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Twelfth Five Year Plan
(2012-2017)
Social Sectors
Volume III
Contents
List of Acronyms
List ofAnnexures
vii
viii
x
xi
xviii
20.
Health
1
21.
Education
47
22.
Employment and Skill Development
124
23
Women's Agency and Child Rights
164
24.
Social Inclusion
221
List of Figures
List of Tables
List of Boxes
)
20
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 services. Other sectors that impact on
good health, such as clean drinking water and sanita
tion are dealt with in other Chapters of the Plan.
AN OVERVIEW
2.
3.
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 ofBoctors^peFlakh of population was only
45, whereas, the desirable number is 85 per lakh
population. Similarly, the number of Nurses and
4.
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.
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.
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.
The problems outlined above are likely to worsen
in future. Health care costs are 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
Twelfth Five Year Plan
2
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
5.
health challenge, both in terms of mortality and
disability (Figures 20.1 and 20.2).
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
\0.10
10.50
0.7%
0.21
19.28
0.54
0.9%
1.4%
z:^u2%
0.89
— 0.95
L88^E49
2.78
2.85
3.67
6%
7%!
6.30
7%
9.49
0.6%
2.69
24%
■ Communicable
Diseases (37%)
■ Non Communicable
Diseases (53%)
■ Injuries (10%)
■ Infectious and parasitic diseases
■ Respiratory infections
■ Perinatal conditions (h)
n Maternal conditions
Nutritional deficiencies
Cardiovascular diseases
■ Respiratory diseases
■ Malignant Cancer
■ Digestive diseases
■ Genitourinary diseases
■ Diabetes mellitus
■ Neuropsychiatric conditions
; Others
Congenital anomalies
n 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
■ Nutritional deficiencies
■ Unintentional injuries
■ Cardiovascular diseases
■ Respiratory infections
■ Digestive diseases
• Neuropsychiatric
conditions
■ Musculoskeletal diseases
Skin diseases
Oral conditions
■ Respiratory diseases
■ Other neoplasms
■ Congenital anomalies
■ Perinatal conditions (h)
Diabetes mellitus
■ Maternal conditions
■ Endocrine disorders
Sense organ diseases
■ Intentional injuries
■ 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 27 per cent
of the total
-Z0'09rwHich is
very low by any standard. Public expenditure on
Core Health (both plan and non-plan and taking
ffie'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.
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.
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
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.
Maternal Mortality Ratio <(MMR) which measures number of women of reproductive age
(15-49 years) dying due toi 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 (316),
Chhattisgarh (275), Odisha (277), Rajasthan
(331), Uttar Pradesh (345) and Uttarakhand
(188). 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.
2. 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-if period, an improvement 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.
3. 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
1.
Twelfth Five Year Plan
4
4.
5.
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
TFR, namely 2.1, has been attained by nine states.
High fertility remains a problem in seven States,
namely Bihar (CBR 2011 27.7; TFR 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.
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.
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
Eleventh Plan Monitorable Target
Baseline Level
Recent Status
1
Reducing Maternal Mortality Ratio (MMR) to 100 per
100000 livebirths.
254
(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)
S. No.
Health
5
TABLE 20.2
Allocation and Spending by Ministry of Health in Eleventh Plan
(Figures in ? Crore)
Eleventh Plan 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%
DHR
4,496
1,938
1,870
96.5%
AIDS Control
5,728
1,500
1,305
87.0%
93,981
89,576
95.3%
Department
1,40,135
Total
Note: Outlay for the new departments of DHR and AIDS Control was transferred from Department of HEW.
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
States Core
Health
Centre
States
Total
Centre
States
Total
XPlan
*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%
1.09%
0.75%
1.27%
2.02%
2010- 11
27,466
55,955
0.36%
0.73%
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. ASH As 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 AllMS like institutes and up^radation of 13 medical colleges has been taken up
under Pradhan Mantri Swasthya Suraksha Ydjaria
(PMSSY). Seventy-two State Government medi
cal colleges "Eave 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 Common 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
2.
3.
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.
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 Flepatitis 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.
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
2.
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 residual 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.
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 11 (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 (PLHA) in 2011. The pro
gramme includes Targeted Interventions focused
on High Risk Groups and Bridge populations,
Link Workers Scheme, Integrated Counselling and
Testing Services, Community Care, Support and
Treatment Centres, Information, Education, and
Communication (IEC) and condom promotion.
Gaps in the programme include low rate of coverage
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 valid'ation 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.
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 FILEG
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.
1.
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 country. This means
2.
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.
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,
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 co m pre hen 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 services (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
onTyprovider 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
HeakFrPackage (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
service providers charging a fee for service, 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 summary 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 every
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 Stale 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 services 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 service 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 services are provided
by both public and private providers. Primary care
payment is by Fee for Service. In-patient service pay
ment is through Fee for Service 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 moving 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:
1.
2.
3.
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.
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.
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.
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
caFe^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 basicdeliverable 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 (LLIN), 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
NUM. Individual Stales, in consultation with the
MoHFW, expert groups and institutions may final
ise the detaHTof 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 every 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 (IMR) 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.
No
Name of the States/UTs
Recent Status
Target for Twelfth Plan
IMR
MMR
Anaemia
IMR
MMR
Anaemia
44
212
55.3
25
100
28
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
5
Chhattisgarh
48
269
57.5
28
122
6
Goa
11
NA
38
6
7
Gujarat
41
148
55.3
24
8
Haryana
44
153
56.1
26
28
9
Himachal Pradesh
38
NA
43.3
22
22
10
Jammu & Kashmir
41
NA
52.1
24
11
Jharkhand
39
261
69.5
23 -
12
Karnataka
35
178
51.5
15
13
Kerala
12
81
32.8
14
Madhya Pradesh
59
269
56
15
Manipur
11
NA
35.7
6
16
Maharashtra
25
104
48.4
15
India
1
6
34
25
•'J
28
19
67
28
26
109 i
35
H
26
37
16
122
28
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
31
21
Punjab
30
172
38
16
78
19
22
Rajasthan
52
318
53.1
30
145
27
23
Sikkim
26
NA
60
24
Tamil Nadu
HBHHI
22
97
53.2
13
25
Tripura
29
NA
65.1
17
26
Uttar Pradesh
57
359
49.9
27
Uttarakhand
36
359
55.2
21
163
20
28
28
West Bengal
32
145
63.2
66
32
29
Andaman 8< Nicobar Islands
23
NA
NA
44
33
163
30
Delhi
28
NA
44.3
31
Chandigarh
20
NA
NA
11
12
15
12
20
32
Dadra & Nagar Haweli
35
NA
NA
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.
■IM
27
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, IMR, 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 very 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 services 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/AIDS
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)
%
Department of
MoHFW
Eleventh Plan
Expenditure
Twelfth
Plan Outlay
Increase
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%
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 2011-12 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_£r^ble 20.6). With the incentive meas
ures proposed, States’ total funding, Plan and Nonplan, 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
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.
FUNDING AS AN INSTRUMENT OF INCENTIVE
AND REFORM
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.
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 laam-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 outside 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 are 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.
Rural 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 al 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, W. 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 SIFPSA
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 Bima 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 ?100 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
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
20.63. Key feature of RSBY is that it provides for
private health service 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
secondary level of patients who should preferably
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 are
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.
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 would also be done. The 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 Flealth 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. The
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 redressal
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 for continued professional
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 (PG'IMER) 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 NCT Delhi that seeks to provide quality tertiary
health care. Its services: are free for BPL card holders of Delhi, and charges for other classes are competitive. Its business
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 world.
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:
1.
2.
3.
4.
5.
6.
7.
Universal registration of births, deaths and cause
of death. Maternal and infant death reviews.
Nutritional surveillance, particularly among
women in the reproductive age group and chil
dren under six years of age.
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.
Out-patient and in-patient information through
Electronic Medical Records (EMR) to reduce
response time in emergencies and improve gen
eral hospital administration.
Data on Human Resource within the public and
private health system
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.
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.
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 primary 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 are 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
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.
27
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 ofcashless, 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.
