other Backward Classes
Open and Distance Learning
Open Design School
Organisation for Economic
Co-operation & Development
Out of Pocket
Out of School Children
Oral Rehydration Solution
Protection of Civil Rights Act
Public Distribution System
Punjab Engineering College
Panchayat Extension to Scheduled
Areas Act
Physical Education Teacher
Postgraduate
Post Graduate Institute of Medical
Education and Research
Primary Health Centre
Doctor of Philosophy
Project Implementation Plan
Programme for International
Student Assessment
People living with HIV/AIDS
Pradhan Mantri Adarsh Gram
Yojana
xvi
Acronyms
PMDT
PMGSY
PMS
PMSSY
POA Act
PPP
PRI
PS
PSL
psscive
PSUs
PTA
PTG
PTR
PVTGs
PYKKA
QMT
R&D
RCH
RDA
RDK
RGI
RGNCS
RGNFS
RGSEAG
RKS
RMP
RMSA
R&R
RRTCs
RSBY
RSC
RTE
RUDSETI
SEA
SC
SCA
SCAs
Programmatic Management of
Drug-resistant Tuberculosis
Pradhan Mantri Gram Sadak Yojana
Post Matric Scholarship
Pradhan Mantri Swasthya Suraksha
Yojana
Prevention of Atrocities Act
Public-Private Partnership
Pahchayati Raj Institution
Primary School
Priority Sector Lending
Pandit Sunder Lai Sharma Central
Institute of Vocational Education
Public Sector Undertakings
Parent Teacher Association
Primitive Tribal Groups
Pupil Teacher Ratio
Particularly Vulnerable Tribal
Groups
Panchayat Yuva Krida Khel Abhiyan
Quality Monitoring Tools
Research and Development
Reproductive and Child Health
Recommended Dietary Allowance
Rapid Diagnostic Kits
Registrar General of India
Rajiv Gandhi National Creche
Scheme
Rajiv Gandhi National Fellowships
Scheme
Rajiv Gandhi Scheme for
Empowerment of Adolescent Girls
Rogi Kalyan Samitis
Registered Medical Practitioner
Rashtriya Madhyamik Shiksha
Abhiyan
Rehabilitation and Re-settlement
Regional Resource and Training
Centres
Rashtriya Swasthya Bima Yojana
Residential School Complex
Right to Education
Rural Development and Self
Employment Training Institute
Skilled Birth Attendants
Scheduled Caste
Special Central Assistance
State Channelizing Agencies
SCDC
SCERT
SCP
SCR
SCSP
SDCs
SEMIS
SFAP
SGSY-SP
SHGs
SHSRC
SI A
SIE
SIEMAT
SIHFW
SII J&K
SJE
SKA
SKP
SMC
SMEPWD
SNT
SOS
SPO
SPQEM
SRCs
SRF
SRI
SRMS
SRS
SSA
SSCs
ST
STDCs
STEP
Scheduled Caste Development
Corporation
State Council of Educational
Research & Training
Special Component Plan
Student Classroom Ratio
Scheduled Caste Sub Plan
Skill Development Centres
Secondary Education Management
Information System
Student Financial Aid Programme
Swarnajayanti Gram Swarozgar
Yoj a n a - Spec i a 1 Proj e c t s
Self Help Groups
State Health System Resource Centre
Supplemental Immunization Activity
State Institute of Education
Slate Institute of Educational
Management & Training
State Institute of Health and Family
Welfare
Special Industry Initiative for Jammu
& Kashmir
Social Justice and Empowerment
Sarva Krida Abhiyan
Skill Knowledge Providers
School Management Committee
State Mission for Empowerment of
Persons with Disabilities
Semi Nomadic Tribe
Stale Open School
State Project Office
Scheme for Providing Quality
Education in Madarasas
Socio Religious Communities
Senior Research Fellowship
Social and Rural Institute
Scheme for Rehabilitation of Manual
Scavengers
Sample Registration System
Sarva Shiksha Abhiyan
Sector Skill Councils
Scheduled Tribe
State Tribal Development
Corporations
Support to Training and
Employment Programme for
Women
Acronyms
STET
STI
TB
TBA
TEI
TEQIP
TET
TFR
THE
TISS
TLC
TLE
TLM
TNTFP
TPDS
TREAD
TRI
TRIFED
TRIPs
TSC
TSP
TVET
UEE
UG
State Teacher Eligibility Test
Sexually Transmitted Infection
Tuberculosis
Traditional Birth Attendant
Teacher Education Index
Technical Education Quality
Improvement Programme
Teacher Eligibility Test
Total Fertility Rate
Times Higher Education
Tata Institute of Social Sciences
Teaching and Learning Centre
Teaching Learning Equipment
Teaching Learning Material
Traditional Non Timber Forest
Product
Targeted Public Distribution System
Trade Related Entrepreneurship
Assistance and Development
Tribal Research Institute
Tribal Cooperative Marketing
Development Federation of India
Limited
Trade-Related Aspects of Intellectual
Property Rights
Total Sanitation Campaign
Tribal Sub-Plan
Technical and Vocational Education
& Training
Universalisation of Elementary
Education
Undergraduate
UGC
UHC
UID
ULB
UMDT
UNCRPD
UNESCO
UNICEF
UP
UPS
UPSS
USA
UT
VEC
VET
VEND
VHNSC
VHSND
VO
VRCs
VTPs
WCD
WCP
WFPR
WHO
WTO
xvii
University Grants Commission
Universal Health Coverage
Unique Identification
Urban Local Bodies
Uniform Multi-Drug Therapy
Regimen
United Nations Conventions on the
Rights of Persons with Disabilities
United Nations Educational,
Scientific & Cultural Organisation
United Nations International
Children Emergency Fund
Uttar Pradesh
Upper Primary School
Usual Principal Subsidiary Status
United States of America
Union Territory
Village Education Committee
Vocational Education & Training
Village Health and Nutrition Day
Village Health Nutrition Sanitation
Committee
Village Health, Sanitation and
Nutrition Day
Volunteer Organisations
Vocational Rehabilitation Centres
Vocational Training Providers
Women and Child Development
Women and Child Programmes
Work Force Participation Rate
World Health Organization
World Trade Organisation
Annexures
22.1
22.2
22.3
22.4
Employment Across Various Sectors (in millions) 1999-2000, 2004-5, 2009-10—on UPSS
basis
Absolute Increase/Decrease Employments Across Various Sectors (in millions) in
Manufacturing, 1999-2000, 2004-5, 2009-10
Incidence of Unemployment for 15 Years and Above Age Group, by Level of Education,
2004-5 and 2009-10 (UPSS) in Percentage
Dependency Ratio Across India States, Census 2001
160
161
162
163
Health
20.1. Health should be viewed as not merely the
absence of disease but as a state of complete physical,
mental and social well-being. The determinants of
good health are: access to various types of health ser
vices and an individual’s lifestyle choices, personal,
family and social relationships. The latter are outside
the scope of this Chapter. The focus in this Chapter
is on the strategy to deliver preventive, curative and
public health seivices. Other sectors that impact on
good health, such as clean drinking water and sanita
tion arc dealt with in other Chapters of the Plan.
AN OVERVIEW
20.2. At present, India’s health care system consists
of a mix of public and private sector providers of
health services. Networks of health care facilities at
the primary, secondary and tertiary level, run mainly
by State Governments, provide free or very low cost
medical services. There is also an extensive private
health care sector, covering the entire spectrum from
individual doctors and their clinics, to general hospi
tals and super speciality hospitals.
20.3. The system
weaknesses:
1.
suffers
from
the
following
Availability of health care services from the pub
lic and private sectors taken together is quantita
tively inadequate. This is starkly evident from the
data on doctors or nurses per lakh of the popula
tion. At the start of the Eleventh Plan, the num
ber of doctors per lakh of population was only
45, whereas, the desirable number is 85 per lakh
population. Similarly, the number of Nurses and
Auxiliary Nurse and Midwifes (ANMs) avail
able was only 75 per lakh population whereas the
desirable number is 255. The overall shortage is
exacerbated by a wide geographical variation in
availability across the country. Rural areas are
especially poorly served.
2. Quality of healthcare services varies consider
ably in both the public and private sector. Many
practitioners in the private sector are actually not
qualified doctors. Regulatory standards for public
and private hospitals are not adequately defined
and, in any case, are ineffectively enforced.
3. Affordability of health care is a serious problem
for the vast majority of the population, especially
in tertiary care. The lack of extensive and ade
quately funded public health services pushes large
numbers of people to incur heavy out of pocket
expenditures on services purchased from the pri
vate sector. Out of pocket expenditures arise even
in public sector hospitals, since lack of medi
cines means that patients have to buy them. This
results in a very high financial burden on families
in case of severe illness. A large fraction of the out
of pocket expenditure arises from outpatient care
and purchase of medicines, which are mostly not
covered even by the existing insurance schemes.
In any case, the percentage of population covered
by health insurance is small.
4. The problems outlined above are likely to worsen
in future. Health care costs arc expected to rise
because, with rising life expectancy, a larger pro
portion of our population will become vulner
able to chronic Non Communicable Diseases
(NCDs), which typically require expensive
2
Twelfth Five Year Plan
treatment. The public awareness of treatment
possibilities is also increasing and which, in turn,
increases the demand for medical care. In the
years ahead, India will have to cope with health
problems reflecting the dual burden of disease,
that is, dealing with the rising cost of managing
NCDs and injuries while still battling commu
nicable diseases that still remain a major public
health challenge, both in terms of mortality and
disability (Figures 20.1 and 20.2).
5. The total expenditure on health care in India,
taking both public, private and household outof-pocket (OOP) expenditure was about 4.1 per
cent of GDP in 2008-09 (National Health
Accounts [NHA] 2009), which is broadly com
parable to other developing countries, at similar
0.08
\).10
2.53
3%
0.7%
19.28
I 0.9%
: J
1.4%
2%
2%
.
. cn\\0.21
AV'54
/ ’ ‘ z > I 0.89
WiF"' T—0.95
“
wTl-49
,^?Pi5%
2.78
2 85
11.62 |
6%
7%'
1
■
j .
I'
3.67
■ '
6.30
7% || |f
0.6%
F n%
F
|
7.11
9.49
3.23
2.69
0.5%
24%
■ Communicable
Diseases (37%)
B Non Communicable
Diseases (53%)
tl Injuries (10%)
■ Infectious and parasitic diseases
« Respiratory infections
Perinatal conditions (h)
Maternal conditions
Nutritional deficiencies
Cardiovascular diseases
® Respiratory diseases
Malignant Cancer
w Digestive diseases
Genitourinary diseases
Diabetes mellitus
Neuropsychiatric conditions
Others
Congenital anomalies
Unintentional injuries
Intentional injuries
11.79
Dark Maroon: Communicable Diseases (43.94%)
Black: Non Communicable Diseases (43.02%)
Light Maroon: Injuries (13.04%)
■ Infectious and parasitic
diseases
Genitourinary diseases
Skin diseases
Nutritional deficiencies
Unintentional injuries
Cardiovascular diseases
s Respiratory infections
11 Digestive diseases
Musculoskeletal diseases
Neuropsychiatric
conditions
Oral conditions
O Respiratory diseases
S Other neoplasms
S Congenital anomalies
■ Perinatal conditions (h)
Diabetes mellitus
Maternal conditions
Endocrine disorders
Sense organ diseases
■ Intentional injuries
8 Malignant neoplasms
Source: Mortality and Burden of Disease Estimates for WHO
Member States in 2008.
Source: Global Burden of Disease Estimates for WHO Member
States 2009.
FIGURE 20.1: Disease Burden of India, 2008
(Estimated number of deaths by cause)
FIGURE 20.2: Disability Adjusted Life Years in India, 2009
(Estimated percentage of DALY by cause)
Health
levels of per capita income. However, the public
expenditure on health was only about Z1 per cent
of the total in 2008-09 (NHA, 2009), which is
very low by any standard. Public expenditure on
Core Health (both plan and non-plan and taking
the Centre and States together) was about 0.93
per cent of GDP in 2007-08. It has increased to
about 1.04 per cent during 2011-12. It needs to
increase much more over the next decade.
on child-sex ratio, the goals have not been fully met.
Despite efforts through the flagship of NRHM, wide
disparity in attainments across states outlines the
need for contextual strategies.
1.
20.4. The enormity of the challenge in health was
realised when the Eleventh Plan was formulated and
an effort was made to increase Central Plan expendi
tures on health. The increase in Central expenditures
has not been fully matched by a comparable increase
in State Government expenditures (Table 20.3). The
Twelfth Plan proposes to take corrective action by
incentivising States.
