2012 icsa gs indian economics lecture 4


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2012 icsa gs indian economics lecture 4

  1. 1. UPSC Civil Services Examination,2012 Health and Family Welfare in India Incorporating the Mid-term Appraisal of Eleventh Five Year Plan Prof. Subir Maitra, Institute for Civil Service Aspirants, Salt Lake ,Kolkata (in collaboration with Confedaration of Indian Industries--CII) iasstudymat.blogspot.com 21.01.2012 Prof. S.Maitra21 January, 2012 1 iasstudymat.blogspot.com
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  10. 10. 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. Prof. S.Maitra21 January, 2012 10 iasstudymat.blogspot.com
  11. 11. Health: Eleventh Plan Goals•To raise public spending on health from 0.9 per cent of GDP to 2-3per cent of GDP, with improved arrangement for communityfinancing and risk pooling.•To undertake architectural correction of the health system toenable it to effectively handle increased allocations and promotepolicies that strengthen public health management and servicedelivery 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, integratedcomprehensive primary health care, with emphasis on servicesaddressing women’s and children’s health and universalimmunization.•Prevention and control of communicable and non-communicablediseases, including locally endemic diseases.•Population stabilization, gender and demographic balance.•Revitalize local health traditions and mainstream AYUSH.•Promotion of healthy lifestyles. S.Maitra 21 January, 2012 Prof. 11 iasstudymat.blogspot.com
  12. 12. 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 until2012.•Filaria / Microfilaria Reduction Rate: 70 per cent by 2010, 80 per cent by 2012 andelimination 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 10,000thereafter.•Tuberculosis DOTS series: Maintain 85 per cent cure rate through entire mission period andalso 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 20per cent to over 75 per cent.•Engaging 4,00,000 female Accredited Social Health Activists (ASHAs). Prof. S.Maitra 21 January, 2012 12 iasstudymat.blogspot.com
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  14. 14. 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 areavailable on the progress of MMR during the Eleventh Plan period i.e. the periodbeginning 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 wisedecline during the pre-Eleventh Plan period varied from an average of 26 per year forUttar Pradesh/Uttarakhand, 20 per year for Bihar/Jharkhand, 19 per year forRajasthan, 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, thescope for expanding timely access to quality institutional care is limited, particularlyfor those living in remote and inaccessible areas. In such a scenario, the MMR goal Prof. S.Maitraof 21 January,achievable only through appropriate area specific interventions. 100 is 2012 iasstudymat.blogspot.com 14
  15. 15. Infant Mortality Rate (IMR) Although IMR is showing a downward trend, but the rate of improvement heretoo has to be three times that in the past so as to attain the level expected by the endof Eleventh Plan. All India IMR was 57 in 2006 and 53 in 2008 (SRS), a decrease of 4in two years. High focus States of NRHM have shown marginally better performancein rural areas, where IMR has decreased by 5 in two years. Tamil Nadu has alsoshown marginally better performance, a decline of 6 in two years. To achieve IMR of28 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 onvalidated models such as the Gadchiroli model and make focused efforts forencouraging breast feeding and safe infant and child feeding practices. Whileemphasis on early breast feeding is part of ASHAs training, special training onneonatal care for community and facility level health functionaries will facilitate afaster reduction in IMR. Prof. S.Maitra 21 January, 2012 15 iasstudymat.blogspot.com
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  20. 20. HOME BASED NEWBORN CARE (HBNC)•Efforts to improve home based care have proven successful at improvingchild survival. Home Based Newborn and Child Care is to be provided by atrained Community Health Worker (such as the ASHA) who guides andsupports the mother, family, and TBA in the care of newborn, and attendsthe newborn at home if she is sick. The worker is supervised by a fieldperson (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 Gadchirolimodel, where appreciable decline in IMR has been documented on the basisof work done by a VO called SEARCH. Gadchiroli has shown how ordinarywomen can do extraordinary things: a well-trained local woman can notonly lower neonatal mortality but can also bring about attitudinal change.The women Shishu Rakshaks of Gadchiroli have managed to dispel manymyths surrounding pregnancy and have been able to ensure betternutrition, care, immunization, and hygiene.•The national strategy during the Plan will be to introduce and makeavailable high-quality HBNC services in all districts/areas with an IMRmore than 45 per 1000 live births. Apart from performance incentive toASHAs, an award will be given to ASHAs and village community if nomother–newborn or child death is reported in a year. Prof. S.Maitra 21 January, 2012 20 iasstudymat.blogspot.com
