INDEX

1. Prologue
2. Weaknesses of Indian Health Care System
3. National Health Mission
a. Reproductive, Maternal, Newborn, Child Health and Adolescent (RMNCH+A) Services
b. National Rural Health Mission
c. National Urban Health Mission
4. Other Major Schemes
5. Evaluation of 11th 5YP
6. The Way Ahead
7. Sources

PROLOGUE
It would require a very brave person to argue that India has a functioning health care system
and since I am not that brave, in this article, I have discussed Indian healthcare systems
Weakness, Govt. Schemes relating to Health Care, 11th 5YP Evaluation and the Way Ahead
plus in between I have bracketed the related fodder points*.
*these are not just conventional fodder points but also integrated ideas for brain-storming as
well!!
At present, Indias 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 hospitals and super specialty hospitals.

WEAKNESSES OF INDIAN HEALTH CARE SYSTEM

1. AVIALIABILITY of health care services from the public and private sectors taken
together is inadequate.
At the start of the Eleventh Plan, the number of doctors per lakh of population was only 45,
whereas, the desirable number is 85 per lakh population. Similarly, the number of Nurses and
Health Auxiliary Nurse and Midwifes (ANMs) available was only 75 per lakh population whereas
the desirable number is 255. The overall shortage is exacerbated by a wide geographical
variation in availability across the country. Rural areas are especially poorly served.
2. LOW LEVELS OF PUBLIC SPENDINGBetween 1996-97 and 2005-06, total government
spending on health was stagnant at about 1 percent of GDP, and the public expenditure

elasticity with respect to GDP was at 0.94, lower than the average for low-income
countries (1.16) for the same period.
Despite efforts to increase public spending after 2005-06 including the adoption of NRHM, the
expenditure increased only marginally to 1.2 percent of GDP in 2009-2010. The present state of
the public health system is a result of decades old neglect by successive governments.
3. QUALITY of healthcare services varies considerably 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.
4. AFFORDABILITY of health care is a serious problem for the vast majority of the
population, especially in tertiary care.
The lack of adequately funded public health services pushes large numbers of people to incur
heavy out of pocket expenditures on services purchased from the private sector. Out of pocket
expenditures arise even in public sector hospitals, since lack of medicines means that patients
have to buy them. This results in a very high financial burden on families in case of severe
illness.
As a result of 1+2+3+4Thugs, jhollachhap tantriks, Bangauli doctors come up and loot the
poors existing resources.
FODDER POINT#1
{In India, the Constitution assigns the states responsibility for the provision of social services
Entry 6 in the state list of the 7th Schedule of the Constitution assigns *Public health and
sanitation, hospitals and dispensaries to the state governments] and coequal responsibility with
the central government for the provision of economic services. However, since all broad-based
tax handles except the general sales tax are assigned to the central government, there is a high
degree of vertical fiscal imbalance. Further, the wide interstate disparities in revenue capacity
make it difficult to ensure comparable levels of public services in different states at comparable
tax rates.}
Now look at the centrally sponsored schemes

I.

National Health Mission

Earlier, there was NRHM, but after the Union Cabinet approved NUHM, NHM was created and
both NRHM & NUHM are made sub-mission of over-arching NHM.
It seeks to provide
A. Reproductive, Maternal, Newborn, Child Health and Adolescent (RMNCH+A) Services

a. Maternal Health It includes:

Improved access to skilled obstetric care through facility development,

Increased coverage and quality of ante-natal and post natal care,
Increased access to skilled birth attendance, institutional delivery.

This will be done through mapping and identifying health facilities as delivery points and
strengthening them for delivery of comprehensive package of RMNCH+A services.
b. Access to safe abortion servicesthe focus would be to improve access to
comprehensive abortion care, including post abortion contraceptive counseling and
services, by expanding the network of facilities providing MTP services.
c. Prevention and Management of Sexually Transmitted Infections (STI) Key strategies
include:

Prevention of STI through community health education and as part of adolescent health
education,
Provision of diagnosis and treatment services at health facilities at 24*7 and lower
levels, and
Laboratory and diagnostic based services at Level 3 facilities.
Special focus would be given on linking up with Integrated Counseling and Treatment
Centers (ICTCs) and establishing appropriate referrals for HIV testing and RTI/STI
management.