Achieving Quality Standards
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 services 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
28 Twelfth Five Year Plan
provide curative and emergency care for the popula
tion residing in islands and flood plains of the Slate.
be used to universalise the upgrading of standards of
health facilities and teaching colleges.
Continuum of Care
Decentralised Planning
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
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 Stales 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 ASHAs 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 Stales should incorporate all dispensations of health and health care, and ail
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.
Health
provided. Indian Public Health Standards (1PHS)
would be revised accordingly. Individual States can
choose from a range of staffing options, including
those suggested by the Working Group on NRHM
and by the HLEG, both options will be included in
the Central funding envelop. Such flexibility to States
in location, size and staffing of the health care facili
ties would ensure optimum utilisation of existing
resources, and infrastructure. Every Panchayat and
urban municipal ward should have at least one sub
centre. The sub-centre’s package of assured services,
and consequent staffing will vary according to the
epidemiological and health systems contexts.
PRIORITY SERVICES
Access to Essential Medicines in All Public
Facilities
20.117. Availability of essential medicines in public
sector health facilities free of cost is critical to achieve
affordable health care for the bulk of the population.
This is the area which provides the speediest scope
for improved service delivery in return for allocation
of sufficient resources. A set of measures including
revision and expansion of the Essential Drugs List,
ensuring the rational use of drugs, strengthening the
drug regulatory system, and supporting the setting
up of national and state drug supply logistics corpo
rations is being recommended as core components.
States would be encouraged to plan and partially
fund universal access to essential drugs and diagnos
tic services in all government health care facilities.
Drug supply would be linked to centralised procure
ment at state level to ensure uniform drug quality
and cost minimisation by removing intermediaries.
20.118. The provision of essential medicines free of
cost must be backed by logistic arrangements to pro
cure generic medicines from suppliers of repute that
match pre-qualifying standards. The MoU instru
ment shall be used to encourage States to adopt the
TNMSC model, for professional management of
procurement, storage and logistics. Support to
rational and generic drug prescription for the pri
vate sector requires a different approach. This can
be achieved through expansion of the existing Jan
Aushadhi stores in all sub-divisions and blocks.
29
These stores could be linked to centralised procure
ment at state level.
Strategy for Maternal and Child Health
20.119. Maternal and child health care will continue
to be a major focus, especially given the inadequate
progress in reducing IMR and MMR. Programme
monitoring needs to track experiences and out
comes of women rather than only disbursement of
cash. Training being provided to the Skilled Birth
Attendants (SBA) needs to be evaluated indepen
dently. Plans need to be made for rational posting
of those SBAs who have received this training, so
as to reach the maximum population with skilled
attendance at birth. Appropriate area-specific inter
ventions will be made such as equipping Traditional
Birth Attendants (TBAs)Zdais for safe deliveries,
(especially in remote and inaccessible areas) universalising access to the SBA over a period of time, and
prioritising better access to emergency obstetric care
(both public and private) within a two-hour travel
time in cases of complications. The quality of care
being provided in routine institutional deliveries
needs to be carefully monitored and accessible griev
ance redressal mechanisms put in place.
20.120. Simple strategies for prevention of pre-term
births, and reducing deaths among pre-term babies
can make a difference in survival and health of chil
dren during the critical first month of life. These will
be built into protocols for health workers and stand
ards for health facilities (Figure 20.3).
20.121. Home-based newborn care, drawing on
validated models, such as that of Gadchiroli in
Maharashtra, and focused efforts to encourage
breastfeeding and safe infant and child feeding prac
tices will be promoted. While emphasis on early
breastfeeding is a part of Accredited Social Health
Activists’ (ASHAs) training, special training on neo
natal care for community and facility-level health
functionaries will result in a faster reduction in IMR.
The findings of Maternal Death Reviews and Infant
death audits will be used to fill gaps in health systems,
in skills and service provision. Control and manage
ment of diseases like malaria, TB and HIV/AIDS,
and conditions like hypertension and gestational
30
Twelfth Five Year Plan
CARE OF THE PRE MATURE BABY
PREVENTION OF PRE-TERM BIRTH
• Preconception care package, including family planning • Essential and extra newborn care, especially feeding
support
(e.g., birth spacing and adolescent friendly services),
education and nutrition especially for girls, and STI • Neonatal resuscitation
• Kangaroo Mother care
prevention
• Chlorhexidine cord care
• Antenatal care packages for all MANAGEMENT OF PRE TERM
• Management of premature
women, including screening
LABOUR
babies with complications,
for and management of STIs,
• Tocolytics to slow down labour
especially respiratory distress
high blood pressure, diabetes
• Antenatal corticosteroids
syndrome and infection
and behaviour changes and
• Antibiotics for pPROM
targeted care of women at
increased risk of preterm birth
• Provider education to promote appropriate induction • Comprehensive neonatal intensive care, where capacity
allows
and cesarean
• Policy support including smoking cessation and
employment safeguards of pregnant women
REDUCTION OF
PRE-TERM BIRTH
MORTALITY
REDUCTION
■
AMONG BABIES BORN PRE-TERM
Source: Born too Soon: Global Action Report on Pre-term births, WHO 2012; pPROM: Premature Rupture of Membrane.
FIGURE 20.3: Strategies to Prevent Pre-Term Births and Manage Pre-Term Babies
diabetes which are directly related to maternal mor
tality would be integrated with RCH service delivery.
20.122. AYUSH doctors, wherever feasible, would
to be given SBA, RCH and IMNCI training and
their services will be used in meeting unmet needs.
This will increase the availability of trained human
resource for better outreach of child and maternal
health services.
Universal Immunisation Coverage
20.123. The goal of ensuring universal coverage of
routine immunisation through campaigns in dis
tricts throughout the country is now within reach
and will be achieved by the end of the Twelfth Plan.
Registered Medical Practitioners (RMPs) will be
used in this effort, wherever feasible. There is need
for expanding the use of available vaccines for vari
ous preventable diseases through an evidence based
approach. The existing alternate vaccine delivery
mechanism through mobile immunisation services
for outreach work will be upgraded. Other dis
ease specific recommended strategies will also be
adopted; such as, in the case of measles, periodic
Supplemental Immunization Activities (SIAs), that
is, mass vaccination campaigns aimed at immunis
ing 100 per cent of a predefined population within
several days or weeks, introduction of a routine
second dose in high prevalence states, laboratorysupported surveillance, and appropriate manage
ment of measles cases. Public awareness of the
benefits of immunisation will be built, so that they
demand the services. Effective implementation of
the Mother and Child Tracking system and Mother
and Child Protection Card jointly issued by the
MoHFW and the MoWCD would be used in captur
ing immunisation data better. Electricity supply will
be ensured, especially at places where cold chains are
maintained.
Family Welfare
20.124. The experience of Indonesia and Japan
shows that, as compared to limiting methods,
emphasis on family spacing methods like IUCD
and male condoms has had a better impact in meet
ing the unmet needs of couples. A recent study has
estimated that meeting unmet contraception needs
could cut maternal deaths by one-third. There is,
therefore, a need for much more attention to spacing
methods such as, long term IUCD. IUCD insertion
Health
on fixed days by ANMs (under supervision of LHV
for new ANMs) would be encouraged. Availability of
MTP by Manual Vacuum Aspiration (MVA) tech
nique and medical abortions will be ensured at fixed
points where Mini-Laparotomy is planned to be
provided. Services and contraceptive devices would
be made easily accessible. This would be achieved
through strategies including social marketing,
contracting and engaging private providers. Post
partum contraception methods like insertion of IUD
which are popular in countries like China, Mexico,
and Egypt and male sterilisation would be promoted
while ensuring adherence to internationally accepted
safety standards.
Communicable Disease Control
20.125. State and District specific action plans will
incorporate status and strategies for TB control,
with universal and assured access to quality DOTS
services. PMDT services will be included in the stan
dards of care and made available in all districts for
comprehensively tackling the challenge of drug
resistant TB.
20.126. An increasing incidence of vector borne
diseases like malaria, dengue and chikungunya in
urban, peri-urban and rural areas because of expand
ing urbanisation, deficient water and solid waste
management has been reported. To control this,
the emphasis would be on avoidance of mosquito
breeding conditions in homes and workplaces and
minimising human-mosquito contact. The spread of
zoonotic diseases will also be prevented by strength
ening integrated surveillance of transmission
between wildlife, close bred veterinary populations
and human communities.