20.5. As an input into formulating the Twelfth
Plan strategy, it has relied on the High Level Expert
Group (HLEG) set up by the Planning Commission
to define a comprehensive strategy for health for the
Twelfth Five Year Plan. The Group’s report is acces
sible on the web site of the Planning Commission.
In addition, wide consultations have been held with
stakeholders and through Working Groups and
Steering Groups. Based on the HLEG report and
after extensive consultations within and outside the
Government, as well as a close review of the actual
performance of the sector during the Eleventh Plan
period, a new strategy for health is being spelt out
in the Twelfth Plan towards rolling out Universal
Health Coverage—a process that will span several
years. The consensus among stakeholders is that
the magnitude of the challenge is such that a viable
and longer term architecture for health can be put
in place only over two or even three Plan periods.
However, a start must be made towards achieving
the long term goal immediately.
2.
REVIEW OF ELEVENTH PLAN
PERFORMANCE
20.6. A review of the health outcome of the Eleventh
Plan and of NRHM is constrained by lack of end-line
data on most indicators. Analysis of available data
reveals that though there has been progress, except
3
3.
Maternal Mortality Ratio (MMR) which mea
sures number of women of reproductive age
(15-49 years) dying due to maternal causes per
1,00,000 live births, is a sensitive indicator of the
quality of the health care system. The decline in
MMR during the 2004-06 to 2007-09 of 5.8 per
cent per year (that is, 254 to 212) has been com
parable to that in the preceding period (a fall of
5.5 per cent per year from 301, over 2001-03 to
2004-06). MMR of 212 (2007-09) is well short
of the Eleventh Plan goal of 100. Besides Kerala
(81), two more States namely Tamil Nadu (97)
and Maharashtra (104) have realised MDG tar
get of 109 in 2007-09, while Andhra Pradesh
(134), West Bengal (145), Gujarat (148) and
Haryana (153) are in closer proximity. A major
burden of MMR is in EAG states, where the aver
age MMR was 308 in 2007-09 (SRS), and con
tinues to remain high as per the recent Annual
Health Survey (2010-11). These are Assam
(381), Bihar (305), Jharkhand (278), MP (310),
Chhattisgarh (275), Odisha (277), Rajasthan
(331), Uttar Pradesh (345) and Uttarakhand
(1.88). Suboptimal performance in EAG states
points to gaps in Ante-Natal Care, skilled birth
attendance and Emergency Obstetrical care and
to draw lessons from maternal death reviews.
Infant Mortality Rate (IMR), death of children
before the age of one year per 1,000 live births,
is a sensitive indicator of the health and nutri
tional status of population. IMR fell by 5 per cent
per year over the 2006-11 period, an improve
ment over the 3 per cent decline per year in the
preceding five years, but short of the target of
28. The decline in IMR has accelerated, but is
short of the required pace. While seven states
have achieved the target, IMR is still high in MP,
Odisha, UP, Assam, and Rajasthan.
Total Fertility Rate (TFR), which measures the
number of children born to a woman during her
entire reproductive period, fell by 2.8 per cent
per annum over the 2006-10 period from 2.8 to
4
Twelfth Five Year Plan
2.5, which is faster than the decline of 2 per cent
per year in the preceding five years, but short of
the Eleventh Plan goal of 2.1. Replacement level
TER, namely 2.1, has been attained by nine states.
High fertility remains a problem in seven States,
namely Bihar (CBR 2011 27.7; TER 2010 3.7),
Uttar Pradesh (27.8; 3.5), Madhya Pradesh (26.9;
3.2), Rajasthan (26.2; 3.1), Jharkhand (25.0; 3.0),
Chhattisgarh (24.9; 2.8) and Assam (22.8; 2.5).
Reasons are early marriage, close spacing of
births, high unmet need and lack of skilled con
traceptive services. Low couple protection rate
(40.4 per cent Family Welfare Statistics in India,
2011) and a high unmet need for contraception
(20.5 per cent) in 2007-08 point to gaps in ser
vice delivery.
4. On the goal of raising child sex ratio, there has
been a reversal. All States and UTs except Punjab,
Haryana, Himachal Pradesh, Gujarat, Tamil
Nadu, Mizoram, Andaman and Nicobar Islands
and Chandigarh have witnessed a decrease in the
child sex ratio (0-6 years) in the 2001-11 decade.
5. Progress on goals on reducing malnutrition and
anaemia cannot be assessed for want of updated
data, but localised surveys indicated that the sta
tus has not improved.
FINANCING FOR HEALTH
20.7. During the Eleventh Plan funding for health by
Central Government has increased to 2.5 times and
of States to 2.14 times that in Tenth Plan, to add up
to 1.04 per cent of GDP in 2011-12. When broader
determinants of health (drinking water and sanita
tion, ICDS and Mid-Day Meal) are added, the total
public spending on health in Eleventh Plan comes to
1.97 per cent of GDP (Tables 20.2 and 20.3).
20.8. An analysis of performance reveals achieve
ments and gaps. These follow.
INFRASTRUCTURE
20.9. There has been an increase in number of pub
lic health facilities over the 2007-11 period—Sub
Centres by 2 per cent, PHC by 6 per cent, CHC by
16 per cent and District Hospitals by 45 per cent.
Yet shortfalls remain, 20 per cent for Sub-Centres,
24 per cent for PHCs and 37 per cent for CHCs, partic
ularly in Bihar, Jharkhand, Madhya Pradesh and Uttar
Pradesh. Though most CHCs and 34 per cent Primary
Health Centres (PHCs) have been upgraded and
operationalised as 24 x 7 facilities and First Referral
Units (FRU) have doubled, yet the commitment of
Eleventh Plan to make all public facilities meet IPHS
norms, and to provide Emergency Obstetric Care at
all CHCs have not been achieved. Access to safe abor
tion services is not available in all CHCs, a gap which
is contributing to maternal mortality. Though Mobile
Medical Units (MMUs) have been deployed in 449
districts of the country, their outreach medical ser
vices are not adequate for the need.
TABLE 20.1
Eleventh Plan Monitorable Goals and Achievements
S. No.
Eleventh Plan Monitorable Target
Baseline Level
Recent Status
254
Reducing Maternal Mortality Ratio (MMR) to 100 per
100000 live births.
(SRS, 2004-06)
212
(SRS. 2007-09)
2
Reducing Infant Mortality Rate (IMR) to 28 per 1000
live births.
57
(SRS, 2006)
44
(SRS, 2011)
3
Reducing Total Fertility Rate (TFR) to 2.1.
2.8
(SRS, 2006)
2.5
(SRS, 2010)
4
Reducing malnutrition among children of age group
0-3 to half its level.
40.4
(NFHS, 2005-06)
No recent data available
5
Reducing anaemia among women and girls by 50%.
55.3
(NFHS, 2005-06)
No recent data available
6
Raising the sex ratio for age group 0-6 to 935
927
(Census, 2001)
914
(census. 2011)
i
Health
5
TABLE 20.2
Allocation and Spending by Ministry of Health in Eleventh Plan
(Figures in ? Crore)
Department
Eleventh Elan Allocation
Eleventh Plan release
Eleventh Plan Expenditure
% Expenditure to Release
HFW
1,25,923
87,460
83,407
95.4%
Of which under
NRHM
89,478
68,064
66,127
97.2%
AYUSH
3,988
3,083
2,994
97.1%
1,938
1,870
96.5%
4,496
DHR
5,728
1,500
1,305
87.0%
1,40,135
93,981
89,576
95.3%
AIDS Control
Total
Note: Outlay for the new departments of DHR and AIDS Control was transferred from Department of HFW.
TABLE 20.3
Funding for Health in Eleventh Plan: Core and Broad Health Components
(Figures in ? Crore)
% GDP (Broad Health)
% GDP Core Health
Year
Centre Core
Health
Stales Core
Health
Centre
States
Total
Centre
States
Total
X Plan
47,077
1,07,046
0.29%
0.65%
0.94%
0.56%
1.18%
1.74%
2007- 08
16,055
30,536
0.32%
0.61%
0.93%
0.71%
1.17%
1.89%
2008- 09
19,604
36,346
0.35%
0.65%
0.99%
0.75%
1.22%
1.98%
2009- 10
25,652
44,748
0.40%
0.69%
1.09%
0.78%
1.24%
2.02%
2010- 11
27,466
55,955
0.36%
0.73%
1.09%
0.75%
1.27%
2.02%
2011- 12
30,587
62,343
0.34%
0.70%
1.04%
0.74%
1.19%
1.94%
XI Plan
1,19,364
2,29,928
0.35%
0.68%
1.04%
0.75%
1.22%
1.97%
Note: Core health includes health care expenditure of central ministries (MoHFW, Labour on RSBY and so on) on health; Broad health
includes Drinking Water and Sanitation, Mid-Day Meal and ICDS (Plan and non-Plan).
HEALTH PERSONNEL
20.10. ASHAs positioned under NRHM have been
successful in promoting awareness of obstetric and
child care services in the community. Better train
ing for ASHA and timely payment of incentive have
come out as gaps in evaluations. Despite considerable
improvement in health personnel in position (ANM
27 per cent, nurses 119 per cent, doctors 16 per cent,
specialists 36 per cent, pharmacists 38 per cent), gap
between staff in position and staff required at the end
of the Plan was 52 per cent for ANM and nurses, 76
per cent for doctors, 88 per cent for specialists and
58 per cent for pharmacists. These shortages are
attributed to delays in recruitment and to postings
not being based on work-load or sanctions. Public
health cadre as envisioned in the Eleventh Plan to
manage NRHM is not yet in place. Similarly, lack of
sound HR management policies results in irrational
distribution of available human resource and suboptimal motivation.
TRAINING CAPACITY
20.11. Setting up of 6 AIIMS like institutes and upgradation of 13 medical colleges has been taken up
under Pradhan Mantri Swasthya Suraksha Yojana
(PMSSY). Seventy-two State Government medi
cal colleges have been taken up for strengthening to
enhance their capacity for PG training. Huge gaps,
however, remain in training capacity for all category
of health personnel.
COMMUNITY INVOLVEMENT
20.12. Though Rogi Kalyan Samitis (RKS) are in
position in most public facilities, monthly Village
6 Twelfth Five Year Plan
Health and Nutrition Days are held in most villages,
Jan Sunwais (public hearings) and Co mon Review
Missions have been held yet, their potential in terms
of empowering communities, improving account
ability and responsiveness of public health facilities
is yet to be fully realised.
4.
SERVICE DELIVERY
1. To reduce maternal and infant mortality, insti
tutional deliveries are being promoted by pro
viding cash assistance to pregnant women under
Janani Suraksha Yojana (JSY). Though institu
tional deliveries have increased in rural (39.7 to 68
per cent) and urban areas (79 per cent to 85 per
cent) over the 2005-09 period, low levels of full
Ante-Natal care (22.8 in rural, and 26.1 in urban in
2009, CES) and quality of care are areas of concern.
2. Full immunisation in children has improved
from 54.5 per cent in 2005 (CES) to 61 per
cent in 2009 (CES) during the Eleventh Plan.
Additions to the Universal Immunization Pro
gram include Hepatitis B, Japanese Encephalitis
(JE) vaccine in endemic districts, and Pentaval
ent vaccine, which is a combination vaccine
against Diphtheria, Pertussis, Tetanus, Hepatitis
B and Haemophilus influenza B. There has been
no reported case of polio during 2011. Immun
isation cover is far from universal as envisioned
in Eleventh Plan, and remains particularly low
in UP (41 per cent), MP (43 per cent), Bihar
(49 per cent), Rajasthan (54 per cent), Gujarat
(57 per cent) and Chhattisgarh (57 per cent),
Assam (59 per cent) and Jharkhand (60 per
cent). In contrast, some States like Goa (88 per
cent), Sikkim (85 per cent), Punjab (84 per cent)
and Kerala (82 per cent) have achieved high
level of immunisation coverage. Home Based
Neonatal Care (HBNC) through ASHAs has
been promoted to improve new born care prac
tices in the community and to enable early detec
tion and referral. Continued high rates of child
mortality suggest that the public health system
has not been very effective in promoting healthy
practices as breastfeeding, use of ORS and pre
ventive and care seeking behaviours.