d. Newborn and Child HealthThis will be through a continuum of care from the
community to facility level and include the provision of home based newborn and child
care through ASHAs and ANMs, supplemented by AWW, and community level care for
acute respiratory infections, diarrhea, and fevers, including home remedies, first contact
curative care, or referral as appropriate.
e. Universal ImmunizationSustaining Pulse polio campaigns and achieving over 80%
routine immunization in all districts will be emphasized. Introduction of new and
underutilized vaccines will be considered on the basis of recommendations of the
National Technical Advisory Group on Immunization (NTAGI). Improved cold chain
management would be ensured with adequate densities of Ice Lined Refrigerators (ILRs)
and deep freezers. Adequate number of vaccination sessions and sites, and logistics
arrangements to reach all such sites especially in remote areas will be a key area of
intervention.
f. Adolescent HealthAdolescent Health programmes include the following priority
interventions:

Iron and Folic Acid (IFA) supplementation,

facility-based adolescent health services,
community based health promotion activities,
Information and counseling on sexual and reproductive health (including menstrual
hygiene), substance abuse, mental health, non-communicable diseases, injuries and
violence including domestic violence.
These interventions will be operationalized through various platforms including
Adolescent Friendly Health Clinics (AFHC), VHNDs, Schools, Anganwadi Centers and
Nehru Yuva Kendra Sangathan (NYKS), Teen Clubs and a dedicated Adolescent Health
Day.

g. Family PlanningMeeting unmet needs for contraception through provisioning of a

range of family planning methods will be prioritized. In high fertility states the aim is to
reduce fertility to replacement levels and states which have achieved replacement levels
will sustain it.
Family planning services would be utilized as a key strategy to reduce maternal and child
morbidities and mortalities in addition to stabilizing population. Post-partum and post abortion
contraception would be a priority. All states would be encouraged to focus on promotion of
especially Intra-Uterine Contraceptive Devices (IUCDs).
h. Addressing the Declining Sex RatioImproving the adverse child sex ratio will be crucial
and strategies that lie within the domain of health include:

Stricter enforcement of the PCPNDT Act,

improved monitoring and sensitization of the medical community,
a greater role for civil society action in addressing son preference,
addressing neglect of the girl child in illness care,
observing sex ratios in hospital admissions for illness in children, and
Providing proactive support for girl children through the ASHA and Anganwadi system.

B. NATIONAL RURAL HEALTH MISSION

Q1. What does the National Rural Health Mission (NRHM) seeks to provide?
A1. NRHM seeks to provide effective health care to the rural population, especially the
disadvantaged groups including women and children, by improving access, enabling community
ownership and demand for services, strengthening public health systems for efficient service
delivery, enhancing equity and accountability and promoting decentralization.

Q2. Does NRHM cover the entire country?

A2. The NRHM covers the entire country, with special focus on 18 States where the challenge of
strengthening poor public health systems and thereby improving key health indicators is the
greatest.
FODDER MATERIAL#2
{We have a shortage of more than 1 million doctors. But we make such stringent rules in
running a medical college that no one can start medical colleges in this country; even if one
starts, it costs over Rs.200-300 crore, whereas anywhere in the world one can start a medical
college with any building. They dont need 25 acres of land and teachers retiring at 60.}
Q3. Which are the focus states under NRHM?
A3. The States of Uttar Pradesh, Uttaranchal, Madhya Pradesh, Chhattisgarh, Bihar, Jharkhand,
Orissa Rajasthan, Himachal Pradesh, Jammu and Kashmir, Assam, Arunachal Pradesh,
Manipur, Meghalaya, Nagaland, Mizoram, Sikkim and Tripura are covered under NRHM.
Q4. What is the key National health programme covered under NRHM?
A4. NRHM subsumes key national programmes, namely, the Reproductive and Child health II
project (RCH II), the National Disease Control Programmes (NDCP) and the Integrated Disease
Surveillance Project (IDSP).
Q5. What are the core strategies of NRHM?
A5. The core strategies of NRHM include

Decentralized village and district level health planning and management,

Appointment of Accredited Social Health Activist (ASHA) to facilitate access to health
services,
Strengthening the public health service delivery infrastructure, particularly at village,
primary and secondary levels,
Mainstreaming AYUSH, improved management capacity to organize health systems and
services in public health,
Emphasizing evidence based planning and implementation through improved capacity
and infrastructure,
Promoting the non-profit sector to increase social participation and community
empowerment, promoting healthy behaviors and improving inter-sectorial convergence.