20.127. Improved entomological surveillance for
source reduction, strengthening and expanding
diagnostic services, strengthening case management
through standard guidelines, enhanced community
participation and inter-sectoral collaboration, enact
ment and enforcement of civic and building by-laws
would be encouraged. Anti-microbial resistance will
be closely monitored through effective surveillance,
and enforcement of guidelines on the sale and pre
scription of antibiotics.
31
20.128. There would also be a thrust on identified
geographic areas where the problems are most severe.
The strategies employed would be disease manage
ment including early case detection and prompt treat
ment, strengthening of referral services, integrated
vector management, use of Long Lasting Insecticidal
Nets (LLIN) and larvivorous fishes. Other interven
tions including behaviour change communication
will also be undertaken.
Prevention and Control of
Non-Communicable Diseases
20.129. For the escalating threat of NCDs like car
diovascular diseases, diabetes, cancers and chronic
respiratory diseases which are emerging as major kill
ers, a package of policy interventions would be taken
up. These include raising taxes on tobacco, enforcing
bans on tobacco consumption in electronic media,
counselling for quitting tobacco, early detection and
effective control of high blood pressure and diabetes,
screening for common and treatable cancers; and salt
reduction in processed foods (Table 20.7).
20.130. Care for the elderly would focus on promot
ing healthy lifestyles, encouraging care within fami
lies, linking strengths of Indian Systems of Medicine
with Modern Systems of Medicine in rejuvenation
therapies, and preferential attention in all public
facilities.
20.131. Problems relating to mental health, espe
cially in conflict zones would be managed with sensi
tivity at the community level, through better training
of community workers and primary care teams, and
through education of care givers.
Focus on Public Health
20.132. Insufficient focus on public health is a major
weakness of the system and must be urgently cor
rected. Effective public health management requires
a certain degree of expertise. There is an urgent real
need for a dedicated Public Health cadre (with sup
port teams comprising of epidemiologists, ento
mologists, public health nurses, inspectors and male
Multi-Purpose Workers) backed by appropriate
regulation at the state level. At present, only Tamil
Nadu has a dedicated public health cadre. In other
32
Twelfth Five Year Plan
TABLE 20.7
Interventions to Combat Non-Communicable Diseases (NCDs)
Non-Communicable Disease (NCD)
Interventions
1. Tobacco control
Raise taxes on tobacco
Clean indoor air legislation
Tobacco advertising ban
• Information and labelling
• Brief advice to help quit tobacco
• Counselling to quit
2. CVD prevention
Salt reduction in processed food via voluntary agreement with industry, and/or via legislation
Health education through mass media
Treatment for high Blood pressure, cholesterol and education
3. Diabetes and complications
Health education on diet and physical activity
Diabetes detection and management in primary health care
Intensive glycaemic control
Retinopathy screening and photocoagulation
Neuropathy screening and preventive foot care
4. Cancer
Screening for cervical, breast and oral cancer
Strengthening of cancer therapy in District Hospitals
5. Dental Caries
Education on oral health and hygiene; reducing dietary sugars; water fluoridation
6. General measures
•
•
•
Promote physical activity in schools and society
Restrict marketing of and access to food products high in salt, sugar or unhealthy fats
Targeted early detection and diagnosis using inexpensive technologies
Note: The list is illustrative only.
States, the erstwhile Public Health cadre has been
merged with the regular medical cadre. The choice
of having a separate Directorate of Public Health on
the lines of Tamil Nadu or incorporating it suitably
in the existing set-up will be left to the judgement of
States.
20.133. A centrally recruited, professionally trained
and constitutionally protected service on the lines of
All-India services would be the preferred model for
the Public Health Service. A second option would
be to have separate public health cadres at Centre
and States.
20.134. The Centre and States would develop good
quality training programmes for public health func
tionaries, including the suggested new cadre of pub
lic health officers.
20.135. Public health officials should be made
responsible for the health of all people residing
in their assigned areas or jurisdictions, including
migrants. Their responsibilities would, thus, not
be limited to only those who visit or use the health
facilities, but would require them to actively reach
out and impact health outcomes in their respec
tive catchment areas. An implication of such an
approach would be that all data generated in the
facility would be analysed in terms of the denomina
tor, that is, the total population at risk in the jurisdic
tion of that facility. Public health officials should also
be deployed in Municipal areas to assist the Urban
Local Bodies in maintaining public health.
20.136. The National Centre for Disease Control (for
merly National Institute of Communicable Diseases)
shall function as the apex public health institute for
providing surveillance, prevention and control of
all diseases of public health importance. The upgradation of NCDC covers physical infrastructure
including public health labs and additional trained
human resource. It is also proposed that NCDC
branches will be opened/strengthened in State Head
quarters to provide timely technical assistance to the
State health authorities in routine disease surveil
lance and in addressing epidemic-prone diseases.
Health
20.137. Even though the subject of Public Health falls
in the State list, a draft Model Public Health legislation
has been prepared by the MoHFW, which could serve
as a useful reference for States in framing their own
Public Health Acts. The experience of Tamil Nadu
in prevention of diseases and promotion of health
through a Public Health Cadre, and the regulatory
mechanism using Public Health Legislation deserve
emulation. Also required are systems to implement
those Acts, and mechanisms to motivate and involve
the community in ensuring that provisions are com
plied with. One aspect of community-based monitor
ing could be to conduct public health audits in States,
including in major cities and publicise the results to
help build public pressure to improve conditions and
bridge capacity gaps where needed. The indicators
for such audits could include faecal contamination of
water, vector density, food safety and safe disposal of
solid and liquid wastes.
20.138. While safety measures at the workplace
are necessary for the safety of workers and adjoin
ing residents, and must be enforced, the workplace
also presents an opportunity to introduce and prac
tice promotive behaviour, such as a healthy diet and
exercise. Ban on consumption of tobacco in public
places is a progressive legislation, but it needs effec
tive enforcement. Regular screening of workers for
occupational diseases should be introduced. The reg
ulations relating to workplace safety can be enforced
more effectively if there is greater coordination
between District health and labour authorities.
20.139. Institutions like schools, workplaces and
prisons provide opportunities for preventive health
check-ups, regular and group exercises, early detec
tion of disease and for dissemination of information
on lifestyle choices, yoga, exercise and healthy living.
Thus, regular health status and competency check
ups, including laboratory investigations, of children
in schools, employees in workplaces and prisoners
in jails would be done, with the Government health
machinery taking responsibility for public institu
tions. Age old principles of healthy living and pre
vention, including those documented in AYUSH
texts would be popularised during such health check
ups. Employees and workers will be informed of the
33
ill-effects of sedentary lifestyle, and encouraged to
increase physical activity.
20.140. Employees and their families, in large and
medium industries of the organised sector can also
form an excellent sentinel surveillance system, espe
cially for risk factors of NCDs, incidence of diseases
and health care costs as they are linked to organised
intra-mural health services or reimbursement sys
tems which maintain regular records. An ‘organised
sector’ surveillance system (such as one involving the
Indian Railways network and PSUs) can be estab
lished, at relatively low cost and also support work
site based programmes, health promotion and early
care seeking.
Behaviour Change Communication
20.141. The state of peoples’ health is dependent on
living habits that are partly determined by individual
behaviour choices. The existing campaigns urging
the avoidance of harmful behaviours such as use of
tobacco, alcohol and drugs, advocating the use of hel
mets and seat belts, valuing the girl child, shunning of
sex-selective abortions, adoption of the small family
norm would be further strengthened. Home-based
newborn care, exclusive and continued breastfeed
ing are time tested and proven strategies to promote
child health and survival, and need to be encouraged
on a priority basis. Mass media campaigns on mental
illness should be launched, to reduce the stigma, pro
mote early care seeking and encourage family mem
bers to be supportive and sensitive.
