Health and Family Welfare in India:Incorporating the Mid-term Appraisal of Eleventh Five Year Plan

CSE-2011/GENERAL STUDIES(PRELIMS)/PROF. S.M/HAND OUT #7
Health: Eleventh Plan Vision
 Health as a right for all citizens is the goal that the Plan will strive towards.
 A comprehensive approach that encompasses individual health care, public health, sanitation, clean drinking water, access to food, and knowledge of hygiene, and feeding practices.
 To transform public health care into an accountable, accessible, and affordable system of quality services.
 Convergence and development of public health systems and services that are responsive to the health needs and aspirations of the people.
 Public provisioning of quality health care to enable access to affordable and reliable heath services, especially in the context of preventing the non-poor from entering into poverty or in terms of reducing the suffering of those who are already below the poverty line.
 Reducing disparities in health across regions and communities by ensuring access to affordable health care.
 Good governance, transparency, and accountability in the delivery of health services that is ensured through involvement of Panchayati Raj Institutions (PRI)s, community, and civil society groups.

Health: Eleventh Plan Goals
 To raise public spending on health from 0.9 per cent of GDP to 2-3 per cent of GDP, with improved arrangement for community financing and risk pooling.
 To undertake architectural correction of the health system to enable it to effectively handle increased allocations and promote policies that strengthen public health management and service delivery in the country.
 Reduction in child and maternal mortality.
 Universal access to public services for food and nutrition, sanitation and hygiene.
 Universal access to public health care services, integrated comprehensive primary health care, with emphasis on services addressing women’s and children’s health and universal immunization.
 Prevention and control of communicable and non-communicable diseases, including locally endemic diseases.
 Population stabilization, gender and demographic balance.
 Revitalize local health traditions and mainstream AYUSH.
 Promotion of healthy lifestyles.

Health: Eleventh Plan Objectives
 Reducing Maternal Mortality Ratio (MMR) to 1 per 1,000 live births.
 Reducing Infant Mortality Rate (IMR) to 28 per 1,000 live births.
 Reducing Total Fertility Rate (TFR) to 2.1.
 Providing clean drinking water for all by 2009 and ensuring no slip-backs.
 Reducing malnutrition among children in the age group 0–3 year to half its present level.
 Reducing anaemia among women and girls by 50 per cent.
 Raising the sex ratio in the age group 0–6 years to 935 by 2011–12, and to 950 by 2016–17.
 Malaria Mortality Reduction Rate: 50 per cent up to 2010, additional 10 per cent by 2012.
 Kala Azar Mortality Reduction Rate: 100 per cent by 2010 and sustaining elimination until 2012.
 Filaria / Microfilaria Reduction Rate: 70 per cent by 2010, 80 per cent by 2012 and elimination by 2015.
 Dengue Mortality Reduction Rate: 50 per cent by 2010 and sustaining at that level until 2012.
 Cataract operations: Increase to 46 lakhs by 2012.
 Leprosy Prevalence Rate: Reduce from 1.8 per 10,000 in 2005 to less that 1 per 10,000 thereafter.
 Tuberculosis DOTS series: Maintain 85 per cent cure rate through entire mission period and also sustain planned case detection rate.
In terms of systems improvements the NRHM targets were:
 Upgrade all PHCs into 24x7 PHCs by the year 2010.
 Upgrading all Community Health Centres to Indian Public Health Standards.
 Increase utilization of first referral units from bed occupancy by referred cases of less than 20 per cent to over 75 per cent.
 Engaging 4,00,000 female Accredited Social Health Activists (ASHAs).