Q6. Who heads the steering group for NRHM?

A6. The Mission Steering Group is under the Chairmanship of the Union Minister for Health &
Family Welfare. He/she will provide policy guidance and operational oversight at the National
level.
Q7. Are state governments key stakeholders in this? What is their role?
A7. The State Governments have been part of the Stakeholder Consultations for finalization of
the strategy of the Mission.

Q8. What is ASHA?

A8. ASHA will be a health activist in the community who will create awareness on health and
its social determinants and mobilize the community towards local health planning and
increased utilization and accountability of the existing health services.
FODDER MATERIAL#3
{Dr Naresh Trehan, chairman and managing director of Medanta, points to the Accredited Social
Health Activists (ASHA), or community health workers in the country. There are 800,000 of
them at the village level. But theyre trained badly. We need to ask how can we up-skill them?
How can we make them our frontline workers who identify early signs of a disease?}

C. NATIONAL URBAN HEALTH MISSION

Q1. What does the National Urban Health Mission (NUHM) seeks to provide?
A1. NUHM will specifically address the peculiarities of urban health needs, which constitutes
non-communicable diseases (NCDs) as a major proportion of the burden of disease. The primary
health care system being envisaged under NUHM will screen, diagnose and refer the cases of
chronic diseases to the secondary and tertiary level through a system of referral.

Q2. What is the working area of NUHM?

A2. During the Mission period all 779 cities with a population of above 50000 and all the district
and state headquarters (irrespective of the population size) would be covered. This will be in
partnership with the NRHMs efforts so far to ensure that there is no duplication of services.
Urban areas with population less than 50,000 will be covered through the health facilities
established under the National Rural Health Mission (NRHM).
Q3. What are the high-focus areas of NUHM?
A3. The NUHM would have high focus on:

Urban Poor Population living in listed and unlisted slums,

All other vulnerable population such as homeless, rag-pickers, street children, rickshaw
pullers, construction and brick and lime kiln workers, sex workers, and other temporary
migrants,
Public health thrust on sanitation, clean drinking water, vector control, etc.

Q4. How NUHM will help improve the existing healthcare system?
A4. The NUHM would encourage the effective participation of the community in planning and
management of health care services.

It would promote a community health volunteer - Accredited Social Health Activist (ASHA) in
urban poor settlements (one ASHA for 1000-2500 urban poor population covering about 200 to
500 households); ensure the participation by creation of community based institutions like
Mahila Arogya Samiti (50-100 households) and Rogi Kalyan Samitis.
Such MAS will be given annual grant of Rs.5000 by NUHM. This amount can be used for
conducting fortnightly/monthly meetings of MAS, sanitation and hygiene, meeting emergency
health needs etc.
FODDER MATERIAL#4
{Today, a nurse who has worked in hospitals for 20 years cannot give a paracetamol tablet
legally. Unless the government comes up with a regulation that alternative medical specialists
and nurses can look at primary care, there is no future. For the last 12 years, Ive been speaking
about it, everyone thinks its a great idea, but nothing happens in reality, because medical
lobbies are very powerful.}
Q5. What is the specific function, it seeks to do as many of such activities are already under
NRHM?
A5. Yes, many components of the NRHM cover urban areas as well. These include funding
support for the Urban Health and Family Welfare Centre, funding of National Health
Programmes like TB, immunization, malaria, etc., BUT the only limitation has been the fact that
norms for urban area primary health infrastructure were not part of the NRHM proposal, setting
a limit to support for basic health infrastructure in urban areas, under the NRHM.
Municipal Corporations, Municipalities, Notified Area Committees and Nagar (Town)
Panchayats were not units of planning under NRHM, with their own distinctive normative
framework and now under NUHM substantial level of planning are to be done by Urban SelfGovernments.
Q6. But there is a significant private sector in Urban part of the country, so why NUHM?
A6. An overview of the private sector:

Serious supply gaps and distributional inequities;

Need for uniform standards and treatment protocols;
Need for cost controls and quality assurance mechanisms;
Regulations to protect consumer interests and enforcement systems;

These gaps result in very high burden on poor, so NUHM will share that burden.