20.142. Electronic (including ‘new’ media) and
print media can play a critical role in informing and
empowering communities and individuals on issues
relating to health and quality of life. This includes
using mobile telephones, multimedia tools as well
as Community Radio Stations to achieve this objec
tive. While regulation of the media falls outside the
domain of the MoHFW, there is a need to encour
age the media to carry messages that make healthy
living popular, and to avoid the display of unhealthy
behaviour like smoking. Since there are several
media-dark areas where the NCD disease burden
is increasing, innovative state specific Behaviour
34
Twelfth Five Year Plan
Change Communication strategies would also be
required apart from electronic and print media.
20.143. The MoHFW would also champion meas
ures like legislation, regulation and fiscal measures
to reduce the exposure of citizens to health risks.
An existing agency of the MoHFW, Central Health
Education Bureau (CHEB), shall be assigned the
responsibility of undertaking and guiding Health
Promotion all over the country. In this task, it will
use the health promotion Portal for dissemination of
information. The CHEB shall involve multi-sectoral
actors, conduct health impact assessment and will be
developed as the Institute of Health Promotion.
20.144. Teaching self-care to patients and care givers
of chronic diseases not only empowers them to man
age their condition, but can also make a significant
difference to long term health outcomes. NGOs can
play a very active role in such campaigns, as the suc
cess of BRAG, Bangladesh in reducing infant mortal
ity by promoting use of Oral Rehydration Solution
has shown.
INSTRUMENTS FOR SERVICE DELIVERY
Effective Governance Structures
20.145. The broad and flexible governance struc
ture of the National Health Mission would be used
to seek willing participation of all sectoral agencies,
and civil society in identifying risks and planning
for their mitigation, and integrated delivery of qual
ity services. States would be advised to converge the
existing governance structures for social sector pro
grammes, such as drinking water and sanitation,
ICDS, AIDS control and NRHM at all levels, pool
financial and human resource under the leadership
of local PRI bodies and make multi-sectoral social
plans to collectively address the challenges.
20.146. The existing National Programme Coordina
tion Committee (NPCC) of NRHM will be expanded
to serve the National Health Mission. It will be made
more representative of all social sectors, sub-sectors
within the health sector, and include expertise on
monitoring and independent evaluation. All the four
Secretaries of the MoHFW will be on this commit
tee, which will be chaired by Secretary Health, and
can also serve as a forum for coordination within the
Ministry.
20.147. Gaps in the management capacity at the state
level need to be addressed. States will be encouraged
to set up efficiently functioning agencies/cells for
procurement and logistics, recruitment and place
ment of human resource, human resource manage
ment, design, construction and upkeep of health care
buildings, use of Information Technology, Finan
cial management, transport systems, standards set
ting and quality control, monitoring and evaluation
of process and outcomes. States shall be advised to
expand the roles and responsibilities of Medical
Officers in charge of public health facilities to cover
all determinants of health, with a focus on improving
national health outcome indicators. Their territorial
jurisdiction should be made co-terminus with the
developmental machinery, as Rural Development
Blocks.
20.148. States can empower facility managers with
more financial and hiring powers so that they can
take quick decisions on service related local issues.
The Rogi Kalyan Samiti model of facility autonomy
launched under NRHM would be expanded to ena
ble investment in facility upkeep and expansion, or
even filling temporary HR gaps. Enhanced auton
omy would have to be matched by greater account
ability for the management of the facility for timely
and quality care, and availability of essential drugs.
This will also need stringent regulation to ensure
that mismanagement of funds, drugs and equip
ments does not happen.
20.149. In order to promote sound FIR management
policies across the states, the Central Government
would design model management systems incorpo
rating improved methods for recruitment, retention
and performance, incentive-based structures, career
tracks for professional advancement based on com
petence. These guidelines could include strategies
suggested in Box 20.6.
Health
Accountability for Outcomes
20.150. In order to ensure that plans and pronounce
ments do not remain on paper, a system of account
ability shall be built at all levels, namely Central
Government reporting to the Parliament on items
which are its business, States reporting on service
delivery and system reforms commitments under
taken through the MoU system, district health soci
eties reporting to States, facility managers reporting
on health outcomes of those seeking care, and terri
torial health managers reporting on health outcomes
in their area. Accountability shall be matched with
authority and delegation; the MoHFW shall frame
model accountability guidelines which will suggest
a framework for accountability to the local com
munity, requirement for documentation of unit cost
of care, transparency in operations and sharing of
information with all stakeholders.
Health Delivery Systems
20.151. Trained and competent human capital is the
foundation of an effective health system. Without
adequate human resources, additional expenditure
on health will not lead to additional services and will
only bid up wages. In this context it is important for
the Twelfth Plan to embark on a clear strategy to
expand the supply of appropriately trained health
workers to support health care objectives being
targeted.
35
20.152. Effectively functioning health systems
depend on human resource, which range from medi
cal, AYUSH and dental graduates and specialists,
graduate and auxiliary nurses, pharmacists to other
allied health professionals. The production of human
resource in health is a time consuming process, tak
ing as long as nine years for a specialist, to eighteen
months for an ANM. The current availability of
health personnel in the country (Table 20.8) is below
the minimum requirement of 250 per lakh of popu
lation {Human Resources for Health: Overcoming
the Crisis, 2004, Joint Learning Initiative, page 23).
Given the existing production capacity, we can
expect an availability of 354 health workers by 2017.
It is generally accepted that the doctor to nurse ratio
should be at least 1:3 for the team to perform opti
mally. This ratio is currently 1:1.6 and is expected to
improve to 1:2.4 by end of Twelfth Plan if no new
colleges are started. These numbers regarding total
availability mask the fact that there is substantial
regional variation in the distribution of doctors and
nurses, because of which we should plan for a total
availability which is significantly higher than the rec
ommended minimum. The basic data on the avail
ability and rate of new additions is summarised in
Table 20.8.
20.153. We need to take up a large scale expansion
in teaching capacity in this plan so the situation
improves towards the end of this plan, and reaches
Box 20.6
Suggested Items in Model HR Guidelines
• Quality standards for facilities should be taken as guiding principle for sanctioning posts, which would indicate the
maximum staff that can be posted. In case a facility does not attract expected case-loads, the staff may be rationalised.
• Recruitment should be decentralised with a quicker turnaround time and preference must be given to residents of the
region of proposed deployment.
• Fair and transparent system of postings and timely promotions.
• Financial and non-financial incentives (like preferential eligibility for post graduate courses, promotions, subsequent
choice of postings, reimbursement of children’s school fee) would be suggested to States for adoption, for performance
and service in remote areas.
• Measures to reduce professional isolation by preferential access to continuing medical education and skill up-gradalion
programmes, as well as back-up support on tele-medicine (Internet or mobile based) and by networking of professionals
working in similar circumstances.
• Measures to reduce social isolation by investing in processes that bring community and providers closer together.
• Completion of training of ASHAs and retraining of the existing cadre of workers as Male Multi-Purpose Workers, AWW
and ANMs, to make them relevant to local needs, and for their own upward mobility.
36
Twelfth Five Year Plan
optimal levels by the end of Thirteenth Plan. If we
adopt a goal of 500 health workers per lakh popula
tion by the end of Thirteenth Plan, we would need
an additional 240 medical colleges, 500 General
Nursing and Midwifery (GNM)/nursing colleges
and 970 ANMs training institutes. If work on these
new teaching institutions begins from the 2013-14
annual plan, and is completed by the end of the
Twelfth Plan, the flow of nurses and ANMs would
begin within this plan, while doctors from these
institutions would be available only from the begin
ning of the Thirteenth Plan. The ratio of doctors to
nurses will then rise from 1:1.6 in 2012 to 1:2.8 in
2017 and reach 1:3 in 2022.
20.154. The projected availability of HR in health
during the Twelfth Plan is given in Figure 20.4.
A density of 398 workers per lakh would be well
achieved by 2017, and 509 by 2021.
Expansion of Teaching Facilities
20.155. The Government shall take the lead role in
creating teaching capacity in health, while private
sector colleges would also be allowed. Initiatives
would be taken to upgrade existing District hospi
tals and CHCs into knowledge centres, where medi
cal, nursing and para-medical teaching and refresher
courses can be held side-by-side with patient care.