  21. 21. National Rural Health Mission•NRHM was launched on April 12, 2005, to provide accessible, affordable and accountable qualityhealth services to the poorest households in the remotest rural regions. Allocation has been increased toRs. 12,070 crore in interim budget for 2009-10 compared to Rs. 12,050 crore in 2008-09. NRHM isbeing operationalized throughout the country, with special focus on 18 states which includes 8Empowered 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 reliableprimary health care facilities, especially, to the poor and vulnerable sections of the population. It alsoaims at bridging the gap in rural health care services through the creation of a cadre of Accredited SocialHealth Activists (ASHA) and improved hospital care, decentralization of programme to district level toimprove intra and inter-sectoral convergence and effective utilization of resources. NRHM further aimsto provide overarching umbrella to the existing programmes of health and family welfare includingRCH-II, malaria, blindness, iodine deficiency, filaria, kala-azar, tuberculosis, leprosy and for integrateddisease surveillance. Further, it addresses the issue of health in the context of sector-wide approachtowards sanitation and hygiene, nutrition and safe drinking water as basic determinants of good health inorder to have greater convergence among the related social sector departments i.e. AYUSH, Women &Child Development, Sanitation, Elementary Education, Panchayati Raj and Rural Development. Themission further seeks to buildgreater ownership of the programme among the community throughinvolvement of Panchayati Raj Institutions, NGOs and other stakeholders at national, state, district andsub-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 tobelow 100/100,000 live births & TFR to 2.1 by 2012. Prof. S.Maitra 21 January, 2012 21 iasstudymat.blogspot.com
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  24. 24. Performance of NRHM:•7.49 lakh Accredited Social Health Activists (ASHAs) have been selected though the total number ofthose who have completed all training modules is low. Against the target of 6 lakh fully trained ASHAs by2008 there are 5.19 lakh ASHAs positioned with drug kits, but their training is still to be completed. Onlyabout 1.99 lakh ASHAs have completed all five modules and 5.65 lakh have completed up to fourthtraining module.•4.51 lakh Village Health and Sanitation Committees (VHSCs) have been set up against the target of 6lakh VHSCs by 2008. The operational effectiveness of the VHSCs, however, needs considerableimprovement.•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 StaffNurses against the target of 18,000 PHCs by 2009.•3,966 Community Health Centres (CHCs) are functional on 24X7 basis. However, information regardingthe target of strengthening 3250 CHCs with seven specialists and nine staff nurses by 2009 is notavailable. In any case, the number of CHCs/Sub-Divisional Hospitals or equivalent, which have beenupgraded to First Referral Unit (FRU) has increased from 750 (as on 31 March 2005) to 1934 (as on 31December 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 atPHC/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 ProgrammeManagers 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 inAndhra Pradesh, Gujarat, Karnataka, Goa, Uttarakhand, Assam and Rajasthan, GPS enabled MMUs inGujarat, Haryana and Tamil Nadu are operational. Prof. S.Maitra 21 January, 2012 24 iasstudymat.blogspot.com
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  26. 26. Human Resources for Health•Measures have been taken during the Eleventh Five Year Plan period to solvethe problem of shortage of basic education infrastructure and humanresources:.•Ensure availability of medical professionals in rural areas on a permanentbasis, posting of doctors with adequate monetary as well as non-monetaryincentives, such as suitable accommodation, class I status, preferential schooladmissions for children of doctors living in remote areas, transfer or posting ofchoice after a stipulated length of stay and training opportunities.•States to expand the pool of medical practitioners including a cadre ofLicentiate Medical Practitioners and practitioners of Indian Systems of Medicineand Homeopathy (AYUSH).••Increase age of retirement of doctors (all Central and State Governmentincluding Defence, Railways, etc.) to 62 years. States will be encouraged toretain public health doctors on contract basis for further period of three yearstill the age of 65 years, especially in the notified hardship areas.•• A series of one-year duration Certificate Courses for MBBS graduates will belaunched in deficit disciplines like public health, anaesthesia, psychiatry,geriatric care, and oncology. The private sector will also be encouraged toparticipate Prof. S.Maitra 21 January, 2012 26 iasstudymat.blogspot.com