Q7. Is there is a similarity in urban health care all over India?

A7. There are 2 models of service delivery prevalent in urban areas. In states like Uttar Pradesh,
Bihar and Madhya Pradesh health care programmes are being planned and managed by the
State government; the involvement of the urban local bodies is limited to the provisioning of
public health initiatives like sanitation, conservancy, provision of potable water and fogging for
malaria. In other states like Karnataka, West Bengal, Tamil Nadu and Gujarat the health care
programmes are being primarily planned and managed by the urban local bodies.
In some of the bigger Municipal bodies like Ahmedabad, Chennai, Surat, Delhi and Mumbai the
Medical/Health officers are employed by the local body whereas in smaller bodies, health
officers are mostly on deputation from the State health department.
Though bigger corporations demonstrate improved capacity to manage their heatlh
programmes, there is still a need to build their capacity.
Q8. What is the single biggest reason for this state of current health care system?
A8. The multiplicity of service providers in the urban areas, with the ULBs and State
Governments jointly provisioning even primary health care, has led to a dysfunctional referral
system and a consequent overload on tertiary hospitals and underutilized primary health
facilities.
In simple words, due to under-utilization of primary health care, a person suffering from
common viral fever goes to sarkari hospitals providing secondary/tertiary services, which
further results in inefficiency on the part of those hospitals providing secondary/tertiary
services.
Q9. What are the core strategies of NUHM?
A9. These are:

Improving the efficiency of public health system in the cities by strengthening,

revamping and rationalizing existing government primary urban health structure and
designated referral facilities,
Promotion of access to improved health care at household level through community
based groups : Mahila Arogya Samitis,
Increased access to health care through creation of revolving fund, IT enabled services
(ITES) and e- governance for improving access improved surveillance and monitoring,
Prioritizing the most vulnerable amongst the poor.

Public Health Challenges & Possible Responses

KEY PUBLIC HEALTH

CHALLENGES IN URBAN AREAS

1.

Poor households not knowing

where to go to meet health
need.

2.

Contaminated water, poor

sanitation.

3.

Poor environmental health, poor

housing.

4.

Unregistered practitioners first

point of contact use of
irrational and unethical medical
practice.

5.

Community organizations

POSSIBLE RESPONSES UNDER

THE
NATIONAL URBAN HEALTH
MISSION
The biggest challenge is to
connect every household to
health facilities. The role of the
slum level Community Worker is
a possible intervention. The
Community Worker becomes
the first point of contact for any
health need. She has the
authority to connect households
to health facilities.
Work towards a possible public
health bill that sets standards
for provision of basic
entitlements like water and
sanitation facilities.
Work with urban local bodies to
increase access to functional
toilets.
Work with urban local bodies to
set standards for environmental
sanitation, set up systems of
waste disposal, basic housing
systems, etc.
Develop systems of accrediting
private not fully qualified
practitioners if they do basic
specially designed courses for
them, which gives them some
level of acceptable competence.
Make them work under the
supervision of government
doctors.
Establish vibrant community

helpless in health matters

6.

Weak public health planning

capacity in urban local bodies.

7.

No system of counseling and

care for adolescents.

8.

Over congested secondary and

tertiary facilities and under
underutilized primary care
facilities.

9.

Many slums not having primary

health care facility.

II.