States shall be encouraged to take this up through the
incentive fund of the NHM. The existing state level
teaching institutions such as the State Institutes of
Health and Family Welfare would also be strength
ened. Simultaneously, the existing Government
medical colleges and central Government institu
tions would be strengthened so that the seats could
be increased to the maximum level of 250. Efforts
to support the existing institutions to create more
Post-graduate seats would continue. The long term
goal would be to build at least one training centre in
TABLE 20.8
Availability of HR during Eleventh Plan and Projections for Twelfth Plan
Category
Enrolled and Available
Annual
Capacity
(2011-12)
Expected Availability
by 2017
Desirable
Density
Colleges
Required
Available
if Colleges
Created
Enrolled
Available
Density
Nos.
Total
Density
2017
2021
Physicians
9,22,177
6,91,633
57
42,570
8,48,616
65
11,11,554
85
240
67
85
AYUSH
7,12,121
5,34,091
44
30,000
6,42,386
49
6,40,778
49
0
51
54
Dentists
1,17,827
88,370
7
24,410
1,93,797
15
1,96,157
15
0
16
21
Nurses/
GNM
12,38,874
7,43,324
61
1,78,339
15,08,684
115
22,23,107
170
500
129
170
ANM
6,03,131
3,61,879
30
38,290
5,16,090
39
11,11,554
85
970
60
85
Pharmacist
6,57,230
4,92,923
41
1,00,000
9,18,276
70
9,15,397
70
0
'76;
95
Total
241
354
474
398
509
Nurse/
ANM:
Doctor
Ratio
1.6
2.4
3.0
2.8
3.0
Notes: Density: Per Lakh Population
Current availability based on attrition @ 25 per cent (Physicians, AYUSH, Pharmacists and Dentists), 40 per cent for Nurses and
ANM.
Except for New ANM schools all other colleges will be phased as follows: 50 per cent by 2013, 40 per cent by 2014 and 10 per cent by
2015. ANM schools will be phased as follows 50 per cent by 2014 and 50 per cent by 2015.
New colleges have been assumed to have a capacity of 250 (physicians), 100 (AYUSH, Dentist, Nurses/GN, Pharmacist) and 80
(ANM, bi-annual batch of 40).
Health
c 30.0 —
23.9
-2 25.0 —
5
18.9
25.5
26.9
-W- Doctor
Nurse/ANM
AYUSH
Dentist
Pharmacist
20.6
20.0 —
| 15.0 --
13.4
10.5
15.2
-1T8-
9.1
10.0 -
5.3
5.9
4.5
ZS.0.9
4.6
ZS.U)
4.8
^1.2
2012
2013
2014
-!2bci—
L' 5.0 —
c
5 o.o 4-
2010
r IT
ZM).7
2011
8.6
9.0
9.5
9.9
5J
2^1.7
^1.9
5.3
^2.0
5.4
^2.1
5.5
^2.2
2018
2019
6.5
5.0
^■1.5
2015
5.1
Z^.1.6
2016 2017
Year
2020
37
2021
2022
2023
FIGURE 20.4: Projected HRH Capacity Expansion in the Twelfth Plan
each District, and one para-medical training centre
in each sub-division/block.
20.156. District hospitals which cannot be converted
to teaching institutions, can be accredited with the
National Board of Examinations for training PostGraduate candidates in the Diplomate of National
Board (DNB) programme, in courses such as Family
Medicine. This is a low cost measure which will help
increase production of specialists, bring profession
alism and also help improve standards of patient
care in district hospitals.
20.157. Centres of Excellence for Nursing and Allied
Health Sciences also need to be established in every
State. These Centres would impart higher education
in specialised fields, offer continued professional,
education and have provisions for faculty develop
ment and research. Centres for paramedical educa
tion would to be set up in 149 Government medical
colleges, in addition to initiating paramedical institu
tions in 26 States. Initiatives already taken to upgrade
and strengthen the existing Nursing Schools into
Colleges of Nursing would continue. Establishment
of ANM/GNM schools in under-served areas would
also be accorded priority. A road-map would be pre
pared for strengthening of pre-service, mid-wifery
training and career development.
20.158. In the Pharmacy sector, strengthening and
up-gradation of Pharmacy Colleges and setting up of
Colleges of pharmacy attached to Government med
ical colleges would be initiated, wherever possible.
20.159. There are other categories of skilled health
workers, such as Physician assistants, who increase
the productivity of the medical team, and should
be encouraged. In the context of hospitals, a sur
vey by FICCI in June 2011 has identified five
skill-sets that need immediate attention, namely
Dialysis Technician, Operation Theatre/Anaesthesia
Technician, Paramedic, Lab Technician, Patient
Care Coordinator cum Medical Transcriptionist.
The profession of midwifery will be revived, and pro
vided training and legal authority to serve as autono
mous medical practitioners for primary maternity
care, such as in the Netherlands, so that skilled birth
attendance is universalised. The proposed District
knowledge Centres would create sufficient teaching
capacity for such newer categories of health workers.
20.160. A peculiar feature of India’s healthcare sys
tem is the presence of a large number of non-qualified practitioners, such as traditional birth attendants
(dais), compounders and RMPs. As per law, they are
neither authorised to practice Medicine, nor to pre
scribe drugs. Nonetheless, they work everywhere in
the country and address a huge unfulfilled demand
for ambulatory care, particularly in rural areas. The
challenge is to get them into the formal system.
The plan recommends giving these practitioners,
depending on their qualifications and experience,
an opportunity to get trained and integrate them
into the health work-force in suitable capacities by
mutual consent.
20.161. Another opportunity lies in utilising the ser
vices of AYUSH graduates for providing primary
38
Twelfth Five Year Plan
care. There are two pre-requisites before this can
be done—first by amendment of the legal frame
work to authorise the practice of modern medicine
for primary care by practitioners of Indian Systems
of Medicine; and secondly by supplementing skills
of AYUSH graduates by imparting training in mod
ern Medicine through bridge courses. High profes
sional standards of eligibility for, and qualifying in
the bridge courses should be laid down so that the
quality of such primary care integrated physicians
remains high. States like Tamil Nadu and recently
Maharashtra have shown the lead in this regard.
Associations of allopathic practitioners are gener
ally opposed to AYUSH practitioners being allowed
to prescribe allopathic medicines; they will have to
be persuaded to yield in the national interest of serv
ing the masses, particularly the rural population and
the urban poor. Suitably trained, AYUSH graduates
can provide primary health care, and help fill in the
human resource gaps in rural areas.
20.162. The NHM will encourage the States to modify
the designation and job profiles of human resource
created under various central and externally funded
programmes into generic, multi-functional categories
whose services can be used as per local need.
Community Participation and PRI Involvement
20.163. Government health facilities at the level
of blocks and below can become more responsive
to population needs if funds are devolved to the
Panchayati Raj Institutions (Village Council or its
equivalent in the Scheduled Areas), and these institu
tions made responsible for improving public health
outcomes in their area. States should formalise the
roles and authority of Local Self-Government bod
ies in securing convergence so that these bodies
become stakeholders for sustainable improvements
in health standards. The States would be advised
to make Village Health, Sanitation and Nutrition
Committees as the guiding and operational arms of
the Panchayats in advancing the social agenda.
20.164. Health Action Plan for service delivery, sys
tems management and prevention would be formu
lated through effective public participation to ensure
relevance to local needs and to enable enhanced
accountability and public oversight.
20.165. Greater efforts at community involvement
in planning, delivery, monitoring and evaluation
of health services would be made using established
strategies from NRHM like community based moni
toring, citizens’ charters, patients’ rights, social
audits, public hearings and grievance redressal
mechanisms. Newly elected members of PRIs, espe
cially women members, need support as they grow
into their new roles. NGOs have an important role
in strengthening capacity. An integrated curriculum
will be drawn up to facilitate this process. NGOs can
play a key role in providing support to VHSNCs and
PRIs in capacity building, planning for convergent
service delivery and more effective community based
monitoring. Recognition and instituting awards for
achievers along the lines of Nirmal Gram Puraskar
under the Total Sanitation Campaign will be one
way of incentivisation.
Strengthening Health Systems
20.166. A major objective of enhanced funding,
flexibility to and incentivisation of States is to build
health systems. Some of the components of health
systems strengthening for which States shall be
encouraged are listed in Table 20.9.