3. Despite improvements in infrastructure, and
personnel deployed, evaluation has reported that
5.
utilisation of public facilities for chronic disease
remains low in UP (45 per cent), MP (63 per
cent) and Jharkhand (70 per cent) as compared
to Tamil Nadu (94 per cent) reflecting poor
quality of service.
To reduce fertility, increasing age of marriage,
spacing of births, access to a basket of contracep
tive services are some of the possible innovations
that need to be tried.
The Eleventh Plan commitment of providing
access to essential drugs at public facilities has
not been realised. This reflects in continued high
out-of-pocket expenditure on health care, as
suggested by some local surveys.
GOVERNANCE OF PUBLIC HEALTH SYSTEM
20.13. The Eleventh Plan had suggested Governance
reforms in public health system, such as perfor
mance linked incentives, devolution of powers and
functions to local health care institutions and mak
ing them responsible for the health of the people liv
ing in a defined geographical area. NRHM’s strategy
of decentralisation, PRI involvement, integration
of vertical programmes, inter-sectoral convergence
and Health Systems Strengthening have been par
tially achieved. Despite efforts, lack of capacity and
adequate flexibility in programmes forestall effective
local level planning and execution based on local dis
ease priorities. Professional procurement agencies
on the lines of Tamil Nadu are still not in place at
the Centre and most States making the process frag
mented, with little forecasting or use of the power of
monopsony. Wide variation in the performance of
health facilities across states have been reported with
Tamil Nadu topping and UP and MP at the bottom,
pointing to the need for learning from best practices
within the country through state level initiatives.
DISEASE CONTROL PROGRAMMES
1.
National Vector Borne Disease Control Pro
gramme encourages states to take measures, as
disease management, integrated vector manage
ment and supportive interventions like behav
iour change communication, for the prevention
and control of diseases like Malaria, Dengue,
Chikungunya, Japanese Encephalitis (JE),
Lymphatic Filariasis and Kala-azar. India bears
Health
a high proportion of the global burden of TB
(21 per cent), leprosy (56 per cent) and lym
phatic filariasis (40 per cent). Though there has
been progress in the Eleventh Plan in reducing
rate of new infections, case load and death from
these diseases, a robust surveillance system at
the community level is lacking and considerable
hidden and residua] disease burden remains.
Multi-drug resistance to TB is being increas
ingly recognised. Gaps in infectious disease con
trol programmes relate to testing services in all
PHCs, active engagement with private providers,
prescribing standard treatment, restricting overthe-counter sale of anti TB drugs, and timely
referral through a continuum of care.
2. Among the NCDs, Cardiovascular Diseases
(CVD) account for 24 per cent of mortality fol
lowed by Respiratory Disease, and malignant
cancers. During the Eleventh Five Year Plan
National Programme for the Prevention and
Control of Cancer, Diabetes, Cardiovascular
Diseases and Stroke (NPCDCS) was initiated
in 100 selected districts in 21 states. So far, 87
lakh people have been screened for diabetes
and hypertension, out of which 6.5 per cent are
suspected to be diabetic and 7.7 per cent are
suspected to be suffering from hypertension.
Despite enhanced allocations for the National
Mental Health Programme, it has lagged behind
due to non-availability of qualified mental health
professionals at district and sub-district levels.
Training of non-physician mental health profes
sionals and implementation of community based
mental health programmes are needed to reduce
the rising burden of mental health disorders.
NCD programmes need to be integrated within
NRHM to provide preventive, testing, care and
referral services.
REGULATION
20.14. The Food Safety and Standards Act (FSSA),
2006 came into force from 5.8.2011 and replaced
multiple food laws, standard setting bodies and
enforcement agencies with one integrated food law.
The Government of India has enacted the Clinical
Establishments (Registration and Regulation) Act,
2010 for Registration and Regulation of Clinical
7
Establishments. The Government of India has noti
fied important amendments in rules under the Pre
Conception and Pre-Natal Diagnostic Techniques
(Prohibition of Sex Selection) Act, 1994, including
amendment to Rule .1.1 (2) of the PC and PNDT
Rules, 1996 to provide for confiscation of unregis
tered machines and regulating the use of portable
ultrasound equipment and services offered by mobile
clinics. The Transplantation of Human Organs Act,
1994 has been amended to make the process of organ
donation and reception more streamlined and mal
practice free. Quality and reach of regulation are
major issues.
HMIS
20.15. During the Eleventh Plan, a web based
Health Management Information System (HMIS)
application software has been developed and made
operational for online data capture at district and
sub-district levels on RCH service delivery indica
tors. The data captured is scanty, restricted to public
facilities and is not always used for programme plan
ning or monitoring.
AIDS CONTROL
20.16. Against a target to halt and reverse the HIV/
AIDS epidemic in India, there has been a reduc
tion of new HIV infections in the country by 57
per cent. Still, an estimated 20.9 lakh people were
living with HIV/AIDS (PI.HA) in 2011. The pro
gramme includes Targeted Interventions focused
on High Risk Groups and Bridge populations,
Link Workers Scheme, Integrated Counselling nd
Testing Services, Community Care, Support and
Treatment Centres, Information, Education, and
Communication (IEC) and condom promotion.
Gaps in the programme include low rate ofcoverage
of Anti-Retroviral Therapy among infected adults
and children, low levels of opioid substitution ther
apy among injection drug users (3 per cent), testing
of pregnant women for HIV and Syphilis (23 per
cent) and low Anti-Retroviral coverage for prevent
ing mother to child transmission. There is scope for
greater integration with NRHM to avoid duplication
of efforts, as in reaching non-high risk groups and
distribution of condoms.
8 Twelfth Five Year Plan
INDIAN SYSTEMS OF MEDICINE AND
HOMOEOPATHY (AYUSH)
20.17. Against the Eleventh Plan objective of‘main
streaming AYUSH systems to actively supplement
the efforts of the allopathic system’, 40 per cent
PHCs, 65 per cent CHCs and 69 per cent District
hospitals have co-located AYUSH facilities. Though
considerable progress has been made in documenting
identity and quality standards of herbal medicines,
scientific validation of AYUSH principles, remedies
and therapies has not progressed. Similarly, though
the National Medicinal Plants Board has supported
many projects for conservation, cultivation and stor
age of medicinal plants, only 20 per cent of the 178
major medicinal plant species traded as raw drugs
are largely sourced from cultivation. Nine AYUSH
industry clusters through Special Purpose Vehicle
having common facility centres for manufacture and
testing of AYUSH medicines are being set up in eight
States. While AYUSH sector has considerable infra
structure, it remains under-utilised.
HEALTH RESEARCH
20.18. The newly established department of Health
Research, and Indian Council of Medical Research
(ICMR) have piloted several innovations, including
an on-line Clinical Trials Registry, Uniform Multi
drug Therapy Regimen (UMDT) for Leprosy, and
lymphatic filariasis, kits for improved diagnosis
of malaria, dengue fever, TB (including drug resis
tant), cholera, Chlamydia infection. Leptospirosis;
and development of indigenous H1N1 vaccine. Yet,
health research in India has yet to make a major
impact on the health challenges facing the country.
The reasons are that ICMR has focused on biomedi
cal research, especially in communicable diseases,
while gaps in health attainments are largely due to
behavioural factors, inadequate attention to preven
tion and fragile health systems.
TWELFTH PLAN STRATEGY
20.19. The Twelfth Plan seeks to strengthen ini
tiatives taken in the Eleventh Plan to expand the
reach of health care and work towards the long
term objective of establishing a system of Universal
Health Coverage (UHC) in the countiy. This means
that each individual would have assured access to a
defined essential range of medicines and treatment
at an affordable price, which should be entirely free
for a large percentage of the population. Inevitably,
the list of assured services will have to be limited by
budgetary constraints. But the objective should be to
expand coverage steadily over time.
20.20. Based on the recommendations of the HLEG
and other stakeholder consultations, it is possi
ble to outline the key elements of the strategy that
should be followed in the Twelfth Plan. These ele
ments should be seen as a part of a longer term plan
to move towards UHC, which is a process that will
unfold over two or three Plan periods.
There must be substantial expansion and
strengthening of the public sector health care
system if we are to meet the health needs of rural
and even urban areas. The bulk of the popula
tion today relies upon private sector health
providers, paying amounts which they cannot
afford, because of the inadequate reach of the
public sector. While the private sector can con
tinue to operate for those who can afford it, an
expansion of good quality affordable public sec
tor care is essential. As supply in the public sec
tor increases, it will cause a shift towards public
sector providers freeing the vulnerable popula
tion from dependence on high cost and often
unreachable private sector health care.
2. Health sector expenditure by the Centre and
States, both Plan and Non Plan, will have to be
substantially increased by the end of the Twelfth
Plan. It has already increased from 0.94 per cent
of GDP in the Tenth Plan to 1.04 per cent in
the Eleventh Plan (Table 20.3). The provision
of clean drinking water and sanitation as one of
the principal factors in the control of diseases
is well established from the history of industri
alised countries and it should have high prior
ity in health related resource allocation. The
percentage for this broader definition of health
sector related resources needs to be increased to
2.5 per cent by the end of the Twelfth Plan. Since
expenditure on health by the State Governments
is about twice the expenditures by the Centre,
1.
Health
the overall targets for public sector health expen
diture can only be achieved if, along with the
Centre, State Governments expand their health
budgets appropriately. A suitable mechanism
should therefore be designed to incentivise an
increase in State Government spending.
3. Financial and managerial systems will be re
designed to ensure more efficient utilisation of
available resources, and to achieve better health
outcomes. Coordinated delivery of services
within and across sectors, delegation matched
with accountability, fostering a spirit of inno
vation are some of the measures proposed to
ensure that ‘more can be done from less for
more’ for better health outcomes.
4. Efforts would be made to find a workable way
of encouraging cooperation between the public
and private sector in achieving health goals. This
would include contracting in of services for gap
filling, and also various forms of effectively regu
lated and managed PPP, while also ensuring that
there is no compromise in terms of standards of
delivery and that the incentive structure does not
undermine health care objectives.
5. The present Rashtriya Swasthya Bima Yojana
(RSBY) which provides ‘cash less’ in-patient
treatment for eligible beneficiaries through an
insurance based system will need to be reformed
to enable access to a continuum of comprehen
sive primary, secondary and tertiary care. The
coverage of RSBY was initially limited to the
BPL population but, was subsequently expanded
to other categories. It should be the objective ot
the Twelfth Plan to use the platform and existing
mechanisms of RSBY to cover the entire popula
tion below the poverty line. In planning health
care structures for the future, it is desirable to
move away from a ‘fee-for-service’ mechanism
for the reasons outlined by the HLEG, to address
the issue of fragmentation of services that works
to the detriment of preventive and primary
care and also to reduce the scope for fraud and
induced demand.
6. Availability of skilled human resources remains
a key constraint in expanding health service
delivery. A mere expansion of financial resources
9
devoted to health will not deliver results if health
personnel are not available. A large expansion
of medical schools, nursing colleges, and so on,
is therefore necessary and public sector medical
schools must play a major role in the process.
Since the present distribution of such colleges is
geographically very uneven, a special effort will
be made to expand medical education in States
which are at present under-served. In addition,
a massive effort will be made to recruit and
train paramedical and community level health
workers.
7. An important lesson from the Eleventh Plan is
that the multiplicity of Central Sector and Cen
trally Sponsored Schemes addressing individual
diseases, or funding activities or institutions,
prevents a holistic health-systems-approach,
leads to duplication and redundancies, and
makes coordinated delivery difficult. This mul
tiplicity also constrains the flexibility ot States to
make need based plans or deploy their resources
in the most efficient manner. As a result, new
programmes cannot take off and old ones do not
reach their maximum potential. The way for
ward is to focus on strengthening the pillars of
the health system, so that it can prevent, detect
and manage each of the unique challenges that
different parts of the country face.
8. A series of prescription drugs reforms, promo
tion of essential, generic medicines, and mak
ing these universally available free of cost to
ail patients in public facilities as a part of the
Essential Health Package will be a priority.
9. Effective regulation in medical practice, public
health, food and drugs is essential to safeguard
people against risks, and unethical practices.
This is especially so given the information gaps
in the health sector which make is difficult for
individuals to make reasoned choices.
10. The health system in the Twelfth Plan will con
tinue to have a mix of public and private service
providers. The public sector health sendees need
to be strengthened to deliver both public health
related and clinical services. The public and pri
vate sectors also need to coordinate for deliv
ery of a continuum of care. A strong regulatory
10 Twelfth Five Year Plan
system would supervise the quality of services
delivered. Standard treatment guidelines should
form the basis of clinical care across public and
private sectors, with adequate monitoring by the
regulatory bodies to improve quality and control
the cost of care.