Maternal Mortality Ratio (MMR)
To reach the MMR target of 100 by 2012, the required rate of decline from 254 (SRS 2004-06) has to be, on an average, 22 per year. Unfortunately, no data are available on the progress of MMR during the Eleventh Plan period i.e. the period beginning 2007-08. However, earlier data shows that MMR came down from 301 (SRS 2001-03) to 254 (SRS 2004-06), i.e., an average decline of 16 per year. Achieving the Eleventh Plan target clearly requires much faster progress. State wise decline during the pre-Eleventh Plan period varied from an average of 26 per year for Uttar Pradesh/Uttarakhand, 20 per year for Bihar/Jharkhand, 19 per year for Rajasthan, 18 per year for Orissa/ West Bengal to 15 per year for Madhya Pradesh/Chhattisgarh.
When 52.2 per cent of the deliveries are conducted at home (DLHS-3, 2007-8) and comprehensive obstetric care continues to be a problem in many States, the scope for expanding timely access to quality institutional care is limited, particularly for those living in remote and inaccessible areas. In such a scenario, the MMR goal of 100 is achievable only through appropriate area specific interventions.
Infant Mortality Rate (IMR)
Although IMR is showing a downward trend, but the rate of improvement here too has to be three times that in the past so as to attain the level expected by the end of Eleventh Plan. All India IMR was 57 in 2006 and 53 in 2008 (SRS), a decrease of 4 in two years. High focus States of NRHM have shown marginally better performance in rural areas, where IMR has decreased by 5 in two years. Tamil Nadu has also shown marginally better performance, a decline of 6 in two years. To achieve IMR of 28 by 2012, the required rate of decrease has to be an average of 6 per year. Intensive and urgent efforts are required to adopt homebased newborn care based on validated models such as the Gadchiroli model and make focused efforts for encouraging breast feeding and safe infant and child feeding practices. While emphasis on early breast feeding is part of ASHAs training, special training on neonatal care for community and facility level health functionaries will facilitate a faster reduction in IMR.




HOME BASED NEWBORN CARE (HBNC)
 Efforts to improve home based care have proven successful at improving child survival. Home Based Newborn and Child Care is to be provided by a trained Community Health Worker (such as the ASHA) who guides and supports the mother, family, and TBA in the care of newborn, and attends the newborn at home if she is sick. The worker is supervised by a field person (ANM/LHV or a doctor) who visits the community once in 15 days. Community acceptance and coverage of such care has been quite good.
 The GoI approved the implementation of HBNC based on the Gadchiroli model, where appreciable decline in IMR has been documented on the basis of work done by a VO called SEARCH. Gadchiroli has shown how ordinary women can do extraordinary things: a well-trained local woman can not only lower neonatal mortality but can also bring about attitudinal change. The women Shishu Rakshaks of Gadchiroli have managed to dispel many myths surrounding pregnancy and have been able to ensure better nutrition, care, immunization, and hygiene.
 The national strategy during the Plan will be to introduce and make available high-quality HBNC services in all districts/areas with an IMR more than 45 per 1000 live births. Apart from performance incentive to ASHAs, an award will be given to ASHAs and village community if no mother–newborn or child death is reported in a year.
National Rural Health Mission
• NRHM was launched on April 12, 2005, to provide accessible, affordable and accountable quality health services to the poorest households in the remotest rural regions. Allocation has been increased to Rs. 12,070 crore in interim budget for 2009-10 compared to Rs. 12,050 crore in 2008-09. NRHM is being operationalized throughout the country, with special focus on 18 states which includes 8 Empowered Action Group States (Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Uttar Pradesh, Uttarakhand, Orissa and Rajasthan), 8 NE states, Himachal Pradesh and Jammu & Kashmir.
• The main aim of NRHM is to provide accessible, affordable, accountable, effective and reliable primary health care facilities, especially, to the poor and vulnerable sections of the population. It also aims at bridging the gap in rural health care services through the creation of a cadre of Accredited Social Health Activists (ASHA) and improved hospital care, decentralization of programme to district level to improve intra and inter-sectoral convergence and effective utilization of resources. NRHM further aims to provide overarching umbrella to the existing programmes of health and family welfare including RCH-II, malaria, blindness, iodine deficiency, filaria, kala-azar, tuberculosis, leprosy and for integrated disease surveillance. Further, it addresses the issue of health in the context of sector-wide approach towards sanitation and hygiene, nutrition and safe drinking water as basic determinants of good health in order to have greater convergence among the related social sector departments i.e. AYUSH, Women & Child Development, Sanitation, Elementary Education, Panchayati Raj and Rural Development. The mission further seeks to buildgreater ownership of the programme among the community through involvement of Panchayati Raj Institutions, NGOs and other stakeholders at national, state, district and sub-district levels to achieve the goals of National Population Policy 2000 and National Health Policy. The expected outcomes of the mission include reduction of IMR to below 30/1000 live births, MMR to below 100/100,000 live births & TFR to 2.1 by 2012.
Performance of NRHM:

 7.49 lakh Accredited Social Health Activists (ASHAs) have been selected though the total number of those who have completed all training modules is low. Against the target of 6 lakh fully trained ASHAs by 2008 there are 5.19 lakh ASHAs positioned with drug kits, but their training is still to be completed. Only about 1.99 lakh ASHAs have completed all five modules and 5.65 lakh have completed up to fourth training module.
 4.51 lakh Village Health and Sanitation Committees (VHSCs) have been set up against the target of 6 lakh VHSCs by 2008. The operational effectiveness of the VHSCs, however, needs considerable improvement.
 40,426 Sub-centres (SCs) have been provided two ANMs against the target of 1.05 lakh SCs by 2009. 8,745 SCs are without even a single ANM.
 8,324 Primary Health Centres (PHCs) are functional on 24X7 basis and 5,907of them have three Staff Nurses against the target of 18,000 PHCs by 2009.
 3,966 Community Health Centres (CHCs) are functional on 24X7 basis. However, information regarding the target of strengthening 3250 CHCs with seven specialists and nine staff nurses by 2009 is not available. In any case, the number of CHCs/Sub-Divisional Hospitals or equivalent, which have been upgraded to First Referral Unit (FRU) has increased from 750 (as on 31 March 2005) to 1934 (as on 31 December 2009).
 510 out of total 578 District Hospitals (DHs) have been strengthened to act as FRUs.
 29,223 Rogi Kalyan Samitis (RKSs)/Hospital Development Committees have been constituted at PHC/CHC/DH levels against the target of 37,100 RKSs by 2009.
 State & District Societies are in place except at the State level in West Bengal. District Programme Managers and District Accounts Managers are in position in 581 and 579 districts respectively.
 356 Districts have operational Mobile Medical Units (MMUs) against the target of 600 MMUs by 2009 (one for each district). In addition, boat clinics in Assam & West Bengal, emergency transport system in Andhra Pradesh, Gujarat, Karnataka, Goa, Uttarakhand, Assam and Rajasthan, GPS enabled MMUs in Gujarat, Haryana and Tamil Nadu are operational.



Human Resources for Health
 Measures have been taken during the Eleventh Five Year Plan period to solve the problem of shortage of basic education infrastructure and human resources:.
 Ensure availability of medical professionals in rural areas on a permanent basis, posting of doctors with adequate monetary as well as non-monetary incentives, such as suitable accommodation, class I status, preferential school admissions for children of doctors living in remote areas, transfer or posting of choice after a stipulated length of stay and training opportunities.
 States to expand the pool of medical practitioners including a cadre of Licentiate Medical Practitioners and practitioners of Indian Systems of Medicine and Homeopathy (AYUSH).
 •Increase age of retirement of doctors (all Central and State Government including Defence, Railways, etc.) to 62 years. States will be encouraged to retain public health doctors on contract basis for further period of three years till the age of 65 years, especially in the notified hardship areas.
 • A series of one-year duration Certificate Courses for MBBS graduates will be launched in deficit disciplines like public health, anaesthesia, psychiatry, geriatric care, and oncology. The private sector will also be encouraged to participate

Qualitative Feedback of NRHM: Voices from the Field

Accredited Social Health Activists (ASHAs)

The appointment of locally recruited women as Accredited Social Health Activists (ASHAs) who would link potential beneficiaries with the health service system is an important element of the NRHM. The good part is that
7.49 lakh ASHAs have been appointed; but several issues still need to be resolved. Not only is there a lack of transparency in the selection, ASHAs are often inadequately trained. Besides, their only focus seems to be on facilitating institutional deliveries. The ASHA who accompanies the expectant mother faces considerable hardship because she has nowhere to stay for the duration of confinement as institutional accommodation facilities are non-existent. They also often experience long delays in payment of incentives.




Village Health and Nutrition Day (VHND)

An important activity of NRHM, Village Health and Nutrition Day is to promote regular community-oriented health and nutrition activities. The event is held on a fixed day every month to sensitise the community and is popularly known as ‘Tika Karan Divas’. However, implementation is ad-hoc in most villages of the high focus States. Surveys revealed that only a few pockets in some States like Tamil Nadu, Andhra Pradesh, West Bengal and Assam were aware of VHND. The other drawback of the programme was that it often restricted itself to immunisation and antenatal check up are done on the day. There is no nutrition education. To have the desired impact, VHNDs need to be implemented with the full intended content of activities and with regularity. This can be achieved through more active involvement of NGOs and community based organizations.