NATIONAL AIDS CONTROL
ORGANISATION
20.167. The programme strategy would be two
pronged: intensification of interventions for high
risk groups and bridge populations, and integration
of prevention (including mother to child transmis
sion), testing, counselling and treatment services
among the general population, including pregnant
women, with the routine ROH programme. To
achieve mainstreaming of services, the State AIDS
Control Societies and District AIDS Prevention
and Control Unit (DAPCU) will be linked with the
National Health Mission structure at these levels.
To build a multi-dimensional reporting system, the
information systems on health systems, and AIDS
control shall be synergised.
Health
39
TABLE 20.9
Illustrative List of Health Systems Strengthening in States
Health System
Elements
Suggested Health System Strengthening Activities by States
1. Effective
Public Health
Administration
Enact and Enforce Public Health Act
Put in place a Public Health cadre, whose members shall be responsible for detecting public health problems
within their jurisdiction, framing strategy for its correction and implementing it
Develop and deploy a Health Management Cadre, for providing management support to public health
programmes and hospital administration
Mandatory practice of Clinical Treatment Guidelines and prescription of generic medicines listed in the
National List of Essential Medicines in all Government facilities
Mandatory test audit of medical prescriptions by faculty of medical colleges
Improve governance through stronger oversight mechanisms that include citizen participation, social audit
and greater transparency
Develop an effective and responsive grievance redress system
Frame policies for, and provide services so as to achieve the goals of the National Population Policy (2000).
2. Health Financing
Increased expenditure on Health Sector
Prioritise strengthening of Primary Health Care in state budgets
3. Health Regulation
Extend and enforce Central Clinical Establishment Act
Empower Public Health functionaries under relevant laws namely Pre-conception and Pre-natal Diagnostic
Techniques Act, Food Safety Standard Act, and Drugs and Cosmetics Acts
4. Develop Human
Resource for
Health
Develop District Hospitals and Community Health Centres (CHCs) into Medical and para-medical
training institutions with improved quality of training
Organise bridge Courses for AYUSH graduates and legally empower them to practice as Primary Health
care physicians
Encourage career progression of ASHA and AWW into ANM, and assure career tracks for competency
based professional advancement of nurses
5. Health
Information
Systems
Build a Health Information System by networking of all health service providers, establishing state level
disease surveillance systems, universal registration of births and deaths to give accurate picture of health of
the population
6. Convergence and
Stewardship
Assess Health impact of policies and activities of departments other than health
Main-streaming of AYUSH into NHM
Main-streaming of STI and HIV prevention and treatment up to district levels into NHM
Main-streaming of all disease control programmes into NHM
Empower Panchayats with funds, functions and functionaries to play a meaningful role in bringing
convergence in the social sector
Achieve inter-sectoral coordination at Block, District and State levels by using the mission structure of NHM
Create and support systems for grievance redressal
Synergise the working of ASHA and AWW by declaring AWC as the convergence station for all village
level NHM and ICDS personnel, and Sub-centre as the HQ of ICDS supervisors
Ensure that only double fortified salt (Iron-Iodine) is used in ICDS Scheme, Mid-Day Meal and sold
through Public Distribution System
7. Health Services
Master plan for ensuring each district is able to provide assured set of services to all its residents
Road-map for achieving Indian Public Health Standards at all facilities
Public health care facilities are provided financial and administrative autonomy
Develop an effective grievance redress system
8. Ensure access
to Medicines,
Vaccines and
Diagnostics
Create a Special Purpose Vehicle to procure, store and distribute medicines, vaccines and diagnostics
through an open, tender based procurement
Mandate availability of drugs under the National List of Essential Medicines in all health facilities
Strengthen state level drug regulation
Ensure Jan Aushadhi stores in all Block Headquarters
40 Twelfth Five Year Plan
20.168. The primary goal of NACP during Twelfth
Plan will be to accelerate the process of reversal
and further strengthen the epidemic response in
India through a well-defined, integration process.
The programme will be further strengthened and
programme management capacities decentralised
to state and district levels. NAGP-IV will remain a
prevention oriented plan with adequate coverage
of HIV care in the context of the concentrated epi
demic situation in India. NACP will synergise with
other national programmes and align with the over
all Twelfth Five Year Plan goals of inclusive growth
and development. The key priorities of NACP-IV
will be as follows:
• Preventing new infections by sustaining the reach
of current interventions and effectively addressing
emerging epidemics.
• Preventing Patent-to-Child Transmission
• Focusing on IEC strategies for behaviour change,
demand-generation for HIV services among those
at risk and awareness among general population
• Providing comprehensive care, support and treat
ment to people with infection
• Reducing stigma and discrimination through
greater involvement of HIV affected persons
• Ensuring effective use of strategic information at
all levels
. Building capacities of NGO and civil society part
ners, especially in states of emerging epidemics
• Integrating HIV services with the health system in
a phased manner
• Mainstreaming H1V/AIDS activities with all
key central and state level Ministries/departments and leveraging resources of the respective
departments
• Leveraging social protection and insurance
mechanisms
STRATEGIES FOR NACP-IV
1. Intensifying and consolidating prevention ser
vices with a focus on (/) high-risk groups and vul
nerable population and (i/) general population;
2. Expanding IEC services for (/) general popula
tion and (//) high-risk groups with a focus on
behaviour change and demand generation;
Increasing access and promoting comprehensive
care, support and treatment;
4. Building capacities at national stage, district and
facility levels and
5. Strengthening Strategic Information Manage
ment Systems
3.
INDIAN SYSTEMS OF MEDICINE AND
HOMOEOPATHY SERVICES (AYUSH)
20.169. Practice and promotion of AYUSH in the
States would be carried out under the broad umbrella
of the National Health Mission. A revamped
National Programme Coordination Committee of
the National Health Mission with Secretaries of all
the departments under the MoHFW, and chaired
by Secretary Health, would provide the funding and
programme guidance for convergence and main
streaming of AYUSH in the health care system.
20.170. States would be encouraged to integrate
AYUSH facilities, and provide AYUSH services in
all facilities offering treatment in modern systems of
medicine. The goal is to ensure that all Government
health care facilities offer suitable AYUSH services as
per laid down standards.
20.171. In addition, the concept of AYUSH Gram
will be promoted, wherein one village per block will
be selected for implementation of integrated primary
care protocols of AYUSH and modern system of
medicine. In these villages, herbal medicinal gardens
will be supported, regular Yoga camps will be organ
ised, preferably through PRI institutions and youth
clubs, and the community provided basic knowledge
on hygiene, promotion of health and prevention of
diseases.
STRENGTHENING AYUSH
20.172. The strengths of Indian Systems of Medicine
and Homoeopathy, if suitably used, can help advance
the goals of the Twelfth Plan. AYUSH systems would
be main-streamed using their areas of strengths
namely in preventive and promotive health care, dis
eases and health conditions relating to women and
children, older persons, NCDs, mental ailments,
stress management, palliative care, rehabilitation
and health promotion.
Health
20.173. Every element of health system strengthen
ing and development, particularly use of IT, is equally
applicable to AYUSH systems and institutional
capacity development and would be pursued. What
follows are additional measures and institutional
capacity development tailored to unique opportuni
ties and requirements of AYUSH systems.
RESEARCH
20.174. The National Health Policy of 2002 set an
objective, which involved a re-orientation and pri
oritisation of research to validate AYUSH therapies
and drugs that address chronic and life style-related
emerging diseases. Cross-disciplinary research and
practice requires standardisation of terminologies
of classical therapies, and development of Standard
and Integrated Treatment Protocols. These would be
developed based on core competencies and inherent
strengths of each system, and comparative efficacy
studies. National Health Programmes shall use such
composite protocols.
20.175. To take this ambitious research agenda for
ward, all five Research Councils of AYUSH will pool
resources, particularly human resource, clinical facil
ities and information, to avoid duplication. For this
to happen on an institutionalised basis, a common
governance structure for the five Research Councils
would be put in place.
20.176. The documentation of traditional knowl
edge associated with medicinal plants is very impor
tant not only to preserve it for posterity but also to
contest bio-piracy and bio-prospecting. This will be
continued.