  27. 27. Qualitative Feedback of NRHM: Voices from the FieldAccredited Social Health Activists (ASHAs)The appointment of locally recruited women as Accredited Social Health Activists (ASHAs) who would linkpotential beneficiaries with the health service system is an important element of the NRHM. The good partis that7.49 lakh ASHAs have been appointed; but several issues still need to be resolved. Not only is there alack of transparency in the selection, ASHAs are often inadequately trained. Besides, their only focusseems to be on facilitating institutional deliveries. The ASHA who accompanies the expectant motherfaces considerable hardship because she has nowhere to stay for the duration of confinement asinstitutional accommodation facilities are non-existent. They also often experience long delays in paymentof incentives.Village Health and Nutrition Day (VHND)An important activity of NRHM, Village Health and Nutrition Day is topromote regular community-oriented health and nutrition activities. Theevent is held on a fixed day every month to sensitise the community and ispopularly known as ‘Tika Karan Divas’. However, implementation is ad-hoc in most villages of the high focus States. Surveys revealed that only afew pockets in some States like Tamil Nadu, Andhra Pradesh, West Bengaland Assam were aware of VHND. The other drawback of the programmewas that it often restricted itself to immunisation and antenatal check upare done on the day. There is no nutrition education. To have the desiredimpact, VHNDs need to be implemented with the full intended content ofactivities and with regularity. This can be achieved through more activeinvolvement of NGOs and community based organizations. Prof. S.Maitra 21 January, 2012 27 iasstudymat.blogspot.com
  28. 28. Janani Suraksha Yojana (JSY)Launched to promote institutional deliveries, JSY provides cashincentive to expectant mothers who opt for institutional delivery.Poor women from the remote districts in Bihar, Orissa and otherStates are reported to be visiting institutions to avail JSY benefits.However, except for parts of Southern States, most public healthinstitutions are not well equipped for conducting deliveries at thecommunity or even at the block level. The beneficiaries are oftenasked to purchase gloves, syringes and medicines from the market.The general view, endorsed by visits to the field is that the healthcentres and subdivisional hospitals remain understaffed and arepoorly run and maintained. A very large number are unhygienic andincapable of catering to the patient load. Women who deliver at thehealth facility are discharged a few hours after delivery. Sometimes,deliveries take place on the way to the health facility or even outsidethe locked labour rooms. Lack of co-ordination and mutualunderstanding between the ANM and ASHA results in the sufferingof pregnant women. 21 January, 2012 Prof. S.Maitra 28 iasstudymat.blogspot.com
  29. 29. Maternal & Child HealthNRHM has been able to provide an extensive network of transport facilities inStates that have established emergency transport systems. On the other hand,there is very little awareness about the Integrated Management of Neonatal andChildhood Illnesses (IMNCI) strategy. In the event of illness of either the mother orthe neo-nate, RMPs (some times even local quacks) are consulted. Home-basednew born care based on Gadchiroli model and other community based innovationshave 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 tosupplement the efforts being made to provide quality health care to the poor andunderprivileged population. It provides cashless health insurance cover up to Rs.30,000 perannum per family. The premium is paid by the Centre and State Governments on a 75:25sharing basis with the beneficiary paying only a registration fee.Twenty-five States are in the process of implementing the RSBY and till February 2010, morethan 1.25 crore biometric enabled smart cards have been issued for providing healthinsurance cover to more than 4 crore people, from any empanelled hospital throughout thecountry. Around 4.5 lakh persons have already availed hospitalisation facility. The scheme isnow being gradually extended to the non-BPL category of workers as well. Linkages withRSBY in public sector hospitals need to be strengthened. Prof. S.Maitra 21 January, 2012 29 iasstudymat.blogspot.com
  30. 30. National AIDS Control Programme (NACP)The NACP goal was to halt and reverse the epidemic in Indiaover the five years period of the Eleventh Plan. This was to bedone by integrating programmes for prevention, care, supportand treatment, as well as addressing the human rights issuesspecific to people living with HIV/AIDS (PLWHA).. Althoughthe achievement of physical targets under the programme issatisfactory, MoHFW has yet to introduce a HIV/AIDS Bill toprotect the rights of children, women and HIV infected personsand avoid discrimination at work place. A National BloodTransfusion Authority is to be established during theremaining period of the Plan. Voluntary blood donation has tobe encouraged further to bridge the gap in demand andsupply of blood. Expenditure under National AIDS ControlProgramme including STD control during 2007-08 and2008-09, has been 112.60 per cent and 91.91 per cent of theapproved. Prof. S.Maitra 21 January, 2012 30 iasstudymat.blogspot.com
  31. 31. Pradhan Mantri Swasthya Suraksha Yojana (PMSSY)•The PMSSY envisages substantial expansion of central and state governmentmedical institutions. Phase 1 of PMSSY envisages establishment of six new AIIMSlike 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 estimateis about Rs. 820 crore. For these new ‘AIIMS like institutions’, construction ofmedical colleges and hospital complexes and construction of residentialcomplexes have been taken up as separate activities. Construction of housingcomplex at all six sites has commenced and work for medical colleges andhospital complexes is likely to start in the second quarter of 2010-11.The second component of PMSSY Phase 1 includes upgradation of 13 StateGovernment medical college institutions. These are at Government MedicalCollege, Jammu (Jammu & Kashmir); Government Medical College, Srinagar(Jammu & Kashmir); Kolkata Medical College, Kolkata (West Bengal); SanjayGandhi Post Graduate Institute of Medical Sciences, Lucknow (Uttar Pradesh);Institute of Medical Sciences, BHU, Varanasi (Uttar Pradesh); Nizam Institute ofMedical Sciences, Hyderabad (Andhra Pradesh); Sri Venkateshwara Institute ofMedical Sciences, Tirupati (Andhra Pradesh); Government Medical College,Salem (Tamil Nadu); Rajendra Institute of Medical Sciences, Ranchi Prof. S.Maitra 21 January, 2012 31 iasstudymat.blogspot.com