A. Janani Suraksha Yojana (JSY)

organizations at slum level,

under the umbrella of the urban
local body, wherever feasible.
Co-opt community leaders like
members of Self Help Groups,
womens groups, etc. Provide
untied grants to local
community organizations to
carry out community led action
for public health.
Re-orient existing staff of urban
local bodies to understand
public health challenges better
Adolescents face multiple
problems in urban areas.
Need to mobilize local youth for
community led public health
action. Need to attend to
special needs of adolescent girls
to make them cope with
physiological changes.
Need to generate awareness
through MAS and community
workers in every slum so that
people know clearly where the
house hold has to be sent. Need
based referrals are the only way
of decongesting.
Creating new public health
infrastructure using community
buildings, mobile medical units
based on fixed schedules where
infrastructure cannot be
created.

OTHER MAJOR SCHEMES

Janani Suraksha Yojana (JSY) is a nationwide, centrally sponsored scheme being implemented
with the objectives of reduction in infant and maternal mortality by improving coverage of
institutional delivery among pregnant women. Under the scheme, cash assistance ($) is
provided to pregnant women for giving birth in a health facility.
B. Janani Shishu Suraksha Karyakaram (JSSK)
Under National Rural Health Mission, the Government of India has launched Janani Shishu
Suraksha Karyakaram (JSSK) which entitles all pregnant women delivering in public health
institutions to absolutely free and no expense delivery including Caesarean section. The
initiative stipulates free drugs, diagnostics, blood and diet, besides free transport from home to
institution, between facilities in case of a referral and drop back home. Similar entitlements
have been put up in place for all sick newborns accessing public health institutions for
treatment till 30 days after birth.
C. Routine Immunization Programme and Pulse Polio Immunization Programme
Routine Immunization Programme and Pulse Polio Immunization Programme are under
operation in the country.
Immunization Programme is one of the key interventions for protection of children from life
threatening conditions, which are preventable. It is one of the largest immunization programme
in the world and a major public health intervention in the country.
Under the Universal Immunization Programme, Government of India is providing vaccination to
prevent 7 vaccine preventable diseases i.e. Diphtheria, Pertussis, Tetanus, Polio, Measles,
severe form of Childhood Tuberculosis and Hepatitis B.
D. National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular
Diseases and Stroke (NPCDCS)
National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases
and Stroke (NPCDCS) aims at reducing the burden of Non- Communicable Diseases (NCDs) such
as cancer, diabetes, cardiovascular diseases and stroke which are major factors reducing
potentially productive years of human life, resulting in huge economic loss. The expenditure will
be met on cost sharing basis with the participating States at ratio of 80:20.
The objective of the programme include prevention and control of diabetes at various levels viz.
Sub-centres, Community Health Centre (CHC), District Hospital etc. through screening of all
persons above 30 years of age and all pregnant women for diabetes and hypertension.
E. National Vector Borne Disease Control Programme (NVBDCP)*
The National Vector Borne Disease Control Programme (NVBDCP) is an ongoing centrally
sponsored scheme which is implemented in all the states/UTs for prevention and control of six

vector borne diseases, namely Malaria, Dengue, Chikungunya, Japanese Encephalitis, Kala- Azar
and Lymphatic Filariasis. The Govt. of India provides technical support as well as cash and
commodity assistance as per the approved pattern.
F. National Leprosy Eradication Programme(NLEP)*
G. National AIDS Control Programme
Department of AIDS Control is implementing National AIDS Control Programme-IV as a 100%
centrally sponsored scheme/programme is implemented in all States/UTs.
With its first three phases already successfully over, NACP is currently in its fourth
StageNACP-IV which was approved in October 2013 by Cabinet Committee on Economic
Affairs.
NACP IV will integrate with other national programmes and align with overall 12th Five Year
Plan goals of inclusive growth and development. This phase of NACP will focus on accelerating
the reversal process and ensure integration of the programme response.
The main objective of NACP IV is to:
i. Reduce new infections by 50 percent (2007 Baseline of NACP III).
ii. Provide comprehensive care and support to all persons living with HIV/AIDS and treatment
services for all those who require it.
*Already explained in my January article on diseases.

EVALUATION OF 11th 5 YEAR PLAN

Serial No.

Eleventh Plan Target

Baseline Level

Recent Status

1.

