Public Health System in India

The Ministry of Health and Family Welfare oversees the implementation of policies and programmes for health care around the country, within the framework set by the National Health Policy of 2002 and the priorities set in successive Five Year Plans. While the responsibility for the delivery of health care rests largely with the State Governments, the Government of India plays a role in setting policy and providing resources for the implementation of National Programmes.
The country has a well structured multi-tiered public health infrastructure, comprising District Hospitals, Community Health Centres, Primary Health Centres and Sub-Centres spread across rural and semi-urban areas and tertiary medical care providing multi-Speciality hospitals and medical colleges. Improvements in health indicators can be attributed, in part to this network of health infrastructure. However, the progress has been quite uneven across the regions with large scale inter-State variations. Despite the consistent effort in scaling up infrastructure and manpower, the rural and remote areas continue to be deficit in health facility and manpower. Conscious and vigorous efforts continue to be made during the current year to step up funding in the health sector and to increase spending in the public domain, at least to raise it to the level of 3 per cent of the GDP by 2012.
Despite substantial progress made on many fronts there are still areas of concern. Maternal and Infant Mortality are still unacceptably high in several areas, infectious disease continues to remain a threat to public health. Non-Communicable Diseases including cancers, cardiovascular disease, diabetes and mental illnesses affect sizeable numbers of our population. India does not as yet have an adequate number of all categories of health professionals, whether of doctors, specialist doctors, nurses, nurse practitioners, para-medics and health workers.
The National Health Policy (NHP) was formulated in 2002 to provide prophylactic (preventive) and curative health care services towards building a healthy nation. The NHP- 2002 aims to achieve an acceptable standard of good health amongst the general population of the country. This is sought to be done by increasing access to the decentralized public health system by establishing new infrastructure in deficient areas, and by upgrading the infrastructure in the existing areas and institutions. The challenge has been to provide the country more equitable access to health services across the social and geographical expanse of the country. Thus, keeping in line with this broad objective, several health programmes/ schemes have been launched from time to time. There has been a steady increase in the aggregate public health investment, in the country. The contribution of Central Government towards public investment for provision of health care services has also been enhanced over the years. Expenditure in Health Sector on Public Health is about 1% of the GDP.
National Rural Health Mission (NRHM)
The major thrust in the National Rural Health Mission (NRHM) has been towards achieving qualitative improvements in standards of public health and health care in the rural areas through strengthening of institutions, community participation, decentralization and creating a workforce of health workers viz. ASHAs. While the Mission was formally launched in 2005 and has taken a while to effectively find a firm footing, early indications reflect its positive impact. Reliable estimate based on surveys show an appreciable decline in infant mortality (50 per 1000 live births in 2009 as against 60 in 2003), decline in total Fertility Rate (from 3.0 children per women in 2003 to 2.6 in 2008) and improvement in the percentage of safe deliveries etc. (from 48.0 in 2004 to 52.7 in 2007-08).
A new initiative under NRHM has been taken to identify backward districts for ensuring differential financing. Based on health indicators 264 backward districts across the country have been identified for providing focused attention.
The Reproductive and Child Health (RCH) Programme is a key element of National Rural Health Mission(NRHM). The system strengthening being undertaken under the Mission has lent support to the Programme towards reducing MMR, IMR and TFR. Janani Suraksha Yojana (JSY) has resulted in a steep rise in demand for services in public health institutions with the institutional deliveries registering a substantial increase. The number of JSY beneficiaries has risen from 7.3 lakhs in 2005-06 to about 1 crore in 2009-10.
The National Rural Health Mission (NRHM) launched by the Prime Minister on 12th April 2005 throughout the country with special focus on 18 states, including eight Empowered Action Group (EAG) states, the North-Eastern states, Jammu & Kashmir and Himachal Pradesh seeks to provide accessible, affordable and quality health care services to rural population, especially the vulnerable sections. The NRHM operates as an omnibus broadband programme by integrating all vertical health programmes of the Departments of Health and Family Welfare including Reproductive & Child Health Programme and various diseases control Programmes.