  32. 32. •(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 isRs.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 therespective States. The State Governments will also provide the resources (human resourcesand recurring expenditure) for running the upgraded facilities. Upgrading of two StateGovernment medical college institutions is over. Another four are expected to be upgraded byJuly 2010, two by December, 2010 and the remaining in 2011.•Phase II of PMSSY, approved recently, provides for the establishment of two new AIIMS likeinstitutions in Uttar Pradesh and West Bengal and upgrading of six State Government medicalcollege institutions at Government Medical College, Amritsar (Punjab); Government MedicalCollege, Tanda (Himachal Pradesh); Government Medical College, Nagpur (Maharashtra);Jawaharlal Nehru College of Aligarh Muslim University, Aligarh (Uttar Pradesh); GovernmentMedical College, Madurai (Tamil Nadu) and Pandit B.D. Sharma Postgraduate Institute ofMedical Sciences, Rohtak (Haryana).•Overall expenditure under PMSSY had shown improvement in 2008-09with 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 currentyear (2009-10) is only 47.21 per cent of the approved outlay for 2009-10. Prof. S.Maitra 21 January, 2012 32 iasstudymat.blogspot.com
  33. 33. 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 relatednon-communicable diseases and systemic diseases. To mainstreamAYUSH by designing strategic interventions for wider utilization of AYUSHboth domestically and globally, the thrust areas in the Eleventh Five YearPlan are: strengthening professional education, strategic researchprogrammes, promotion of best clinical practices, technology upgradationin industry, setting internationally acceptable pharmacopoeial standards,conserving medicinal flora, fauna, metals, and minerals, utilizing humanresources of AYUSH in the national health programmes, with the ultimateaim 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 onupgradation of AYUSH educational standards, quality control, andstandardization of drugs, improving the availability of medicinal plantmaterial, R&D, and awareness generation about the efficacy of the systemsdomestically and internationally. Steps were taken in 2006–07 formainstreaming AYUSH under NRHM with the objective of optimumutilization of AYUSH for meeting the unmet needs of the population. Prof. S.Maitra 21 January, 2012 33 iasstudymat.blogspot.com
  34. 34. Health Care Services under AYUSH•The AYUSH sector across the country supported a network of3203 hospitals and 21351 dispensaries. The health servicesprovided by this network largely focused on primary health care.The sector has a marginal presence in secondary and tertiaryhealth care. In the private and not-for-profit sector, there areseveral thousand AYUSH clinics and around 250 hospitals andnursing homes for in patient care and specialized therapies likePanchkarma.•In clinics and nursing homes there are anecdotal reports of therole of AYUSH in the successful management of severalcommunicable and noncommunicable diseases. However, there isno macrodata available about the contribution of AYUSH to majornational programmes for the management of communicable andNCDs. A major challenge in Eleventh Five Year Plan is to identifyreputed clinical centres and support upgradation of their facilitiesvia PPP schemes so that the country can boast of a nationalnetwork of high-quality clinical facilities developed for renderingspecialized health care in strength areas of AYUSH. Prof. S.Maitra 21 January, 2012 34 iasstudymat.blogspot.com
  35. 35. AYUSH under NRHM•Despite having a different scheme of diagnosis, drugrequirements, and treatments as compared to the mainstreamhealth care system, preliminary efforts to integrate AYUSH inNRHM were initiated during the Tenth Plan. It is too early to assessif the AYUSH interventions in NRHM have had significant healthimpact by way of complementing the conventional national healthprogrammes. Integrating AYUSH into NRHM has the potential ofenhancing both the quality and outreach of NRHM, especially withthe availability of a large number of practitioners in this field.Supporting strategic pilot action research projects in the EleventhFive Year Plan to evolve viable models of integration seemsnecessary.Mainstreaming AYUSH•NRHM has mainstreamed AYUSH into the rural health services byco-locating AYUSH personnel in primary health care facilitiesresulting in increase in utilization of AYUSH treatment. AYUSHpractitioners are also used to fill in the position of Allopaths inPrimary Health Centres particularly in States that have asubstantial shortage of MBBS doctors. While this is a positivedevelopment, efforts have to be made for training AYUSH Prof. S.Maitrapractitioners in public health. 21 January, 2012 iasstudymat.blogspot.com 35