Janani Suraksha Yojana (JSY)

Launched to promote institutional deliveries, JSY provides cash incentive to expectant mothers who opt for institutional delivery. Poor women from the remote districts in Bihar, Orissa and other States are reported to be visiting institutions to avail JSY benefits. However, except for parts of Southern States, most public health institutions are not well equipped for conducting deliveries at the community or even at the block level. The beneficiaries are often asked to purchase gloves, syringes and medicines from the market. The general view, endorsed by visits to the field is that the health centres and subdivisional hospitals remain understaffed and are
poorly run and maintained. A very large number are unhygienic and incapable of catering to the patient load. Women who deliver at the health facility are discharged a few hours after delivery. Sometimes, deliveries take place on the way to the health facility or even outside the locked labour rooms. Lack of co-ordination and mutual understanding between the ANM and ASHA results in the suffering of pregnant women.

Maternal & Child Health

NRHM has been able to provide an extensive network of transport facilities in States that have established emergency transport systems. On the other hand, there is very little awareness about the Integrated Management of Neonatal and Childhood Illnesses (IMNCI) strategy. In the event of illness of either the mother or the neo-nate, RMPs (some times even local quacks) are consulted. Home-based new born care based on Gadchiroli model and other community based innovations have yet to be made an integral part of the child health strategy.

Rashtriya Swasthya Bima Yojana (RSBY)

Launch of RSBY by Ministry of Labour & Employment in 2007 has been an important step to supplement the efforts being made to provide quality health care to the poor and underprivileged population. It provides cashless health insurance cover up to Rs.30,000 per annum per family. The premium is paid by the Centre and State Governments on a 75:25 sharing basis with the beneficiary paying only a registration fee.

Twenty-five States are in the process of implementing the RSBY and till February 2010, more than 1.25 crore biometric enabled smart cards have been issued for providing health insurance cover to more than 4 crore people, from any empanelled hospital throughout the country. Around 4.5 lakh persons have already availed hospitalisation facility. The scheme is now being gradually extended to the non-BPL category of workers as well. Linkages with RSBY in public sector hospitals need to be strengthened.

National AIDS Control Programme (NACP)

The NACP goal was to halt and reverse the epidemic in India over the five years period of the Eleventh Plan. This was to be done by integrating programmes for prevention, care, support and treatment, as well as addressing the human rights issues specific to people living with HIV/AIDS (PLWHA).. Although the achievement of physical targets under the programme is satisfactory, MoHFW has yet to introduce a HIV/AIDS Bill to protect the rights of children, women and HIV infected persons and avoid discrimination at work place. A National Blood Transfusion Authority is to be established during the remaining period of the Plan. Voluntary blood donation has to be encouraged further to bridge the gap in demand and supply of blood. Expenditure under National AIDS Control Programme including STD control during 2007-08 and 2008-09, has been 112.60 per cent and 91.91 per cent of the approved.

Pradhan Mantri Swasthya Suraksha Yojana (PMSSY)

 The PMSSY envisages substantial expansion of central and state government medical institutions. Phase 1 of PMSSY envisages establishment of six new AIIMS like institutions at Patna (Bihar), Bhopal (Madhya Pradesh), Bhubaneswar (Orissa), Jodhpur (Rajasthan), Raipur (Chhattisgarh) and Rishikesh (Uttarakhand). The original estimate of each institute was Rs. 332 crore and the latest estimate is about Rs. 820 crore. For these new ‘AIIMS like institutions’, construction of medical colleges and hospital complexes and construction of residential complexes have been taken up as separate activities. Construction of housing complex at all six sites has commenced and work for medical colleges and hospital complexes is likely to start in the second quarter of 2010-11.
 The second component of PMSSY Phase 1 includes upgradation of 13 State Government medical college institutions. These are at Government Medical College, Jammu (Jammu & Kashmir); Government Medical College, Srinagar (Jammu & Kashmir); Kolkata Medical College, Kolkata (West Bengal); Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow (Uttar Pradesh); Institute of Medical Sciences, BHU, Varanasi (Uttar Pradesh); Nizam Institute of Medical Sciences, Hyderabad (Andhra Pradesh); Sri Venkateshwara Institute of Medical Sciences, Tirupati (Andhra Pradesh); Government Medical College, Salem (Tamil Nadu); Rajendra Institute of Medical Sciences, Ranchi (Jharkhand); B.J. Medical College, Ahmedabad (Gujarat); Bangalore Medical College, Bangalore (Karnataka); Grants Medical College & Sir J.J. Group of Hospitals, Mumbai, (Maharashtra) and Medical College, Thiruvananthapuram, (Kerala). The outlay provided is Rs.120 crore per institution, of which Rs. 100 crore would be borne by the Central Government (for SVIMS, Tirupati, it is Rs.60 crore) and the remaining amount will be contributed by the respective States. The State Governments will also provide the resources (human resources and recurring expenditure) for running the upgraded facilities. Upgrading of two State Government medical college institutions is over. Another four are expected to be upgraded by July 2010, two by December, 2010 and the remaining in 2011.
 Phase II of PMSSY, approved recently, provides for the establishment of two new AIIMS like institutions in Uttar Pradesh and West Bengal and upgrading of six State Government medical college institutions at Government Medical College, Amritsar (Punjab); Government Medical College, Tanda (Himachal Pradesh); Government Medical College, Nagpur (Maharashtra); Jawaharlal Nehru College of Aligarh Muslim University, Aligarh (Uttar Pradesh); Government Medical College, Madurai (Tamil Nadu) and Pandit B.D. Sharma Postgraduate Institute of Medical Sciences, Rohtak (Haryana).
 Overall expenditure under PMSSY had shown improvement in 2008-09 with expenditure of 92.86 per cent as against 58.33 per cent in 2007-08. However, the anticipated expenditure based on RE figures in the current year (2009-10) is only 47.21 per cent of the approved outlay for 2009-10.