20.25. Representation in community fora: Wherever
community-level fora exist or are being planned
for, such as Rogi Kalyan Samitis, VHSNC, repre
sentation of the marginalised should be mandatory.
Also, every Village Health Sanitation and Nutrition
Committee would strive to have 50 per cent repre
sentation of women.
INCLUSIVE AGENDA FOR HEALTH
20.21. In order to ensure that all the services in the
Twelfth Plan are provided with special attention to
the needs of marginalised sections of the population
the following will be emphasised in the Twelfth Plan.
20.22. Access to services: Barriers to access would
be recognised and overcome especially for the dis
advantaged and people located far from facilities.
Medical and public health facilities would be acces
sible to the differently-abled. They would be gender
sensitive and child friendly. Information on health
would be accessible to the visually impaired and to all
caregivers; especially to those who look after autistic
and mentally challenged persons. Hospitals would
have facilities for the hearing impaired. Among mar
ginalised groups, the SC and ST populations, and
minorities, the doubly disadvantaged such as the
Particularly Vulnerable Tribal Groups (PVTGs), the
De-notified and Nomadic Tribes, the Musahars and
the internally displaced must be given special atten
tion while making provisions for, setting up and ren
ovating Sub-Centres and Anganwadis.
20.23. Special services: Special services should be
made available for the vulnerable and disadvantaged
groups. For example, counselling of victims of mental
trauma in areas of conflict, or the supply and fitting
of aids for the differently-abled are some examples
of special services for certain categories of users. As
there are other segments of the population which are
also vulnerable, the list should be open-ended.
20.24. Monitoring and evaluation systems: Routine
monitoring and concurrent impact evaluations
should collect disaggregated information on dis
advantaged segments of the population. This is to
assess the ease with which they access services and
their impact, as also to understand how they com
pare to the general population.
20.26. Training of health and rehabilitation profes
sionals should incorporate knowledge of disability
rights, as also the skills to deal with differences in
perspectives and expectations between members of
disadvantaged segments and the general population
that may arise out of different experiences. All health
related training institutes must have a comprehen
sive policy to make their educational programmes
friendly for the differently-abled. This should also
include sensitisation of faculty, staff and trainees.
TOWARDS UNIVERSAL HEALTH
COVERAGE
20.27. The Twelfth Plan strategy outlined is a first
step in moving toward Universal Health Care (UHC).
All over the world, the provision of some form of
universal health coverage is regarded as a basic com
ponent of social security. There are different ways of
achieving this objective and country experiences vary.
We need to ensure much broader coverage of health
services to provide essential health care and we need
to do it through a system which is appropriate to our
needs and within our financial capability.
HLEG’S RECOMMENDATIONS
20.28. The High Level Expert Group has defined
UHC as follows: ‘Ensuring equitable access for all
Indian citizens in any part of the country, regardless
of income level, social status, gender, caste or religion,
to affordable, accountable and appropriate, assured
quality health senaces (promotive, preventive, cura
tive and rehabilitative) as well as services addressing
wider determinants of health delivered to individu
als and populations, with the Government being the
guarantor and enabler, although not necessarily the
only provider of health and related services.’
20.29. This definition affirms that the system must be
available for all who want it, though some, typically
Health
the upper income groups, may opt out. For opera
tional purposes, it is necessary to define with greater
precision, the coverage of assured services, especially
in terms of entitlement for in-patient treatment and
to define the specific mechanism through which the
service will be delivered. The extent of the coverage
offered in terms of the range of treatments covered
will obviously be constrained by finances available,
though it can be expected to expand over time. The
HLEG has recommended the prioritisation of pri
mary health care, while ensuring that the Essential
Health Package (EHP) includes essential services at
all levels of care.
20.30. The HLEG has examined different ways in
which UHC could be delivered without any cash
payment by the beneficiaries. At one end, we can
have a purely public delivery of services from public
sector service providers using private sector only to
supplement critical gaps, and whose costs are cov
ered by budgetary funds. At the other end, we can
have a system where defined services are delivered by
seiTice providers charging a fee for sendee, with pay
ment to the providers being made by State funded
medical insurance, with no payment to be made by
the patient. The HLEG has also recommended: ‘State
governments should consider experimenting with
arrangements where the state and district purchase
care from an integrated network of combined pri
mary, secondary and tertiary care providers. These
provider networks should be regulated by the gov
ernment so that they meet the rules and require
ments for delivering cost effective, accountable and
quality health care. Such an integrated provider
entity should receive funds to achieve negotiated
predetermined health outcomes for the population
being covered. This entity would bear financial risks
and rewards and be required to deliver on health
care and wellness objectives. Ideally, the strength
ened District Hospital should be the leader of this
provider network’ (Recommendation 3.1.10).
20.31. The main recommendations of the HLEG are
outlined in Box 20.1.
11
UHC MODELS AROUND THE WORLD
20.32. While many countries subscribe to the objec
tive of UHC there is a great deal of variety in how
this objective is achieved. Many countries have
adopted a tax-financed model, while others have
adopted an insurance based model. Some countries
deliver care through salaried public providers; others
have adopted capitation as the preferred model for
payment for out-patient care, and fee-for-service for
in-patient care. A summary7 of the UHC models in
some countries follows.
Canada
20.33. Medicare is a regionally administered univer
sal public insurance programme, publicly financed
through Federal and Provincial tax revenue. Out
patient services are provided through private pro
viders. All Secondary and Tertiary care services
are provided by private and non-profit providers.
Primary care payment is mostly ‘Fee for Service’
with some alternatives (for example, capitation).
In-patient service payment is through global budget
(case-based payment in some provinces) which does
not include physician’s cost.
New Zealand
20.34. National Health Service is publicly financed
through general tax revenue. Outpatient services are
provided through private providers. Secondary and
Tertiary care services are mostly provided by public,
some private providers. Primary care payment is a
mix of ‘Capitation’ and ‘Fee for Service’. In-patient
service payment is through global budget and case
based payment, which includes physician’s cost.
Germany
20.35. Statutory Health Insurance is funded by 180
‘sickness funds’. Outpatient services are provided
through private providers. Secondary and Tertiary
care services are provided by public (50 per cent),
private non-profit (33 per cent) and private forprofit (17 per cent) providers. Primary care pay
ment is 'Fee for Service’. In-patient service payment
is through global budget and case-based payment,
which includes physician’s cost.
12
Twelfth Five Year Plan
Box 20.1
Recommendations of High Level Expert Group on Universal Health Coverage
1. Health Financing and Financial Protection: Government should increase public expenditure on health from the current
level of 1.2 per cent of GDP to at least 2.5 per cent by the end of the Twelfth Plan, and to at least 3 per cent of GDP by 2022.
General taxation should be used as the principal source of healthcare financing, not levying sector specific taxes. Specific
purpose transfers should be introduced to equalise the levels of per capita public spending on health across different
states. Expenditures on primary healthcare should account for at least 70 per cent of all healthcare expenditure. The
technical and other capacities developed by the Ministry of Labour for the RSBY should be leveraged as the core of UHC
operations—and transferred to the Ministry of Health and Family Welfare.
2. Access to Medicines, Vaccines and Technology: Price controls and price regulation, especially on essential drugs, should
be enforced. The Essential Drugs List should be revised and expanded, and rational use of drugs ensured. Public sector
should be strengthened to protect the capacity of domestic drug and vaccines industry to meet national needs. Safeguards
provided by Indian patents law and the TRIPS Agreement against the country’s ability to produce essential drugs should
be protected. MoHFW should be empowered to strengthen the drug regulatory system.
3. Human Resources for Health: Institutes of Family Welfare should be strengthened and Regional Faculty Development
Centres should be selectively developed to enhance the availability of adequately trained faculty and faculty-sharing across
institutions. District Health Knowledge Institutes, a dedicated training system for Community Health Workers, State
Health Science Universities and a National Council for Human Resources in Health (NCHRH) should be established.
4. Health Service Norms: A National Health Package should be developed that offers, as part of the entitlement of eveiy
citizen, essential health services at different levels of the healthcare delivery system. There should be equitable access to
health facilities in urban areas by rationalising services and focusing particularly on the health needs of the urban poor.
5. Management and Institutional Reforms: All India and State level Public Health Service Cadres and a specialised State level
Health Systems Management Cadre should be introduced in order to give greater attention to Public Health and also to
strengthen the management of the UHC system. The establishment of a National Health Regulatory and Development
Authority (NHRDA) a, National Drug Regulatory' and Development Authority (NDRDA) and a, National Health
Promotion and Protection Trust (NHPPT) is also recommended.
6. Community Participation and Citizen Engagement: Existing Village Health Committees should be transformed into
participatory Health Councils.
7. Gender and Health: There is a need to improve access to health services for women, girls and other vulnerable genders
(going beyond maternal and child health).
England
20.36. National Health Service is publicly financed
through general tax revenue. Outpatient services are
provided through both public and private provid
ers. Secondary and Tertiary care sendees are mostly
provided by public, some private providers. Primary
care payment is mostly a mix of capitation and pay
for performance for private providers, and salaries
for public providers. In-patient service payment
is through global budget and case-based payment,
which includes physician’s cost.
Thailand
20.37. Universal Health Coverage Scheme is financed
through general tax revenues paid to local contract
ing units on the basis of population size. Outpatient
services are provided through both public and
private providers. Secondary and Tertiary care ser
vices are provided by public and private providers.
Primary care payment is by risk-adjusted capitation.
In-patient sendee payment is through Diagnostic
Related Group (DRG) based capped global budget,
and fixed rate fees for some services.
Sri Lanka
20.38. Universal Health Coverage Scheme is taxfinanced and Government operated. Outpatient
services are provided through public providers.
Secondary and Tertiary care sendees are provided
by both public and private providers. Primary care
payment is by Fee for Sendee. In-patient service pay
ment is through Fee for Sendee for Public Hospital
and Capitation for Private Hospitals.
Health
Mexico
20.39. Seguro Popular Insurance Scheme is financed
through Federal and State general tax revenues
and member’s contributions through premiums
from informal sector, and progressive contribu
tion from enrolled families. Outpatient services are
provided through both public and limited contract
ing in of private providers. Secondary and Tertiary
care services are usually provided by private provid
ers. Primary care payment is a mix of ‘Capitation’
and ‘Fee for Service’. In-patient service payment is
through DRG although such payments take place on
an ad-hoc, non-systematic basis.
20.40. The evidence from countries that have
attempted to move towards UHC points to the criti
cal importance of initial conditions in terms of both
what is necessary and what is feasible, in attempt
ing to meet the objectives of improving coverage,
expanding access, controlling cost, raising quality,
and strengthening accountability.
20.41. In our system, the initial conditions include a
large but severely underfunded public sector, a grow
ing but high cost private sector, with serious issues of
inadequate quality and coverage in both, and an in
effective regulation.
20.42. In movi ng forward, there are two key questions:
1.
2.
How to combine public and private providers
effectively for meeting UHC goals in a manner
that avoids perverse incentives, reduces provider
induced demand, and that meets the key objec
tives specified above?
How to integrate different types and levels of ser
vices—public health and clinical; preventive and
promotive interventions along with primary,
secondary, and tertiary clinical care—so that
continuum of care is assured? Inadequate pre
vention and inappropriate utilisation of second
ary or tertiary care, when primary care should
suffice, would result in much higher cost of care.
20.43. Global evidence from different countries’
experiences gives us some pointers to answering
these questions:
13
A mix of public and private services is the real
ity of most countries. In order to make this mix
work, a strong regulatory framework is essen
tial to ensure that the UHC programme is most
effective in controlling cost, reducing providerinduced demand, and ensuring quality.
2. Provider payment mechanisms, in themselves,
are not magic bullets, and there are limits to
what they can do. Capitation-based networks
can reduce disincentives to continuity of care,
but by themselves, they will not guarantee it. For
this, there have to be, in addition, improvements
in service delivery, improvements in human
resources and related regulatory development
and enforcement.
3. Further, there is a need to build up institutions
of citizens’ participation, in order to strengthen
accountability and complement what the regula
tory architecture seeks to do.
1.
20.44. It must be noted that even developed coun
tries have taken decades to evolve networks that can
implement alternative models of UHC. Many coun
tries are opting for ‘coordinated care’ models where
primary, secondary and tertiary care is delivered as
an integrated framework with the participation of
both public and private sector. The need is first to
strengthen our public health infrastructure at all lev
els. It could be supplemented by private service pro
viders as well as Public Private Partnerships (PPPs).