The NRHM has emerged as a major financing and health sector reform strategy to strengthen States Health systems. The NRHM has been successful in putting in place largely voluntary community health workers in the programme, which has contributed in a major way to improved utilisation of health facilities and increased health awareness. NRHM has also contributed by increasing the human resources in the public health sector, by up-gradation of health facilities and their flexible financing, and by professionalization of health management. The current policy shift is towards addressing inequities, though a special focus on inaccessible and difficult areas and poor performing districts. This requires also improving the Health Management Information System, an expansion of NGO participation, a greater engagement with the private sector to harness their resources for public health goals, and a greater emphasis on the role of the public sector in the social protection for the poor.
The Reproductive and Child Health Programme (RCH), under the umbrella of NRHM, addresses the issue of reduction of Infant Mortality Rate, Maternal Mortality Ratio and Total Fertility Rate through a range of initiatives. The most important of these is the Janani Suraksha Yojana, which has led to a huge increase in institutional deliveries within just four years, the number of beneficiaries rising from 7.39 lakhs per year in 2005-06 to about 1 crore in 2009-10.
Massive training of ANMs (Auxiliary Nurse Midwife) and nurses for safe delivery and management of sick children have also helped in a major way. In parallel to these efforts the up gradation of health facilities to provide emergency obstetric care and to improve access to skilled birth attendants made a significant difference to health outcomes. It is proposed to further accelerate achievement of RCH goals by giving focus to 235 poor performing districts, differential financing based on the performance, and a thrust to improve quality of care through external certification of facilities for quality of care provided. In child health, the major strategies proposed are inter-sectoral interventions against child malnutrition, providing community level care for new born and sick children and strengthening facilities to provide institutional care for sick children. Emphasis on access to safe drinking water, sanitation and nutrition is also being underscored.
Disease Control Programmes have also shown considerable improvements. Polio is near elimination and diseases like Tuberculosis, Neonatal Tetanus, Measles and even HIV have shown decreasing trends. However, Malaria continues to be a challenge. A number of newly emerging diseases like H1N1 have made it essential for us to strengthen surveillance and epidemic response capacities. The crisis in unavailability of skilled human resources for the health sector has been addressed through the rapid expansion of medical education in the country. Under NRHM, the center has financed the addition of over one lakh skilled health care providers to the public health work force. But still much more needs to be done in this direction. In addition, we need to consider a model of Primary Health Care where many of the health services would be provided by the locally selected and adequately trained health care providers with medical doctors contributing largely to more specialised care. Likewise human resources are being augmented by relaxing several norms which were restricting the supply side. However, much more need to be done in addressing the issues related to availability and quality of human resources. Government is also considering the introduction of an undergraduate programme, to be taught in district hospitals, in Rural Health Care, to produce trained medical personnel for posting at Sub-centres, the lowest tier in the health delivery system.
It is proposed to set-up a National Council for Human Resources in Health, as an overarching regulatory body. The Task-force set up for this purpose has submitted its report which is being examined in consultation with the State Governments. The Union Health Budget has increased from Rs. 8000 crore in 2004-05 to over Rs. 21000 crore now. State Health expenditures have also shown higher growth rates in the NRHM period as compared to pre-NRHM period. The challenge now is to increase absorption of funds made available, improve efficiency in the use of these funds, while simultaneously securing greater allocation of funds to the health sector both at the Central and State level.



MAJOR ACHIEVEMENTS:
NATIONAL RURAL HEALTH MISSION
 Large number of medical and paramedical staff has been taken on contract to augment the human resources. During the year 2009-10, about 2475 MBBS doctors, 160 specialists, 7136 ANMs, 2847 staff nurses, 2368 AYUSH doctors and 2184 AYUSH paramedics were appointed.