HUMAN RESOURCES DEVELOPMENT
20.177. Cross-disciplinary learning between modern
and AYUSH systems at the post-graduate level would
be encouraged. Details of modification in syllabi that
would be required at the undergraduate level, in
order to make such cross-disciplinary learning pos
sible, would be worked out by a team of experts from
the different Professional Councils. Collaboration
between AYUSH teaching colleges and with medical
colleges for mutual learning would be encouraged.
AYUSH Chairs in Medical Colleges of the coun
try would be encouraged to provide the necessary
41
technical expertise to jointly take up research, teach
ing and patient care. Orientation of medical students
and doctors about basic concepts, applications and
scientific developments of AYUSH in order to dispel
ignorance and foster cross-system referral would be
encouraged. Relevant AYUSH modules would there
fore be incorporated into medical, nursing and phar
macy course curricula and in the CME programme
for medical practitioners.
PRACTICE AND PROMOTION OF AYUSH
20.178. The Department of AYUSH would develop
standards for facilities at the primary, secondary and
tertiary levels as a part of IPHS; Standard Treatment
Guidelines and a Model Drugs List of AYUSH drugs
for community health workers will be developed.
All primary, secondary and tertiary care institutions
under the MoHFW, State Health Departments and
other Ministries like Railways, Labour, Home Affairs
and so on, would create facilities to provide AYUSH
services of appropriate standards.
20.179. As longevity increases, geriatrics as a disci
pline would need greater attention. AYUSH therapies
have strengths in restoration and rejuvenation. To
bring together the best of care for the elderly that
AYUSH systems have to offer, and to develop it fur
ther using modern scientific methods, a National
Institute on Geriatrics (through AYUSH) will be
set up.
20.180. In view of the growing incidence of meta
bolic and lifestyle diseases like diabetes and hyper
tension and considering the strengths of AYUSH
systems in their prevention and treatment, a National
Institute on Metabolic and Lifestyle Diseases will be
established.
20.181. In view of the growing problem of drug
abuse, and increase in use of tobacco, and the poten
tial of AYUSH therapies and practices, particularly
of Yoga, for disease prevention and health promo
tion, a National Institute for Drug and Tobacco
De-addiction will be established. Each of the three
national institutes would be equipped with post
graduate education and research facilities and house
advanced hospital facilities in all disciplines of
42 Twelfth Five Year Plan
medicine. These institutes would conduct and pro
mote interdisciplinary research in their area, advance
frontiers of knowledge on prevention and condition
management, teach and promote evidence-based use
of AYUSH systems, and are expected to emerge over
time as global centres of research, care and education.
Regulation and Quality Control
20.182. Systems for quality certification of raw mate
rials, accreditation of educational programmes,
health services and manufacturing units and prod
ucts would be promoted in the Twelfth Plan. This
would achieve both minimum standards through
regulations and laws, as well as, excellence through
a voluntary scheme of accreditation. The existing
practice of a common legislation, and regulatory sys
tems for AYUSH and modern medicines would be
further strengthened, with mandated representation
of AYUSH experts at all levels. Modernisation of
pharmaceutical technology, in order to standardise
the use of natural resources and production pro
cesses that are used by AYUSH, will be taken up as a
priority in the Twelfth Plan period.
3. Low child sex ratio and discrimination against
the girl child;
4. Prevention, early detection, treatment, reha
bilitation to reduce burden of diseases—
communicable, non-communicable (including
mental illnesses) and injuries (especially road
traffic related), congenital malformation and
disorders of sex development;
5. Sustainable health financing aimed at reducing
household’s out-of-pocket expenditure;
6. HIS covering universal vital registration, com
munity based monitoring, disease surveillance
and hospital based information systems for pre
vention, treatment and teaching;
7. Measures to address social determinants of
health and inequity, particularly among margin
alised populations;
8. Suggest and regularly update Standard Treat
ment Guidelines which are both necessary and
cost-effective for wider adoption;
9. Public Health systems and their strengthening;
and
10. Health regulation, particularly on ethical issues
in research.
HEALTH RESEARCH
20.183. Given the lag in progress on health indica
tors in the country, need for accelerated progress
and optimal use of limited resources, DHR should
strategically move in a direction which brings forth
actionable evidence in a time bound manner for
quick translation to address national health needs. In
setting its priority areas, DHR would be guided by
the disease profile in the country, burden of disease,
and the possibility of cost-effective intervention.
20.184. The strategy for health research in the
Twelfth Plan would be the following:
20.185. Address national health priorities-. The key
outcome of the efforts of DHR would be to generate
intellectual capital, which may have a public health
impact. DHR would, therefore, prioritise its research
to find cost-effective solutions for health priorities
and health system issues facing the country, namely:
1. Maternal and child nutrition, health and survival;
2. High fertility in parts of the country;
20.186. Existing institutes of ICMR will be re-organ
ised, strengthened and new centres set up in deficit
areas to achieve the above listed goals.
20.187. Build Research Coordination Framework:
Though DHR is the empowered Department on
medical and health research, many organisations are
engaged in research on related topics, namely the
Ministry of Environment and Forest, Departments
of Health and Family Welfare, AYUSH, AIDS con
trol, Space, Science and Technology, Biotechnology,
Agricultural Research; agencies like ICAR, DSIR,
CSIR, NDMA, DRDO and the National Knowledge
Network. DHR would play a lead role in research
involving human health, bringing all the concerned
organisations on one platform to facilitate mutual
discussion, resource pooling and prioritisation, and
avoid duplication, to find innovative solutions to
national priorities in a timely manner. It would also
take the lead in suggesting institutional structures,
like mutual representation in each others’ decision
making and scientific bodies, and 'coordinating
Health
structures’ so that consultation and collaboration
become a norm rather than an exception. Efficient
mechanisms for selection, promotion, development,
assessment and evaluation of affordable technologies
would be established. DHR would bring together
basic, translational and clinical investigators, net
works, professional societies and industry to facilitate
development of programmes and research projects.
DHR would establish a mechanism for coordination
between academia and the industry, with a prefer
ence for multidisciplinary approaches.
20.188. To address the need for operations research
on impediments in delivery of services, DHR will
explore the possibility of stationing multi-disciplinary
research teams within the NHM structure at differ
ent levels, so that practical, relevant and area specific
solutions to problems are suggested to programme
managers. To address the gaps in critical areas such
as Health Information Systems, National Health
Accounts and Public Health delivery DHR will dedi
cate national centres to these needs, and position
specialised teams alongside operational managers.
20.189. Autonomy coupled with accountability in
research: The elements of an efficient research system
are clear enunciation of goals, sufficient resources
with flexibility to raise extra-budgetary funds, func
tional autonomy, accountability and incentives for
performance. DHR would work to observe these
principles in its research institutes so that each one
of them develops into a centre of excellence in its
allotted field.
20.190. Efficient research governance, regulatory and
evaluation framework: DHR would also put in place
appropriate regulations, guidelines, authorities and
structures to strengthen ethics-based research gov
ernance and to protect the interests of research sub
jects especially, in clinical trials. DHR would prepare
guidelines on, among others, Stem Cell Research and
Therapy, Assisted Reproductive Technologies incor
porating rights of egg donors; Ethical Guidelines
for Biomedical Research involving human sub
jects, Ethical Guidelines for Conducting Research
on Mental Illness or Cognitive Impairment,
Compensation to Participants for Research Related
43
Injury in India and Bio-banking. DHR would also
develop mechanisms to evaluate health research
undertaken by various scientific departments includ
ing ICMR. DHR would put in place mechanisms for
benchmarking and accreditation of health research
institutions. The criteria for accreditation of research
institutes would be based on the intellectual capital
generated and its public health impact.
20.191. Nurture development of research centres and
labs: In addition to the development of centres in
deficit and strategic areas, DHR would identify and
fund the development of existing medical colleges
and research centres into specialised subject areas,
which may become capable of conducting cross
cutting, multidisciplinary and translational resear
ches. Similarly, DHR would fund up-gradations of
existing Government labs to increase the capacity
for diagnosis of viral and other infectious diseases at
the national, regional and District levels. A national
list of diagnostic facilities shall be centrally main
tained to help guide decisions on creation of and up
gradation of laboratory facilities. DHR would also
build capacity of States and other institutions on
the periphery for solving various clinical and public
health problems.