Our endeavour, in the long run, is to move towards
an organised system of UHC. We should also learn
from the service contracting arrangements initiated
through RSBY and other State level initiatives.
20.45. In order to achieve health goals, UHC must
build on universal access to services that are deter
minants of health, such as safe drinking water and
sanitation, wholesome nutrition, basic education,
safe housing and hygienic environment. To aim at
achieving UHC without ensuring access to the deter
minants of health would be a strategic mistake, and
plainly unworkable. Therefore, it may be necessary
to realise the goal of UHC in two parallel steps: the
first, would be clinical services at different levels,
defined in an Essential Health Package (EHP), which
the Government would finance and ensure provision
14
Twelfth Five Year Plan
through the public health system, supplemented by
contracted-in private providers whenever required
to fill in critical gaps; second the universal provision
of high impact, preventive and public health inter
ventions which the Government would universally
provide within the Twelfth Five Year plan (Box 20.2).
The UHC would take two plan periods for realisa
tion, but a move in terms of pilots and incremental
coverage can begin in the Twelfth Plan itself.
20.46. Roadmap: The present health care delivery
system needs reform to ensure better utilisation of
resources and health outcomes. The building blocks
of the reform in the Twelfth Plan would be as follows.
Health Services will be delivered with seamless inte
gration between Primary, Secondary and Tertiary
sectors. The Primary Health Care will be strength
ened to deliver both preventive, public health and
curative, clinical services. Publicly funded health
care would predominantly be delivered by public
providers. The primary health care providers within
the network will act as the gateway to secondary
and tertiary care facilities in the network. Private
sector will be contracted in only for critical gap filling.
In areas where both public and private contracted
in providers co-exist, patients shall have a choice in
selecting their provider. Networks of such integrated
facilities at different levels will be encouraged to pro
vide a continuum of care, universally accessible and
affordable services with the District Hospital as the
nodal point. No fee of any kind would be levied on
primary health care services with the primary source
of financing being from general taxation/public
exchequer. Details of the roadmap shall be worked
out by the States through UHC pilots after consider
ing global experience and current local structures.
20.47. UHC Models: Various options for financing
and organisation of delivery of services need to be
carefully explored. Cashless delivery of an Essential
Health Package (EHP) to all ought to be the basic
deliverable in all models. Since out-patient care and
medicines are major elements of household’s outof-pocket and catastrophic expenditure on health,
Box 20.2
Illustrative List of Preventive and Public Health Interventions Funded and Provided by Government
1. Full Immunisation among children under three years of age, and pregnant women
2. Full antenatal, natal and post natal care
3. Skilled birth attendance with a facility’ for meeting need for emergency obstetric care
4. Iron and Folic acid supplementation for children, adolescent girls and pregnant women
5. Regular treatment of intestinal worms, especially in children and reproductive age women
6. Universal use of iodine and iron fortified salt
7. Vitamin A supplementation for children aged 9 to 59 months
8. Access to a basket of contraceptives, and safe abortion services
9. Preventive and promotive health educational services, including information on hygiene, hand-washing, dental hygiene,
use of potable drinking water, avoidance of tobacco, alcohol, high calorie diet and obesity, need for regular physical
exercise, use of helmets on two-wheelers and seat belts; advice on initiation of breastfeeding within one hour of birth and
exclusively up to six months of age, and complimentary feeding thereafter, adolescent sexual health, awareness about
RTI/STI; need for screening for NCDs and common cancers for those at risk
10. Home based newborn care, and encouragement for exclusive breastfeeding till six months of age
11. Community based care for sick children, with referral of cases requiring higher levels of care
12. HIV testing and counselling during antenatal care
13. Free drugs to pregnant HIV positive mothers to prevent mother to child transmission of HIV
14. Malaria prophylaxis, using Long Lasting Insecticide Treated Nets (LL1N), diagnosis using Rapid Diagnostic Kits (RDK)
and appropriate treatment
15. School check-up of health and wellness, followed by advice, and treatment if necessary
16. Management of diarrhoea, especially in children, using Oral Rehydration Solution (ORS)
17. Diagnosis and treatment of Tuberculosis, Leprosy including Drug and Multi-Drug Resistant cases.
18. Vaccines for hepatitis B and C for high risk groups
19. Patient transport systems including emergency response ambulance services of the ‘dial 108’ model
Health
ambulatory EHP would be a priority and every UHC
model would include systems for full and free access
to essential generic medicines, through linkages with
Government pharmacies (for public providers) and
Jan Aushadhi outlets (for all). Since the frequency of
use of services, nature of service delivery and cost of
services are fundamentally different for out-patient
(ambulatory) and in-patient care, and to obviate the
possibility of substitution of primary care by sec
ondary and tertiary care, cost of ambulatory care
would need to be earmarked in each UHC pilot. An
effective health information network that could be
accessed by all service providers and patients (for
their own records) would enable the continuum of
care. All models could learn from the platform devel
oped by RSBY in terms of beneficiary coverage, facil
ity enrolment and prevention of fraud.
20.48. States may be encouraged and partially
funded to run at least one, but up to three UHC
pilots in districts through the ‘Incentive Pool’ under
NHM. Individual States, in consultation with the
MoHFW, expert groups and institutions may final
ise the details of the pilot models before roll out. The
pilots could explore different models for provid
ing universal access to an EHP, including those by
using public facilities in that area after being suit
ably strengthened, empowered and networked, and a
combination of public and private facility networks.
The pilot models must demonstrate the comparative
advantages and costs of different approaches to UHC
that would be appropriate for the level of develop
ment and the socio economic context of that state.
Medical colleges can be asked to devise rigorous
evaluation designs for testing the cost-effectiveness,
patient’s satisfaction and change in household’s outof-pocket expenses.
system with a tax funded UHC system, over a
period of time.
2. The State Health Society should be empowered
with requisite resources and its capacity built to
administer the coverage.
3. Prepare the UHC Plan as a part of the District
Health Action Plan of NHM for the pilot dis
tricts and identify the additional items to be cov
ered for EHP.
4. Frame and ensure compliance with Standard
Treatment and Referral Guidelines.
5. Strengthen the State and District programme
management units to implement the EHP.
6. A robust and effective Health Management
Information System which, in the best case sce
nario, tracks ever}' health encounter and would
enable assessment of performance and help in
allocating resources to facilities.
7. Register all resident families in the area covered.
8. Build an effective system of community involve
ment in planning, management, oversight and
accountability.
9. Build an effective community oversight and griev
ance redressal system through active involvement
of Local Self-Government Agencies and Civil
Society.
10. Develop and strengthen Monitoring and Inde
pendent Evaluation Mechanisms.
OUTCOME INDICATORS FOR TWELFTH
PLAN
20.50. The Twelfth Plan must work towards national
health outcome goals, which target health indicators.
The national health goals, which would be aggregates
of State wise goals (Table 20.4), are the following:
1.
20.49. However, before rolling out UHC on pilot
mode, preparations for the following items need to
be initiated:
1.
Frame a national, core Essential Health Package
for out-patient and in-patient care for uniform
adoption in pilots. It is possible to expand the
package of services under RSBY into an EHP,
with the vision of replacing an insurance based
15
2.
Reduction of Infant Mortality Rate (1MR) to
25: At the recent rate of decline of 5 per cent
per year, India is projected to have an IMR of
36 by 2015 and 32 by 2017. An achievement of
the MDG of reducing IMR to 27 by 2015 would
require further acceleration of this historical rate
of decline. If this accelerated rate is sustained,
the country can achieve an IMR of 25 by 2017.
Reduction of Maternal Mortality Ratio (MMR) to
100: At the recent rate of decline of 5.8 per cent
per annum India is projected to have an MMR
16
Twelfth Five Year Plan
TABLE 20.4
State-Wise Targets on IMR and MMR in Twelfth Plan
SI.
Name of the States/UTs
No
India
Target for Twelfth Plan
Recent Status
I MR
MMR
Anaemia
IMR
MMR
Anaemia
44
212
55.3
25
100
28
1
Andhra Pradesh
43
134
62.9
25
61
31
2
Arunachal Pradesh
32
NA
50.6
19
3
Assam
55
390
69.5
32
177
35
4
Bihar
44
261
67.4
26
119
34
122
28
25
5
Chhattisgarh
48
269
57.5
28
6
Goa
11
NA
38
6
7
Gujarat
41
148
55.3
24
67
28
8
Haryana
44
153
56.1
26
65
28
9
Himachal Pradesh
38
NA
43.3
22
19
22
26
10
Jammu & Kashmir
41
NA
52.1
24
11
Jharkhand
39
261
69.5
23
109
35
12
Karnataka
35
178
51.5
15
80
26
13
Kerala
12
81
32.8
6
37
16
14
Madhya Pradesh
59
269
56
34
122
28
15
Manipur
11
NA
35.7
6
16
Maharashtra
25
104
48.4
15
47
24
18
17
Meghalaya
52
NA
47.2
30
24
18
Mizoram
34
NA
38.6
20
19
19
Nagaland
21
NA
NA
12
20
Odisha
57
258
61.2
33
117
21
Punjab
30
172
38
16
78
19
22
Rajasthan
52
318
53.1
30
145
27
23
Sikkim
26
NA
60
15
24
Tamil Nadu
22
97
53.2
13
25
Tripura
29
NA
65.1
17
26
Uttar Pradesh
57
359
49.9
27
Uttarakhand
36
359
28
West Bengal
32
29
Andaman & Nicobar Islands
31
28
44
27
32
163
20
55.2
21
163
28
145
63.2
11
66
32
23
NA
NA
12
30
Delhi
28
NA
44.3
15
31
Chandigarh
20
NA
NA
12
32
Dadra & Nagar Haweli
35
NA
NA
20
33
Daman & Diu
22
NA
NA
13
34
Lakshadweep
24
NA
NA
14
35
Puducherry
19
NA
NA
11
Note: States which have opted for targets more ambitious than on pro-rate basis are coloured maroon.
33
22
Health
3.
4.
5.
6.
7.
of 139 by 2015 and 123 by 2017. An achievement
of the Millennium Development Goal (MDG) of
reducing MMR to 109 by 2015 would require an
acceleration of this historical rate of decline. At
this accelerated rate of decline, the country can
achieve an MMR of 100 by 2017.
Reduction of Total Fertility Rate (TFR) to 2.1:
India is on track for the achievement of a TFR
target of 2.1 by 2017, which is necessary to
achieve net replacement level of unity, and
realise the long cherished goal of the National
Health Policy, 1983 and National Population
Policy of 2000.
Prevention, and reduction of under-nutrition
in children under 3 years to half of NFHS-3
(2005-06) levels: Underweight children are at an
increased risk of mortality and morbidity. At the
current rate of decline, the prevalence of under
weight children is expected to be 29 per cent by
2015, and 27 per cent by 2017. An achievement
of the MDG of reducing undernourished chil
dren under 3 years to 26 per cent by 2015 would
require an acceleration of this historical rate of
decline. The country needs to achieve a reduc
tion in below 3 year child under-nutrition to half
of 2005-06 (NFHS) levels by 2017. This particu
lar health outcome has a very direct bearing on
the broader commitment to security of life, as do
MMR, I MR, anaemia and child sex ratio.
Prevention and reduction of anaemia among
women aged 15-49years to 28 per cent: Anaemia,
an underlying determinant of maternal mortality
and low birth weight, is preventable and treat
able by a ver}' simple intervention. The preva
lence of anaemia needs to be steeply reduced to
28 per cent by the end of the Twelfth Plan.
Raising child sex ratio in the 0-6 year age group
from 914 to 950: Like anaemia, child sex ratio
is another important indicator which has been
showing a deteriorating trend, and needs to be
targeted for priority attention.
Prevention and reduction of burden of Commu
nicable and Non-Communicable diseases (includ
ing mental illnesses) and injuries: State wise and
national targets for each of these conditions
will be set by the Ministry of Health and Family
Welfare (MoHFW) as robust systems are put in
8.
17
place to measure their burden. Broadly, the goals
of communicable diseases shall be as indicated
in Table 20.5.
Reduction of poor households' out-of-pocket
expenditure: Out-of-pocket expenditure on
health care is a burden on poor families, leads
to impoverishment and is a regressive system of
financing. Increase in public health spending to
1.87 per cent of GDP by the end of the Twelfth
Plan, cost-free access to essential medicines in
public facilities, regulatory measures proposed
in the Twelfth Plan are likely to lead to increase
in share of public spending. The Twelfth Plan
measures will also aim to reduce out-of-pocket
spending as a proportion of private spending on
health.