AYURVEDA, YOGA AND NATUROPATHY, UNANI, SIDDHA, AND HOMEOPATHY (AYUSH)

 There is a resurgence of interest in holistic systems of health care, especially, in the prevention and management of chronic lifestyle related non-communicable diseases and systemic diseases. To mainstream AYUSH by designing strategic interventions for wider utilization of AYUSH both domestically and globally, the thrust areas in the Eleventh Five YearPlan are: strengthening professional education, strategic research programmes, promotion of best clinical practices, technology upgradation in industry, setting internationally acceptable pharmacopoeial standards, conserving medicinal flora, fauna, metals, and minerals, utilizing human resources of AYUSH in the national health programmes, with the ultimate aim of enhancing the outreach of AYUSH health care in an accessible, acceptable, affordable, and qualitative manner.

 During the Tenth Plan, the Department continued to lay emphasis on upgradation of AYUSH educational standards, quality control, and standardization of drugs, improving the availability of medicinal plant material, R&D, and awareness generation about the efficacy of the systems domestically and internationally. Steps were taken in 2006–07 for mainstreaming AYUSH under NRHM with the objective of optimum utilization of AYUSH for meeting the unmet needs of the population.

Health Care Services under AYUSH
 The AYUSH sector across the country supported a network of 3203 hospitals and 21351 dispensaries. The health services provided by this network largely focused on primary health care. The sector has a marginal presence in secondary and tertiary health care. In the private and not-for-profit sector, there are several thousand AYUSH clinics and around 250 hospitals and nursing homes for in patient care and specialized therapies like Panchkarma.

 In clinics and nursing homes there are anecdotal reports of the role of AYUSH in the successful management of several communicable and noncommunicable diseases. However, there is no macrodata available about the contribution of AYUSH to major national programmes for the management of communicable and NCDs. A major challenge in Eleventh Five Year Plan is to identify reputed clinical centres and support upgradation of their facilities via PPP schemes so that the country can boast of a national network of high-quality clinical facilities developed for rendering specialized health care in strength areas of AYUSH.

AYUSH under NRHM
 Despite having a different scheme of diagnosis, drug requirements, and treatments as compared to the mainstream health care system, preliminary efforts to integrate AYUSH in NRHM were initiated during the Tenth Plan. It is too early to assess if the AYUSH interventions in NRHM have had significant health impact by way of complementing the conventional national health programmes. Integrating AYUSH into NRHM has the potential of enhancing both the quality and outreach of NRHM, especially with the availability of a large number of practitioners in this field. Supporting strategic pilot action research projects in the Eleventh Five Year Plan to evolve viable models of integration seems necessary.

Mainstreaming AYUSH

• NRHM has mainstreamed AYUSH into the rural health services by co-locating AYUSH personnel in primary health care facilities resulting in increase in utilization of AYUSH treatment. AYUSH practitioners are also used to fill in the position of Allopaths in Primary Health Centres particularly in States that have a substantial shortage of MBBS doctors. While this is a positive development, efforts have to be made for training AYUSH practitioners in public health.