 Mobile Medical Units increased to 363 districts in 2009-10 from 310 in 2008-09 to provide diagnostic and outpatient care closer to hamlets and villages in remote areas.
 About 50,000 Village Health and Sanitation Committees (VHSCs) set up.
 Under National Programme for Control of Blindness, number of cataract operation performed have registered a significant increase from about 22 lakh operations in 2007-08 to 59 Lakh cataract operations in 2009-10.
The Reproductive and Child Health Programme and National Disease Control Programmes are components of NRHM and their achievement is as under:
REPRODUCTIVE AND CHILD HEALTH
 Under Navjaat Shishu Suraksha Karyakram (NSSK-New born care programme) launched on 15th of September 2009, district level trainers have been developed for all the erstwhile EAG States and Jammu & Kashmir, while State level trainers have been developed in Non EAG States. 1400 trainers have already been trained.
 Under Janani Suraksha Yojana (JSY), a safe motherhood intervention for promoting institutional delivery, the number of beneficiaries increased from 7.39 lakh in 2005-06 to about 1 crore in 2009-10, registering an increase of 10 lakh during 2009-10.
 For the first time, Bivalent Polio Vaccine for 2 wild polio virus (P1 and P3) has been introduced in the immunisation programme in January 2010.
 To obtain accurate data from across the country, a system for name based tracking of pregnant women and children for Ante-Natal Care and immunisation is being put in place. The tracking system will also capture the contact numbers of the beneficiaries and the health providers. This will help national monitoring of the health status of each pregnant women and infants / children across the country. A help desk/call-centre is also being established to randomly cross-check the health services delivered to these mothers and children.
 For the first time, an Annual Health Survey has been launched to provide data on key health indicators like the Total Fertility Rate (TFR), Crude Birth and Death Rates, Infant Mortality Rate (IMR), etc. at the district level and Maternal Mortality Rate (MMR) at the regional level. The survey is being conducted in collaboration with the Registrar General of India and has been launched in the 284 districts of 9 States, namely, Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Uttar Pradesh, Uttarakhand, Orissa, Rajasthan and Assam. A proposal for estimation of anaemia, malnutrition, hypertension, diabetes, testing of iodine in salt used by households has also been approved.
COMMUNICABLE DISEASE CONTROL AND PREVENTION
 For the first time, under the National Vector Borne Disease Control Programme (NVBDCP), 2.23 million Long Lasting Insecticidal Nets (LLINs) distributed in 2009-10 in highly endemic malaria states, Orissa, Assam, West Bengal and Chhattisgarh.
 For the first time in the country, National Sample Survey to estimate burden of Leprosy is being taken up.
 DOTS-Plus programme for management of Multi Drug Resistant (MDR)-Tuberculosis (TB) was initiated in 4 more states bringing up the total to 10 States.
 Global Fund (GFATM) has granted an amount of US $ 100 million (approx.) for malaria control and an amount of US $ 200 million (approx.) for TB control.
 Up gradation of National Centre for Disease Control (NCDC) as Centre of Excellence of Public Health has been taken up During the year 2009-10, under the National Aids Control Programme, an additional 4 district level blood banks and 28 blood component separation units have been established and over 60,000 blood donation camps organised. The free Anti Retroviral Treatment (ART) programme scaled up to 269 centres, and 315,640 patients were receiving free ART as of March, 2010. Second line ART initiated in Centres of Excellence and more than 1100 patients enrolled.
 State of art Blood Banks are being set up in four Metropolitan cities of New Delhi, Kolkata, Mumbai and Chennai at an estimated cost of Rs. 468 crore.
 State of art Plasma Fractionation centre is being set up in Chennai at a cost of Rs. 250 crore to produce blood components currently being imported.
 To create awareness about AIDS, second phase of specifically designed exhibition train, red ribbon express was launched on 1st Dec. 2009 to cover 152 stations in 22 states during its 1 year journey.