FINANCING FOR HEALTH
20.51. In the Twelfth Plan, general tax revenues
would be the principle source of finance for pub
licly delivered health sendees supplemented by part
nerships with the private sector and, contribution
by corporates as a part of their Corporate Social
Responsibility. A designated sin tax to finance a part
TABLE 20.5
National Health Goals for Communicable Diseases
Disease
Twelfth Plan Goal
Tuberculosis
Reduce annual incidence and
mortality by half
Leprosy
Reduce prevalence to <1/10000
population and incidence to zero in
all districts
Malaria
Annual Malaria Incidence of <1/1000
Filariasis
< 1 per cent microfilaria prevalence in
all districts
Dengue
Sustaining case fatality rate of
<1 per cent
Chikungunya
Containment of outbreaks
Japanese Encephalitis
Reduction in mortality by 30 per cent
Kala-azar
Elimination by 2015, that is, <1 case
per 10000 population in all blocks
HIV/Al DS
Reduce new infections to zero and
provide comprehensive care and
support to all persons living with
HIV/AIDS and treatment services for
all those who require it.
18 Twelfth Five Year Plan
TABLE 20.6
Budget Support for Departments of MoHFW in
Twelfth Plan (2012-17)
(Figures in ? Crores)
Budget Support for Central Departments in Eleventh Plan
(2007-12) and Twelfth Plan (2012-17) Projections (? Crores)
Eleventh Plan
Expenditure
Twelfth
Plan Outlay
%
Increase
FUNDING AS AN INSTRUMENT OF INCENTIVE
AND REFORM
Department of
Health and Family
Welfare
83,407
2,68,551
322%
Department of
Ayurveda, Yoga
and Naturopathy,
Unani, Siddha and
Homoeopathy
(AYUSH)
2,994
10,044
335%
Department of
Health Research
1,870
10,029
536%
20.54. In the Twelfth Plan, a paradigm shift is envis
aged in Central Government funding to ensure that
sufficient amounts are made available and, fur
ther that they leverage a comparable effort from
the States. In the Approach Paper to the Twelfth
Plan, it was stated that we should aim at raising
the total expenditure on health in the Centre and
the States (including both Plan and Non-Plan) to
2.5 per cent of GDP by the end of the Twelfth Plan
period. Accordingly, the allocations proposed for the
Twelfth Plan makes Health a priority and will allow
Central Plan, expenditure to expand by about 34 per
cent per year. Since the expenditure by the States is
double the expenditure by the Centre, it is necessary
to ensure that the States match the effort. If this is
achieved, the total expenditure of the Centre and the
States on Core Health would rise to about 1.87 per
cent of GDP at the end of the Twelfth Plan period.
Department of
MoHFW
Aids Control
1,305
11,394
873%
Total MoHFW
89,576
3,00,018
335%
of the health budget can lead to reduced consump
tion of these harmful items (as tobacco and alcohol)
and could be considered.
20.52. For financing the Twelfth Plan the projec
tions envisage increasing total public funding, plan
and non-plan, on core health from 1.04 per cent
of GDP in 20.11-12 to 1.87 per cent of GDP by the
end of the Twelfth Plan. In such an event, the fund
ing in the Central Plan would increase to 3 times the
Eleventh Plan levels involving an annual increase by
34 per cent (Table 20.6). With the incentive meas
ures proposed, States’ total funding, Plan and Non
plan, on Health is expected to increase to three times
the Eleventh Plan levels involving a similar annual
increase. The Central and State funding for Health,
as a proportion of total public sector health fund
ing will remain at 2011-12 levels of 33 per cent and
67 per cent respectively.
20.53. When viewed in the perspective of the
broader health sector, which includes schemes of
Ministries other than Health aimed at improving
the health status of people, namely Drinking Water
and Sanitation, Mid-day Meal and Integrated Child
I
Development Services Scheme the total Government
expenditure as a proportion of GDP in the Twelfth
Plan is likely to increase from 1.94 per cent of GDP
in the last year of the Eleventh Plan to 3.04 per cent
in the corresponding year of the Twelfth Plan.
20.55. A key objective is to ensure that the States
increase their expenditure on health at the same
rate as the Centre. This may become possible if the
transfer to the States is made conditional upon a
higher expenditure by the States on health. States
would be eligible to receive assistance through an
incentive grant on the lines being recommended for
all Centrally Sponsored Schemes. They would be eli
gible if they maintain their health expenditure (Plan
and Non-Plan) as a proportion of their budget at the
base level (average of last three years) at the mini
mum, and also prepare a State wide health sector
plan based on District Health plans. The incentive
grant could be operated as an instrument of equity
between states, where both performance and need
is recognised in making allocative decisions. The
details of the proposed arrangement will be worked
out by the Ministry of Health and Family Welfare in
consultation with Planning Commission.
Health
20.56. Flexibility in Central funding for States may
be built in so that States take the lead in devising
plans suited to their health needs. The proposal for
a flexi fund to the States is being recommended for
all Centrally Sponsored Schemes in the Twelfth Plan.
Accordingly, in the health sector, within the broad
national parameters, States would have the flexibil
ity to plan and implement their own Health Action
Plans. A fixed portion of National Health Mission
funds could be earmarked to States and UTs, using
an objective formula based on the total popula
tion and health lag of the State; these baseline funds
would be allotted and made known to the States. A
sector-wide Memorandum of Understanding (MoU)
between the State and Central Government may for
malise mutual commitments and provide strategic
direction for health sector reforms.
OTHER MODELS OF FINANCING
20.57. Public-Private Partnerships: PPPs offer an
opportunity to tap the material, human and manage
rial resources of the private sector for public good.
But experience with PPP has shown that Govern
ment’s capacity to negotiate and manage it is not
effective. Without effective regulatory mechanisms,
fulfillment of contractual obligations suffers from
weak oversight and monitoring. It is necessary, as the
HLEG has argued, to move away from ad hoc PPPs
to well negotiated and managed contracts that are
regulated effectively keeping foremost the health of
the (aam-admi\ Health has been included with other
infrastructure sectors which are eligible for Viability
Gap Funding up to a ceiling of 20 per cent of total
project costs under a PPP scheme. As a result, pri
vate sector could propose and commission projects,
such as hospitals and medical colleges utside met
ropolitan areas, which are not remunerative per se,
and claim up to 20 per cent of the project cost as
grant from the Government. Some models of PPP in
healthcare covering Primary Health Care, Diagnostic
services, Hospitals which are currently being imple
mented in the States are illustrated in Box 20.3. These
can be considered wherever appropriate for replica
tion and upscaling.
20.58. PPP arrangements should address issues
of compliance with regulatory requirements.
19
observance of Standard Treatment Guidelines and
delivery of affordable care. An additional model
for consideration is the Not-for-profit Public
Private Partnership (NPPP) being followed in the
International Institute of Information Technology
(HIT), which have been set up as fully autonomous
institutions, with partnership of the Ministry of
Human Resource Development, Governments of
respective States and industry members. PPP and
Not-for-Profit PPP models can be considered in
order to expand capacities for tertiary care in the
Twelfth Plan.
20.59. Resource generation by facilities and Colleges:
Given the gap in need and availability of tertiary
care facilities and to ensure maximisation of ben
efits from limited public funds, public facilities
should be encouraged to part-finance their recur
ring costs by mobilising contributions (including
under Corporate Social Responsibility) and Internal
Extra-Budgetary Resources. Under the recently
drafted Companies Bill, the Government has pro
posed that companies should earmark 2 per cent
of their average profits of the preceding three years
for Corporate Social Responsibility (CSR) activi
ties. CSR is mandatory for Central Public Sector
Enterprises, the guidelines of which issued by the
Department of Public Enterprises include health
service as one of the eligible components. To avail
of this opportunity, all publicly funded health care
facilities would be allowed to receive donations,
and funding from companies under their Corporate
Social Responsibility head. Adequate safeguards
have to be built in so as to ensure ‘no-frills fund
ing’ and that donations arc not used to influence
the policies or practices of healthcare facilities in
any way. All medical colleges should be encouraged
to develop their own corpus to attain financial flex
ibility over a period of time. Tamil Nadu has issued
guidelines to authorise Medical Officers in charge
of particular healthcare facilities to enter into MoUs
with interested persons to receive contributions for
capital or recurrent expenditure in the provision and
maintenance of facilities. On available models for
self-generation of revenues, the option for cross-sub
sidy in line with the Aravind eye care system based
in Tamil Nadu could also be explored. Tertiary care
20
Twelfth Five Year Plan
Box 20.3
Public-Private Partnerships (PPP) in Health Sector
Tertiary Care: Rajiv Gandhi Super-speciality Hospital, Raichur, Karnataka
Contracting Arrangements: Government of Karnataka and Apollo Hospitals
Type of Partnership: Joint Venture (Management Contract)
Services: Provides super-speciality clinical care services and management of Hospital. Free Out-patient services for BPL
patients.
Hural Health Care Delivery and management of PHCs
Contracting Arrangements: Karuna Trust and Government of Arunachal Pradesh
Type of Partnership: Contracting in
Services: Manages 11 PHC’s, provides health care facilities to the local population.
Labs, Drug Supply and Diagnostic Services: Hindlabs
Contracting Arrangements: MoHFW and HLL Life Care Ltd
Type of Partnership: Contracting in
Services: A novel initiative, delivers high end diagnostic services at CGHS rates
Health Insurance: Community Health Insurance Scheme
Contracting Arrangements: Karuna Trust, National Insurance Co. and Government of Karnataka
Type of Partnership: Joint Venture
Services: A community health insurance scheme to improve the access and utilisation of health services
Outreach/Health Delivery: Mobile Health Service in Sunderban, IV. Bengal
Contracting Arrangements: Government of West Bengal and Non-profit NGO
Type of Partnership: Contracting in (Joint Venture)
Services: Mobile boat based health services and access to health services in remote areas
RCH Services: Merry Gold Health Network (MGHN) and SAMBHAV Voucher Scheme in UP
Contracting Arrangements: Joint endeavour of Government of India and USAID through UP SIPPSA
Type of Partnership: Social Franchising network and Voucher system
Services: Provide FP/RCH services through accredited private providers
facilities would have an incentive to generate reve
nues if they are allowed flexibility in the utilisation of
self-generated resources within broad policy param
eters laid down by the Government.
RASHTRIYA SWASTHYA BIMA YOJANA (RSBY)
20.60. Health insurance is a common form of
medical protection all over the world and until the
Eleventh Plan, it was available only to government
employees, workers in the organised sector; private
health insurance has been in operation for several
years, but its coverage has been limited. The percent
age of the total population estimated to be covered
under these schemes was only 16 per cent. The poor
did not have any insurance for in-patient care. The
‘Rashtriya Swasthya Rima Yojana’ (RSBY), intro
duced in 2007, was designed to meet the health
insurance needs of the poor.
20.61. RSBY provides for ‘cash-less’, smart card
based health insurance cover of ^30,000 per annum to
each enrolled family, comprising up to five individu
als. The beneficiary family pays only ?30 per annum
as registration/renewal fee. The scheme covers hos
pitalisation expenses (Out-patient expenses are
not covered), including maternity benefit, and pre
existing diseases. A transportation cost of ?T00 per
visit is also paid. The premium payable to insurance
agencies is funded by Central and State Governments
in a 75:25 ratio, which is relaxed to 90:10 for the
(t-ioxj - tOO
tsoqs
Health
21
North-East region and Jammu and Kashmir. The
maximum premium by the Central Government is
limited to ?750 per insured family per year.
be handled at the primary or even preventive stages.
The RSBY also does not take into account state spe
cific variations in disease profiles and health needs.
20.62. RSBY was originally limited to Below Poverty
Line (BPL) families but was later extended to building
and other construction workers, MGNREGA benefi
ciaries, street vendors, beedi workers, and domestic
workers. The scheme is currently being implemented
in 24 States/UTs. About 3.3 crore families have been
covered as on date and 43 lakh persons have availed
hospitalisation under the scheme till November 2012.
Innovative Payment Methods to Improve
Outcomes
20.65. The weakness of line item budget payment
methods for public facilities is well documented.