20.192. Utilise available research capacity by promot
ing extra-mural research: Extramural programmes,
under which grants are competitively awarded on
selected topics, would be expanded to help tap tal
ent in medical colleges, tertiary hospitals, health uni
versities and public health institutions. DHR would
aim to increase the share of extramural funding in
its research budget from the current 33 per cent to
50 per cent by the end of Twelfth Plan. It may also
commission ‘problem-solving research’, following
the Open Source Drug Discovery model of CSIR,
but would need to subject it to strict scrutiny for out
comes. Translational Research would be promoted
so that research findings can be translated into better
health status in the country.
20.193. Human Resource Development: Investments
would be made in producing qualified research
ers, by improving career opportunities for young
researchers and providing good initial support in
44
Twelfth Five Year Plan
the form of start-up grants. Additionally, fellowships
for training researchers in identified advanced fields,
scholarships at the PG level, Young Researcher Pro
grammes to encourage young students, mid-career
research fellowships for faculty development at
medical colleges are some ways to ensure a steady
flow of committed researchers. DHR will explore, in
consultation with concerned regulatory authorities,
the possibility of introducing a stream of research
professionals in medical colleges who would have
avenues for professional advancement equal to those
of teaching faculty. DHR will utilise the potential
of Information Technology to standardise research
methodology courses, and train students in academic
institutions through distance learning.
20.194. Cost-effectiveness studies to frame Clinical
Treatment Guidelines: On the lines of the UK’s
National Institute of Clinical Excellence (NICE),
DHR would develop expertise to assess available
therapies and technologies for their cost-effectiveness
and essentiality, and formulate and update, on a
regular basis, the Standard Treatment Guidelines,
and suggest inclusion of new drugs and vaccines
into the public health system. The formulation of
the Guidelines must, of course, incorporate the best
available evidence, including in AYUSEI systems,
and prevalence of anti-microbial drug-resistance in
order to suggest treatment protocols for regular clin
ical practice. Standard Treatment Guidelines devel
oped by Army Medical Corps can also be referred to.
The justification for housing the proposed institute
outside the Department of Health, but within the
Ministry, is to provide it an element of objectivity
and independence from practitioners, and to avoid
conflict of interest.
CONVERGENCE ACROSS SECTORS FOR
BETTER OUTCOMES
20.195. The impact of policies and programmes of
non-health sectors on health remains invisible for
long periods. It is, therefore, necessary to take proac
tive steps to determine the health impact of existing
and new policies in sectors which have a bearing on
the health of population. The MoHFW would con
stitute a dedicated ‘Health Impact Cell’ to conduct
such an analysis, and its views would be taken into
consideration before framing or modifying poli
cies of non-health Ministries which can potentially
impact public health. The proposed ‘Health Impact
Cell’ in the MoHFW would also perform Monitoring
and Surveillance functions in order to continuously
gather information on health impacts of policies and
programmes of key non-health Departments. It can
harmonise the programme data obtained from the
sectors/non-health Ministries with the health impact
reports received from the field, such as on water and
sanitation related disease outbreaks, and determine
gaps in policies as well as in programme implemen
tation. Various sectors would share data, particu
larly those that are relevant to health outcomes, with
the proposed cell. The proposed cell would also be
equipped to serve early warnings and coordinate
responses to health related emergencies and natural
disasters.
CONVERGENT ACTION ON NUTRITION
20.196. The Ministry of health would build institu
tional arrangements with the Ministry of Women
and Child development so that convergent deliv
ery of services under ICDS becomes the norm. A
national policy on promoting healthy diets, and
regulating extent of salts, and trans fats in foods is
required. Double fortification of salt with iron and
iodine presents a cost-effective and feasible strat
egy to prevent two of the key nutritional deficien
cies in our country. While the Food and Nutrition
Board under the Ministry of Women and Child
Development is expected to take the lead, all health
workers would be sensitised so that they are able to
disseminate knowledge on nutrition and healthy
living.
ANGANWADI CENTRE AS THE CONVERGENCE
HUB
20.197. Nutritional issues call for multi-stakeholder
strategies, including informing communities on how
to maximise nutritional benefits from locally avail
able foods, food fortification and micro-nutrient
supplementation. States shall be encouraged through
the sector-wide MoUs to observe Village Health
and Nutrition Days in complete convergence mode
(Box 20.7) and ensure that Anganwadi Centres
become the hub for all health related services.
Health
45
Box 20.7
Convergence: Village Health and Nutrition Day in North Tripura
The Village Health and Nutrition Day (VHND) organised in North Tripura district in a complete convergence mode secured
it the Prime Minister’s award for excellence in Public administration for 2010-11.
A monthly VHND is to be organised in every village through inter-sectoral convergence and community involvement with
the Anganwadi Centre as the hub for service provision. It is an effective platform for providing first-contact primary health
care. The Village Health, Sanitation and Nutrition Committees are expected to be the organiser with participation of ASHA,
ANM, AWW and the PRI representatives.
As per NRHM guidelines, the services to be provided on VHND include registration of all pregnant women, Ante-Natal
Checkup, Vitamin A administration and vaccination of all eligible children, weighing of children, plotting of weights on
cards and suitable management, administration of drugs to TB patients, provision of contraceptives (condoms and oral) to
all eligible couples as per their choice, supplementary nutrition to underweight children, community awareness generation,
identification of cases needing special attention.
Special and additional features in North Tripura were the following:
• Organisation of a health mela in a transparent and participative manner; extensive publicity through sign-boards and inperson contact for the event
• Pooling of funds from different departments, and clear delineation of roles
• Leadership role of headmasters of schools in training and health education
. Convergence of service providers of health, ICDS, rural development, panchayat, drinking water,, district disability
rehabilitation centre, education and adult literacy
• Additional services provided include disability certificates, wheel chairs to the disabled, medicines and water purification
tablets, doctor’s, consultation, testing of eye, denial and for HIV, Strong cultural orientation to the event by including local
songs, dances, drama, quizzes, sports events, healthy baby shows
• The mid-day meal and ICDS were served together; with a community meal
• Intense training of functionaries
• Effective monitoring, record keeping and display of data on web site
Outcomes: A quantum jump in detection of cases of various diseases and health problems, fewer deaths due to fever,, malaria,
diarrhoea, lowering of MMR and IMR while immunisation coverage improved, identification of malnourished children,
initiation of their treatment and periodical monitoring.
Lesson: Effectively organised VHSND can lead to awareness in the community on health issues, effective utilisation of services
on health, and its determinants.
MAIN-STREAMING DISASTER MANAGEMENT
20.198. The Ministry of Health shall in its policies
and programmes give due consideration to the ele
ments of disaster management, namely Mitigation,
Preparedness, Response and Recovery. At all stages
of disaster management, active engagement of local
communities shall be the ensured.
CONVERGENCE WITHIN DEPARTMENTS OF
MINISTRY OF HEALTH
20.199. Given the fact that many health condi
tions often co-exist and exacerbate each other with
poor nutritional status as the underlying factor.
therapies under different systems of medicine can
synergistically improve health status, and need for
evidence based decision making and practice, all
the four departments of health which are engaged
in their allocated domains can act synergistically
to address the key national health needs. A coor
dinated delivery of national programmes at the
grass-root level can increase outreach and help bet
ter manage programmes. Frontline health workers,
and Government health facilities for primary care
can be developed as single points of contact for all
local residents in meeting their entire range of health
care needs.
46
Twelfth Five Year Plan
CONCLUSION
20.200. The Twelfth Plan faces a colossal task of
putting in place a basic architecture for health secu
rity for the nation. It must build on what has been
achieved through the NRHM and expand it into a
comprehensive NHM. Since the primary responsi
bility for health care rests with the States, the strategy
needs to effectively incentivise State Governments to
do what is needed to improve the public health care
system while regulating the private health care sys
tem, so that together they can work towards address
ing the management of delivery of preventive,
promotive, curative and rehabilitatory health inter
ventions. This is not a task that can be completed
within one Plan period. It will certainly span two or
three Plan periods, to put the basic health infrastruc
ture in place.
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