Reducing Maternal
Mortality Ratio
(MMR) to 100 per
100000 live births.
Reducing Infant
Mortality Rate (IMR)
to 28 per 1000 live

254
(SRS, 200406)

212
(SRS, 200709)

57
(SRS, 2006)

44
(SRS, 2011)

2.

births.
Reducing Total
Fertility Rate (TFR) to
2.1.
Reducing malnutrition
among children of age
group 03 to half its
level.
Reducing anaemia
among women and
girls by 50%.

3.

4.

5.

6.

Raising the sex ratio

for age group 06 to
935

2.8
(SRS, 2006)

2.5
(SRS, 2010)

40.4
(NFHS, 200506)

No recent data
available

55.3
(NFHS, 200506)

No recent data
available

927
(Census, 2001)

914
(census, 2011)

THE WAY AHEAD

Reforms in the health sector will have to address
a.
b.
c.
d.

the need for increasing public spending on health care,

focus on preventative health care,
ensure greater access to health care by the poor, and
Significantly improve the productivity of public spending.

Not only is public spending on health care in India too low, but its distribution across the
country is very uneven. Per capita health care expenditure in the poorest state, Bihar, was
Rs.166 in 2008-09, whereas that same year it was Rs.421 in Tamil Nadu and Rs.507 in Kerala,
relatively more affluent states. This is in spite of the greater emphasis given by the low-income
states to health care spending.
As a lead up to the formulation of the Twelfth Five Year Plan, the government had set up a
High Level Expert Group (HLEG), tasked with the formulation of a plan for Universal Access to
Health Care (UAHC). The HLEG has made several well intentioned recommendations, including:

Increase in public expenditures 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 12th plan, and to at least 3 per cent of GDP by
2022.
Ensure availability of free essential medicines by increasing public spending on drug
procurement.

Use of general taxation as the main source of healthcare financing.

Advise not to use insurance companies or any other independent agents to purchase
health care services on behalf of the government.
Reorientation of health care provision to focus significantly on primary health care.

Also, there is lack of PHC in the villages because the doctors cannot go and live in the villages.
So there the mobile services could be provided so that doctors can go to village and come back.
FODDER MATERIAL#5
{Prathap Reddy, chairman, Apollo Group of Hospitals, has a question. To what extent can the
government absorb health care costs? The answer, he says, lies in first addressing the basics, or
primary health care (PHC). Clean drinking water alone can help eliminate gastric ailments that
afflict 20 crore people.}
What all of this boils down to is that if all threeprimary, secondary, and tertiary health care
were bundled into a single package, the math tots up to a per capita expenditure of at least
Rs.1500. All put together, it will consume anywhere between 3.5 to 3.8 percent of Indias gross
domestic product (GDP).
India GDP is now close to $2 trillion. Three-and-a-half percent of that to provide UHC on all
three fronts is a lot of money. Where does this money come from?
FODDER MATERIAL#6
{People are willing to pay tiny amounts for health care but you have to create a vehicle for them
to contribute. You can do simple things. There are a few million maid servants. When they fall
sick, who pays for care?
The Employer, in whatever limited manner pays that. If there is a scheme for maid servants
where an empnloyer pays Rs.25 every month for the health care, every employer will pay.}
Shrey Khanna

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SOURCES
1. 12th 5YP-Volume-3

2. http://nrhm.gov.in/images/pdf/NHM/NRH_Framework_for_Implementation__08-012014_.pdf
3. http://nrhm.gov.in/nhm/nrhm/nrhm-framework-for-implementation.html
4. http://nrhm.gov.in/nhm/nuhm/nuhm-framework-for-implementation.html
5. http://pib.nic.in/newsite/erelease.aspx?relid=83131
6. http://nrhm.gov.in/nrhm-components/rmnch-a/child-healthimmunization/immunization/background.html
7. http://forbesindia.com/article/universal-health-care/indias-primary-health-care-needsquick-reform/34899/0
8. http://forbesindia.com/article/universal-health-care/health-care-industry-captains-arewary-of-newer-bets/34909/0
9. www.delhiscienceforum.net/public-health/454-health-sector-reforms-in-india.html
10. http://www.nipfp.org.in/media/medialibrary/2013/04/wp_2012_100.pdf
11. http://www.medanthro.net/research/cagh/insurancestatements/Ahlin%20(India).pdf

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