More responsive resource allocation is a challenge
for the Government. Investments in public facili
ties will translate into better access, coverage, qual
ity of care and superior health outcomes only if these
facilities and their personnel perform their expected
tasks in a responsive manner. Payment methods
could be used as one of the instruments to improve
public sector performance. For example, managers
and health personnel in public sector facilities could
be paid bonus for achieving higher coverage of ser
vices as measured by reduction in the use of private
sector services in the coverage area (unless these arc
contracted in by the Government); they can be paid
further incentives for delivering preventive care ser
vices effectively and achieving measurable health
outcomes in their respective areas. UHC pilots to be
rolled out by States could experiment with different
methods of organisation and delivery of services, and
payment systems so that resources allocated are able
to generate better health outcomes.
20.63. Key feature of RSBY is that it provides for
private health sendee providers to be included in
the system, if they meet certain standards and agree
to provide cash-less treatment which is reimbursed
by the insurance company. This has the advantage
of giving patients a choice between alternative ser
vice providers where such alternatives are available.
Several State Governments (such as those of Andhra
Pradesh and Tamil Nadu) have introduced their own
health insurance schemes, which often have a more
generous total cover.
20.64. A general problem with any ‘fee for service’
payment system financed by an insurance mecha
nism is that it creates an incentive for unnecessary
treatment, which in due course raises costs and pre
miums. There is some evidence that this is happen
ing and it is necessary to devise corrective steps to
minimise it. Some groups oppose insurance schemes
per se on these grounds, but that is not realistic. The
beneficiary is able to choose from alternative care
givers covered by a common insurance scheme.
Experience with the RSBY, and with the other State
specific insurance schemes, needs to be thoroughly
studied so that suitable corrective measures can be
introduced before integrating these schemes into a
framework of Universal Health Coverage (UHC).
The shortcomings of RSBY noted so far include
high transaction costs due to insurance intermedi
aries, inability to control provider induced demand,
and lack of coverage for primary health and out
patient care. Fragmentation of different levels of
care can lead to an upward escalation towards the
secondary7 level of patients who should preferably
Health Care for Government Employees
20.66. There is a proposal for introduction of a
health insurance scheme for the Central Government
employees and pensioners on a pan-India basis, with
special focus on pensioners living in non-CGHS
areas. The proposal is to make this scheme voluntary
cum contributory for serving employees and pen
sioners. However, it is proposed to be made compul
sory for the new entrants in Government service.
HEALTH AND MEDICAL REGULATION
20.67. Regulations for food, drugs and the medi
cal profession requires lead action by the Central
Government not only because these subjects fall
under the Concurrent List in the Constitution,
but also because the lack of consistency and well
enforced standards hugely impacts the common
citizen and diminishes health outcomes. Keeping in
22 Twelfth Five Year Plan
view the need to place authority and accountability
together, the proposed Public Heath Cadre in States
would be expected to be the single point for enforce
ment of all health related regulations.
20.68. There is also an urgent need to strengthen
the regulatory systems in the States, where most
of the implementation rests. This would entail the
strengthening of and establishment of testing labs
and capacity building of functionaries. Such propos
als will be part-funded under the National Health
Mission (NHM). Regulation can be made affordable
and effective by encouraging self-regulation, and
entrusting responsibility to Public Health officers.
DRUG REGULATION
20.69. E-governance systems that inter-connect all
licensing and registration offices and laboratories,
GPS based sample collection systems and online
applications for licensing would be introduced. A
repository of approved formulations at both State
and national levels would be developed. The drug
administration system would build capacity in train
ing, and encourage self regulation.
20.70. The MoHFW would ensure that irrational
Fixed Dose Combinations (FDCs) and hazardous
drugs are weeded out in a time bound manner.
20.71. Pharmaco-vigilance, post-marketing surveil
lance, Adverse Drug Response Monitoring, qual
ity control, testing and re-evaluation of registered
products would be accorded priority under drug
regulation.
20.72. Use of generic names or the International
Non-proprietary Name (INN) would be made com
pulsory and encouraged at all stages of Government
procurement, distribution, prescription and use,
as it contributes to a sound system of procurement
and distribution, drug information and rational use
at every level of the health care system. Established
brand manufacturers would be encouraged to bid for
Government procurement, but should provide med
icines in non-propriety names.
20.73. The Drugs and Cosmetics Act would be
amended to include medical devices incorporating
provisions for their risk-based classification, clinical
trials, conformity assessments and penalties. As rec
ommended by the Mashelkar Committee, a Central
Drug Authority needs to be set up. This author
ity would review the issuance of licenses for manu
facture and sale of drugs. Once this Authority is in
place, suitable strengthening of its infrastructure and
laboratories would be done. The Government would
mandate that labels on drugs and food fully disclose
all its ingredients.
20.74. Strengthening of existing, and creation of new
drug testing laboratories is essential to ensure the
quality of drugs being produced in India, whether
they are used for domestic distribution or for export
to other countries.
20.75. A National List of Essential Medicines
would be made operational with the introduction
of Standard Treatment Guidelines, including for
AYUSH. It would be printed and supplied to all
facilities at regular intervals. These guidelines would
incorporate generic prescriptions. Implementation
of Standard Treatment Guidelines in the public and
private sectors is a priority to address drug resistance,
promote rational prescriptions and use of drugs, and
contain health care costs.
20.76. Pharmaceutical marketing and aggressive pro
motion also contributes to irrational use. There is a
need for a mandatory code for identifying and penal
ising unethical promotion on the part of Pharma
companies. Mandated disclosure by Pharmaceutical
companies of the expenditure incurred on drug
promotion, ghost writing in promotion of pharma
products to attract disqualification of the author and
penalty on the company, and vetting of drug related
material in Continuing Medical Education would
be considered, To avoid medical conflicts of inter
est, legislation requiring drug companies to disclose
payments made to doctors for research, consulting,
lectures, travel and entertainment would also be
considered.
Health
20.77. MoHFW would encourage public and patient
education in the appropriate use of drugs, particu
larly antibiotics and antimicrobials, since it would
benefit individual patients and public health.
20.78. Institutional frameworks for regulation
of clinical research and trials to ensure safety of
research subjects will be a priority. In addition, effi
cient assessment and approval of new technologies,
drugs and devices ould also be done. I he pro
cess of approval and introduction of new medical
technologies, and devices, would be notified. India
still has to safeguard itself from TRIPS plus provi
sions which will evergreen patents for more than 20
years. Safeguards like compulsory licensing, parallel
imports, and so on, need to be adopted to protect
nation’s public health.
FOOD REGULATION
20.79. The newly established Food Safety and
Standards Authority of India (FSSAI) would strive
to improve transparency in its functioning and deci
sion making. Bio-safety would be an integral part of
any risk assessment being undertaken by FSSAI.
20.80. Food surveys would be carried out regularly
and their results made public. An annual report on
state of food safety would be published.
20.81. Policies to promote production and consump
tion of healthy food would be developed. Sale and
consumption of unhealthy food would be discour
aged in general and in schools in particular. Public
information campaigns to create awareness on food
safety matters will be launched.
20.82. An appropriate module on food safety and
bio-safety will be introduced in the Medical and
Nursing curriculum.
REGULATION OF MEDICAL PRACTICE
20.83. The provisions for registration and regu
lation of clinical establishments would be imple
mented effectively; all clinical establishments would
also be networked on the Health Information
System, and mandated to share data on nation
ally required parameters. The Government would
23
consider mandating evidence based and cost-effec
tive clinical protocols of care, which all provid
ers would be obliged to follow. It would endeavour
to gradually move towards a regime where clini
cal decision-making would be routinely subjected
to prescription audits to confirm compliance. 1 he
rights of patients to obtain rational treatment of
good quality at reasonable cost would be protected.
Professional councils and faculty in medical col
leges shall be encouraged to undertake prescription
audits to assess extent of compliance with Standard
Treatment Guidelines for identifying violations of
guidelines and taking appropriate action. There is
a need to revise and strengthen the existing regula
tory mechanism for medical practice to prevent wil
ful negligence and malpractice. Grievance rediessal
mechanisms would be put in place.
20.84. Since there are no legislations on registra
tion of clinical establishments in many States, and
the ones existing (as in States of Andhra Pradesh,
Maharashtra, Delhi, Madhya Pradesh, Manipur,
Nagaland, Odisha, Punjab and West Bengal) have
major gaps, all States will be persuaded to adopt the
Central Act under Clause (1) of Article 252 of the
Constitution.
20.85. An appropriate regulatory mechanism would
be considered to ensure compulsory rural service by
medical graduates. Concurrently, a set of monetary
and non-monetary incentives would be built up to
encourage doctors and allied health cadres to serve
in rural areas.
20.86. Effective enforcement of the provisions of Pre
Conception and Pre-Natal Diagnostic Techniques
(Prohibition of Sex Selection) Act and relentless
public awareness measures would be put in place. A
concerted societal conscientisation and communi
cation campaign would be launched to create value
for the girl child and women, along with affirmative
action for girls. Local Self Government Institutions,
specially the newly elected women panchayat and
urban local body members, would be mobilised to
change deeply entrenched behaviours and mind
sets about the girl child. Panchayats and urban local
bodies which are able to achieve a reversal of the
24
Twelfth Five Year Plan
falling trend in child sex ratio would be recognised
and awarded, along the lines of the Nirmal Gram
Puraskar.
NATIONAL LEVEL TERTIARY CARE
INSTITUTIONS
20.87. A single Central Sector Scheme on ‘National
Level Tertiary Care Institutions’ will fund up-grada
tion of existing medical colleges and converting ter
tiary care facilities of the Central Government across
different departments into teaching institutions.
20.88. In the Twelfth Five Year Plan a concerted effort
needs to be made to confer greater autonomy to the
existing Tertiary Care Institution and Hospitals. They
need to be delegated greater administrative and finan
cial powers and need to be empowered to function as
effective Board managed entities (see Box 20.4).
20.89. In the Central Government sector, more
AIIMS like Institutions (ALIs) will be established dur
ing the Twelfth Plan period in addition to the eight
already approved. These would be completed and
made operational during the Plan period. They will
serve as composite centres tor continued piofessional
education, and multi-skilling of health workers.
20.90. The existing teaching institutions will be
strengthened to provide leadership in research and
practice on different medical conditions, and research
themes. Priorities include Cancer, Arthritis and
musculo-skeletal diseases, Child Health, Diabetes,
Mental Health and Neuro Sciences, Geriatrics,
Biomedical and Bioengineering, Hospital and
Health Care Administration, Nursing Education
and Research, Information Technology and TeleMedicine and Complementary Medicine.
20.91. Centres of Excellence need to be created for
training public health professionals in epidemiology,
entomology and microbiology for effective disease
surveillance and disease outbreak investigations and
for effectively responding to outbreaks, epidemics
and disasters, and also for AYUSH.
20.92. A continuous stream of qualified teachers
would be required for serving in the new teaching
institutions proposed. Apex institutions of learn
ing like AIIMS, Post Graduate Institute of Medical
Education and Research (PGIMER) and Jawaharlal
Institute of Post Graduate Medical Education and
Research (JIPMER) will be geared to build capacity
in regional and State teaching institutions for train
ing of trainers.
20.93. A new category of mid-level health-workers
named Community Health Officers, could be devel
oped for primary health care. These workers would
be trained after Class XII for a three year period to
become competent to provide essential preven
tive and primary care and implement public health
activities at sub-centre level. Details of their func
tions, qualifications, designations, placement and
career tracks within the health system need to be
worked out. This new category offers an opportunity
to break through professional silos, develop compe
tencies that draw upon different but complementary
streams of knowledge and help generate employment
while meeting health needs of under-served popula
tions. These Community Health Officers would be
groomed to discharge public health functions.
20.94. Simultaneously, programmes for Continuing
Medical Education would be strengthened and
expanded. Agencies such as the National Academy
Box 20.4
Institute of Liver and Biliary Sciences, Delhi: A Model of Autonomy and Sustainable Financing
The Institute is a super specialty medical institute under Government of NOT Delhi that seeks to provide quality tertiary
hlalth cam its ,^Zs: fre fre^for BPl. card holders of Delhi, and charges for other classes are compehttve. Its bus.ness
model aims at attaining efficiency and self sustenance.
The Institute is governed by a Society in an autonomus manner, which aims to combine the skills and structure of academic
Universities, clinical and research acumen of the super-specialists and the managerial skills of the corporate wo .
Health
of Medical Sciences can play a useful role in provid
ing good quality teaching material and also help in
its dissemination, by using the National Knowledge
Network.