Revival of vaccine manufacturing units in public sector:
Suspension of licences of the three public sector vaccine manufacturing units viz. Central Research Institute (CRI), Kasauli, Pasteur Institute of India, Coonoor and BCG Vaccine Laboratory, Guindy was revoked on 26.02.2010 enabling them to resume production in the larger public interest of vaccine security in the country. CRI, Kasauli has already started production of Diphtheria, Pertusis and Tetanus Toxide (DPT) vaccine from April 2010.
Controlling the H1N1 pandemic
 Over one crore passengers were screened at entry points at 22 international airports and sea ports.
 Facility for laboratory testing of clinical samples for H1N1 and other Influenza increased from 2 to 45.
 40 million capsules of Oseltamivir (anti viral drug) stockpiled of which 21 million have been given to the States/UTs both for preventive chemoprophylaxis and treatment of H1N1 cases. 1.5 million doses of vaccine have been imported and health care workers are being vaccinated across the country.
 Dedicated website: http://mohfw-h1n1.nic.in set up to keep entire information in the public domain for transparency.
NON-COMMUNICABLE DISEASE CONTROL AND PREVENTION
 To increase the availability of trained personnel required for mental health care, 7 regional institutes have been funded against the 11 to be undertaken during 11th Plan for production of clinical psychologists, psychiatrists, psychiatric nursing and psychiatric social workers.
 Further, support has been provided to 9 institutes for 19 PG departments during the year 2009-10 for manpower development. Under the Programme, an amount of Rs. 408 crore has been approved for manpower development and another Rs. 150 crore is under approval for the revised district mental health programme in the states.
 National Policies for Geriatric Care, cardio vascular & diabetes and cancer finalised for a total outlay of about Rs. 1519 crore.
MEDICAL EDUCATION
 To increase the number of doctors across the country and for opening more medical colleges, norms relating to requirement and land and infrastructure have been rationalised in order to attract more entrepreneurs, particularly in under-served and difficult areas.
 The norm of 25 acres of land for setting up a medical college has been relaxed to 20 acres throughout the country. Further relaxation has been granted to hilly areas, notified tribal areas, North Eastern States and some Union Territories where 20 acres of land can be in two pieces within a distance of 10 kms keeping in mind the terrain and non-availability of land in these areas. In major cities, the norm has been further relaxed to 10 acres.
 Infrastructure requirements for setting up new medical colleges have been rationalized and requirement of bed strength and patient occupancy has been relaxed.
 Companies registered in India have been permitted, for the first time, to set up medical colleges.
 To increase availability of doctors, ceiling for MBBS admissions has been raised in Government colleges from 150 to 250 depending on bed strength.
 To encourage Government medical officers and fresh MBBS graduates to serve in remote, difficult and inaccessible areas of the country, two major steps have been taken: (a) 50% of seats in postgraduate diploma courses reserved for government medical officers who have served in these areas for 3 consecutive years. (b) For fresh MBBS graduates wishing to be selected through the national entrance examinations for post-graduate courses, a weightage of 10% is given for each year of rural service, whether appointed on permanent, adhoc or contractual basis, subject to a ceiling of 30%.
 To overcome the acute shortage of faculty in medical colleges and specialists and super specialists in hospitals, Teacher-Student ratio has been relaxed from 1:1 to 1:2. As a result of this, 4000 additional Post Graduate seats have been created this year alone in Government Medical Colleges.
 To overcome shortage of faculty in medical Colleges at different levels, i.e., Assistant Professor, Associate Professor and Professor level, the requirement of number of years of service stipulated in the Medical Council of India (MCI) regulations in each of the three grades has been reduced by one year, i.e., from 4 years to 3 years.
 Similarly, in Central educational institutions like All India Institute of Medical Sciences (AIIMS), New Delhi, Post Graduate Institute of Medical Education and Research (PGI), Chandigarh, Jawaharlal Institute of Post-Graduate Medical Education & Research (JIPMER), Puducherry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore etc, to impart parity with Indian Institutes of Technology (IITs) in promotions, the Assessment Promotion Scheme has been suitably amended. Earlier, it took 15 years for an Assistant Professor to become Professor and as per the revised scheme, it would require only 10 years.