20.95. Good health planning requires high quality
data on estimates of supply and demand of various
categories of health workers. Accurate data on the
number, specialisation, distribution, status of prac
tice of health professionals in the country is, however,
not available. Professional Councils in respective
States and at the national level should therefore, con
tinually update their records on Human Resources,
trying to take into account the extent of internal and
international migration The MoHFW would exer
cise due vigilance to ensure this.
20.96. Licensing of medical professionals with a
view to control the entry of unqualified persons
into the market is governed by various laws. The
National Commission for Human Resources and
Health (NCHRH) would be created as an overarch
ing regulatory body for medical education and allied
health sciences with the dual purpose of reforming
the current regulatory framework and enhancing
the supply of skilled human resource in the health
sector. The proposed Commission would subsume
many functions of the existing councils, namely
Medical Council of India, Dental Council of India,
Nursing Council of India and Pharmacy Council of
India. The proposed NCHRH would also constitute
a National Board for Health Education (NBHE) and
a National Evaluation and Assessment Committee
(NEAC) with a mandate to prescribe minimum
standards for health education, and developing and
maintaining a system of accreditation of health edu
cational institutes respectively. Apart from this, a
National Council has also been proposed to be set
up under NCHRH to inter alia ensure ethical stand
ards among medical professionals. The NCHRH
is expected to assess the demand and availability
to plan for the creation of the right mix of human
resource in health.
25
INFORMATION TECHNOLOGY IN
HEALTH
20.97. Information Technology can be used in at
least four different ways to improve health care and
systems:
1.
2.
3.
4.
Support public health decision making for better
management of health programmes and health
systems at all levels
Support to service providers for better quality of
care and follow up
Provision of quality services in remote locations
through Tele-medicine
Supporting education, and continued learning in
medicine and health
20.98. A composite HIS, when fully operational,
would incorporate the following:
Universal registration of births, deaths and cause
of death. Maternal and infant death reviews.
2. Nutritional surveillance, particularly among
women in the reproductive age group and chil
dren under six years of age.
3. Disease surveillance based on reporting by ser
vice providers and clinical laboratories (public
and private) to detect and act on disease out
breaks and epidemics.
4. Out-patient and in-patient information through
Electronic Medical Records (EMR) to reduce
response time in emergencies and improve gen
eral hospital administration.
5. Data on Human Resource within the public and
private health system
6. Financial management in the public health sys
tem to streamline resource allocation and trans
fers, and accounting and payments to facilities,
providers and beneficiaries. Ultimately, it would
enable timely compilation of the National Health
Accounts on an annual basis.
7. A national repository of teaching modules,
case records for different medical conditions
in textual and audio-visual formats for use by
teaching faculty, students and practitioners for
Continuing Medical Education.
1.
26
Twelfth Five Year Plan
8. Tele-medicine and consultation support to doc
tors at primary and secondary facilities from
specialists at tertiary centres.
9. Nation-wide registries of clinical establishments,
manufacturing units, drug-testing laboratories,
licensed drugs and approved clinical trials to
support regulatory functions of Government.
10. Access of public to their own health information
and medical records, while preserving confiden
tiality of data.
11. Programme Monitoring support for National
Health Programmes to help identify programme
gaps.
20.99. To achieve these goals, computer with inter
net connectivity would be ensured in every PHC and
all higher level health facilities in this Plan period.
Connectivity can be extended to sub-centres either
through computers or through cell phones, depend
ing on their state of readiness and the skill-set of
their functionaries. All District hospitals would be
linked by tele-medicine channels to leading tertiary
care centres, and all intra-District hospitals would
be linked to the District hospital and optionally to
higher centres.
20.100. The role of the MoHFW would be to lay IT
system standards, and define indicators which would
be openly shared. States will be funded for their ini
tiatives in this field at primary7 or secondary levels
through the National Health Mission. Health surveys
would be annually conducted to generate district
level information on health status, which will also
serve to verify the accuracy of routine health infor
mation system
NATIONAL HEALTH MISSION (NHM)
20.101. The Prime Minister in his Independence
Day speech, 2012 had declared: ‘After the success of
the National Rural health Mission, we now want to
expand the scope of health services in our towns also.
The National Rural Health Mission will be converted
into a National Health Mission (NHM) which would
cover all villages and towns in the country.’
20.102. The gains of the flagship programme of
NRHM will be strengthened under the umbrella of
NHM which will have universal coverage. The focus
on covering rural areas and rural population will
continue.
20.103. A major component of NHM is proposed
to be a Scheme for providing primary health care
to the urban poor, particularly those residing in
slums. Modalities and institutional mechanisms for
roll-out of this scheme arc being worked out by the
Ministry of Health and Family Welfare in consulta
tion with Planning Commission. NHM would give
the States greater flexibility to make multi-year plans
for systems strengthening, and addressing threats to
health in both rural and urban areas through inter
ventions at Primary, Secondary and Tertiary levels
of care. The roles and responsibilities of the Centre
and States in the health sector would be made opera
tional through instruments such as State specific and
Sector-wide Memoranda of Understanding (MoU).
The MoU mechanism is a tool for collective priority
setting, involves agreement on measurable outcomes
and their relative weight, allows flexibility in imple
mentation and accountability based on objective
assessment and incentivisation of performance.
20.104. The targets in the MoU would be finalised
through a consultative process so that there is a con
sensus. The MoU will cover the entire health sector,
be subject to rigorous monitoring, and linked to a
performance based appraisal and incentive system.
The MoU would include important policy reforms,
which may not necessarily have budgetary implica
tions such as regulation, HR policies, inter-sectoral
convergence, use of generic medicines. The MoU
can have a set of obligatory parameters, state spe
cific optional parameters and reform parameters.
The MoU will follow the log frame approach in set
ting inputs, outputs, outcomes and impact goals for
the districts and States. System-wide MoUs between
Centre and States would allow a lot of flexibility to
the latter to develop their own strategies and plans
for delivery of services, while committing the States
to quantitative, verifiable and mutually agreed upon
outputs and outcomes.
Health 27
20.105. In addition to the Common Review Mission,
a methodology of external concurrent evaluation
would be finalised and put in place to assess the
progress in MoU goals. These reports will be placed
before the Mission Steering Group at the national
level and before the Governing Body of the State and
district health societies. All major programme com
ponents would be evaluated as part of operational
research and programme evaluation.
20.106. The National Health Mission will incorpo
rate the following core principles.
with an incentive, which they can share with their
teams, to achieve and improve their quality rating.
The service and quality standards shall be defined,
made consistent with requirements under the
Clinical Establishments Act, and performance of
each registered facility made public, and periodically
ranked. The work of quality monitoring will be suit
ably institutionalised.
20.110. To enable access to quality diagnostic facili
ties, pooling of resources available with different
agencies, their up-gradation wherever needed, out
sourcing and in-sourcing strategies would be adopted.
CORE PRINCIPLES
Universal Coverage
20.107. The NHM shall extend all over the country,
both in urban and rural areas and promote univer
sal access to a continuum of cashless, health services
from primary to tertiary care. Separate strategies
shall be followed for the urban areas, using opportu
nities such as easier access to secondary and tertiary
facilities, and better transport and telecommunica
tion services. There is greater scope for contracting
arrangements with the private sector in urban areas,
to fill gaps in strengthened public facilities. Area spe
cific NHM plans shall address the challenges unique
to their areas such as overcrowding, poor sanitation,
pollution, traffic injuries, higher rates of crime and
risky personal behaviour in urban areas.
20.111. The objective would be to achieve a mini
mum norm of 500 beds per 10 lakh population in an
average district. Approximately 300 beds could be at
the level of District Hospitals and the remaining dis
tributed judiciously at the CHC level. Where needed,
private sector services also may be contracted in to
supplement the services provided by the public sec
tor. The sanction of new facilities other than sub
centres should be undertaken only when mapping
of access demonstrates the need for new facilities to
improve accessibility.
20.108. The IPHS standards will be revised to incor
porate standards of care and service to be offered at
each level of health care facility. Standards would
include the complete range of conditions, covering
emergency, RCH, prevention and management of
Communicable and Non-Communicable diseases
incorporating essential medicines, and Essential and
Emergency Surgical Care (EESC).
20.112. States would be encouraged to put in place
systems for Emergency Medical Referral to bridge
the gaps in access to health facilities and need for
transport in the event of an emergency. Standards
for these sendees will specify the time taken to trans
port patients from the location to designated health
facilities, and these standards shall be evaluated
and followed. The possibility of positioning such
referral with the response teams of Fire-Fighting
Departments, as is the practice in many developed
nations, should be explored. These facilities, once
operational, would also help in managing disasters,
in terms of early response, search and rescue, emer
gency care and rehabilitation.
20.109. All government and publicly financed pri
vate health care facilities would be expected to
achieve and maintain these standards. An in-house
quality management system will be built into the
design of each facility, which will regularly measure
its quality achievements. Facilities will be provided
20.113. For ensuring access to health care among
under-served populations, the existing Mobile
Medical units would be expanded to have a presence
in each CHC. Mobile Medical Units may also be
dedicated to certain areas, which have moving popu
lations. For example, boat clinics of C-NES in Assam
Achieving Quality Standards
28
Twelfth Five Year Plan
provide curative and emergency care for the popula
tion residing in islands and flood plains of the State.
be used to universalise the upgrading of standards of
health facilities and teaching colleges.
Continuum of Care
20.114. A continuum of care across health facili
ties helps manage health problems more effectively
at the lowest level. For example, if medical colleges,
district hospitals, CHCs, PHCs and sub-centres
in an area are networked, then the most common
disease conditions can be assessed, prevented and
managed at appropriate levels. It will avoid frag
mentation of care, strengthen primary health care,
reduce unnecessary load on secondary and tertiary
facilities and assure efficient referral and follow up
services. Continuum of care can lead to improve
ments in quality and patient satisfaction. Such link
ages would be built in the Twelfth Plan so that all
health care facilities in a region are organically linked
with each other, with medical colleges providing the
broad vision, leadership and opportunities for skill
up-gradation. The potential offered by tele-medicine
for remote diagnostics, monitoring and case man
agement needs to be fully realised. Appropriate fac
ulty at the medical college can be given responsibility
for training, advising and monitoring the delivery of
services in facilities within their allotted jurisdiction.
The resources saved in avoiding duplication could
Decentralised Planning
20.115. A key element of the new NHM is that it
would provide considerable flexibility to States and
Districts to plan for measures to promote health
and address the health problems that they face (Box
20.5). The NHM guidelines could provide flexibility
to States and districts to plan for results.
20.116. New health facilities would not be set up on
a rigid, population based norm, but would aim to
be accessible to populations in remote locations and
within a defined time period. The need for new facili
ties of each category would thus be assessed by the
districts and States using a ‘time to care’ approach.
This will be done based on a host of contributing
factors, including geographic spread of population,
nature of terrain, availability of health care facility in
the vicinity and availability of transport network. For
example, a travel time of 30 minutes to reach a pri
mary healthcare facility, and a total of two hours to
reach a FRU could be a reasonable goal. As for staff
ing, the healthcare facilities should have a basic core
staff, with provisions for additional hands in response
to an increase in case load, or the range of services
Box 20.5
Flexibility and Decentralised Planning: Key Elements of National Health Mission
1. The guidelines of NHM would be indicative and within broad parameters leave the decision on prioritisation of
requirements to the best judgement of the States and Districts. Each District would develop, through effective public
participation, a multi-year Health Action Plan for prevention, service delivery' and systems management. These plans
would become the basis for resource allocation and be made public to enable social audits of the progress made towards
the goals. The implementation of these plans would involve the local community. The outcomes of these plans would be
subject to Community Based Monitoring (CBM).
2. Health Action Plans at District level and below will aim at convergent delivery of services in an integrated manner to
the last beneficiary. The District Health Plans would factor in all determinants of health, and assign roles to each agency
for achieving convergence. For instance, these plans can leverage the mid-day meal programme for addressing issues of
school child malnutrition and anaemia. Joint training of AWWs and ASH As would be promoted to build camaraderie and
clarity on mutual roles and responsibilities. Anganwadi Centres could be used as base stations for ASHAs, and upgraded
into health posts for the delivery of essential health services.
3. Innovations in service delivery to improve coverage, quality of care, health outcomes and reduce costs would be encouraged,
and recognised.
4. The sector-wide health plans prepared by the States should incorporate all dispensations of health and health care, and all
sources of funding. For instance, medical education, AYUSH, AIDS control, Health Research, convergence with ICDS and
Drinking Water and Sanitation would find space in the state health plans.
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