 To overcome the acute shortage of nurses and ANMs in states with poor health indicators, that have no ANM or GNM school, the Ministry of Health and Family Welfare is focusing on districts, for the first time, to provide training assistance to open 269 GNM and ANM colleges which will increase capacity by an additional 20,000 persons each year.
 Setting up of one national institute and 8 regional institutes of paramedical sciences across the country is under approval for an estimated cost of Rs. 1000 crore.
 To encourage entrepreneurs establish more AYUSH institutions the requirement of land, infrastructure and faculty for the establishment of AYUSH colleges and hospitals have been further rationalised, including reduction in land requirement from 10 acres to 5 acres.
PRADHAN MANTRI SWASTHYA SURAKSHA YOJANA
• For setting up of AIIMS like institutions, environmental clearance was obtained for hospitals and medical colleges to be set up at Bhubaneswar, Patna, Jodhpur, Rishikesh, Raipur and Bhopal sites in 2009. Hostel construction in all the places is at advance stage of completion.
• Works for Medical College Complex for all six sites have been awarded. Award of work for construction of hospital complex is under finalization and work likely to start by June, 2010 to be completed in two years.
• For completion of construction of college and hospital before the prescribed time, an incentive up to Rs. 12.5 Crore shall be payable to contractor. However, for delay beyond the prescribed time of up to 6 months, penalty up to Rs. 25 Crore shall be levied and for delay beyond six months, contractor shall be liable to be blacklisted for a specified period.
MEDICAL HEALTH RESEARCH
 For the first time, Influenza A Vaccine is being developed in the country.
 Seed Virus was obtained from WHO to take up indigenous manufacturing. Three indigenous manufacturers are being supported by the Ministry of Health and Family Welfare to manufacture pandemic H1N1 vaccine by providing Rs 10.00 crores to each as advance market commitment. The research has reached the last and final stage of human trials.
 For 2 patent items, (a) reagent for testing H1N1 influenza virus and (b) strip used in Glucometer for testing diabetes, the Department of Health Research is working on developing indigenous techniques.
 To strengthen public health measures, the Department of Health Research identified 53 technologies (Diagnostic, Management, Prevention and Public Health System) for evaluation for introducing them in the National Public Health Programmers.
 Diabetes prevalence and management survey approved in 8 states of North East and is being launched from June 2010.
 A Centre for Research in Indian Systems of Medicine (CRISM) has been set up at the University of Mississippi (USA) to facilitate scientific validation and dissemination of information on Ayurveda, Siddha and Unani Medicine through collaborative research and advocacy.
HOSPITALS
 Comprehensive Health Check up card was introduced in current session of Parliament for Members of Parliament to help creating a data base of health indicators and detecting the various silent diseases like diabetes and hypertension.
 A state of art Sports Injury Centre is nearing completion at Safdarjung Hospital, New Delhi at an estimated cost of Rs. 75.00 crores. The centre would be commissioned before the Commonwealth Games in October 2010.
 New Emergency Care centre of 290 bed capacity in Ram Manohar Lohia (RML) Hospital is under construction.
LEGISLATION
 The Clinical Establishments (Registration & Regulation) Bill 2010 to provide for the regulation of clinical establishments through compliance with minimum standards of service delivery, etc. was passed by the Lok Sabha on 3rd May 2010.
 A Bill to recognize the Sowa Rigpa (Amchi) system of medicine has been introduced in the Rajya Sabha on 06.05.2010.
 Transplant of Human Organs (THOA) amendment bill was introduced in the Lok Sabha last December and presented to the Parliamentary Standing Committee on 17 February 2010. The THOA amendments would help address the huge gap in demand and supply of organs.