Draft report of AYUSH Steering Committee for 12th Five Year Plan
Health Aspect of 12th five year plan in India
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12th Five Year Plan
Vikash Keshri
Moderated by:Dr. A. M. Mehendale
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Presentation Outline:
• Five year plans: Brief History
• Planning Commission: Constitution & Functions
• Key Achievement in health sector during 11th Five
Year Plan
• Policy Papers concerned:
– High Level Expert Group on Health (HLEG)
Recommendation
– Approach Paper for 12th Plan
• Focus during 12th Five Year Plan:
Report of steering group on Health
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History:
• "The Constitution of India has guaranteed certain
Fundamental Rights to the citizens of India:
– That the citizens, men and women equally, have the right
to an adequate means of livelihood ;
– The ownership and control of the material resources of
the community are so distributed as best to sub serve the
common good ; and
– The operation of the economic system does not result in
the concentration of wealth and means of production to
the common detriment.
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History …
• Set up by a Resolution of the Government of
India in March 1950.
Objectives:
– To promote a rapid rise in the standard of living of the
people by efficient exploitation of the resources of the
country,
– Increasing production and offering opportunities to all
for employment in the service of the community.
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Five Year Pans:
• First Five-year Plan - 1951
Second Five Year Plan: 1956
Third Five Year Plan: 1961
Plan Holiday: 1966 to 69 due to Indo – Pak War.
Fourth Plan: 1969
Fifth Plan: 1974
Sixth Plan: 1979
Seventh Plan: 1984
No plan due to frequent change of 1989- 90 -91-92 government
at the centre
Eighth Plan: 1992
Ninth Plan: 1997
Tenth Plan: 2002
Eleventh Plan: 2007 -12
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Functions of Planning Commission
• Assessment of the material, capital and human resources
of the country
• Formulate a Plan for the most effective and balanced
utilisation of country's resources;
• Determination of priorities, stages to carry out Plan and
propose the allocation of resources.
• Indicate the factors which are tending to retard economic
development.
• Determine the nature of the machinery necessary for the
successful implementation of Plan.
• Appraise from time to time the progress achieved.
• Make recommendation for policy formulations.
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Organization:
• Chairman – Prime Minister of India
• Deputy Chairman
• Minister of state (Planning)
• Members
• Member Secretary
• Senior Officers
• Grievance officer
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11th Five Year Plan: Key Observation in Health sectors
• Goals of health indicators:
• Percentage of GDP on Health: Less than 1% to 1.4 % and 1.8% including water and
sanitation.• Shortage of health professionals.
Goals 2006 Latest
Infant Mortality rate 57 47 (World Bank)
Maternal mortality ratio
242 212 ( SRS)
Institutional deliveries
54 72 (CES, 2009)
Proportion of Fully Immunized Children
59 73 (CES, 2009)
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Why 12th Plan is Important?
• Millennium Development Goals - 2015.
• The Prime Minister’s Independence day speech
on 15th August.
• First time in the history of India widespread
public consultation to prepare the draft of 12th
Five year plan.
• High level Expert Group on Universal Health
Coverage
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High Level Expert Group on Universal Health Coverage
• Chaired by Dr. K. S. Reddy.• Report submitted in October, 2011.• Mandates:
To address the need of Universal Health Coverage. To address the social determinants of health.
• Definition of UHC by HLEG
“Ensuring equitable access for all Indian citizens, resident in any part of the country, regardless of income level, social status, gender, caste or religion to affordable, accountable, appropriate health services of assured quality (Promotive, preventive, curative and rehabilitative) as well as public health services addressing the wider determinants of health delivered to individuals and populations, with the government being the guarantor and enabler, although not necessarily the only provider, of health and related services.”
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Guiding Principles:
1. Universality,2. Equity, 3. Non-exclusion and non-discrimination,4. Comprehensive care that is rational and of good quality,5. Financial protection, 6. Protection of patients' rights that guarantee
appropriateness of care, 7. Patient choice,8. Portability and continuity of care, 9. Consolidated and strengthened public health provisioning, 10. Accountability and transparency, 11. Community participation and12. Putting health in People’s hands.
• Two critical factors to achieve and sustain UHC: Social determinants of health and Gender Issues
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Vision for UHC
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The New Architecture for UHC
1. Health Financing and Financial Protection
2. Health Service Norms
3. Human Resources for Health
4. Community Participation and Citizen
Engagement
5. Access to Medicines, Vaccines and Technology
6. Management and Institutional Reforms
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HEALTH FINANCING AND FINANCIAL PROTECTION:
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Recommendations:• Increase public expenditures on health:
1.2% of GDP to 2.5% by the end of the 12th plan, To at least 3% of GDP by 2022.
• Ensure availability of free essential medicines:– Increasing public spending on drug procurement.
• Use general taxation as the principal source of health care financing – complemented by additional mandatory deductions for health
care from salaried individuals and tax payers, either as a proportion of taxable income or as a proportion of salary.
• Do not levy sector-specific taxes for financing.
• Do not levy fees of any kind for use of health care services under the UHC.
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• Introduce specific purpose transfers to equalize the levels of per capita public spending on health across different states .
• Accept flexible and differential norms for allocating finances.
• Expenditures on primary health care, should account for at least 70% of all health care expenditures.
• Do not use insurance companies or any other independent agents to purchase health care services on behalf of the government.
• Purchases of all health care services under directly by the Central and state governments or autonomous agencies.
• All government funded insurance schemes should, over time, be integrated with the UHC system.
• Develop a National Health Package.
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HEALTH SERVICES:Recommendations:
• Develop a National Health Package
• Develop effective contracting-in guidelines for the provision
of health care by the formal private sector.
• Reorient health care provision to focus significantly on
primary health care.
• Strengthen District Hospitals.
• Ensure equitable access to functional beds for guaranteeing
secondary and tertiary care.
• Ensure adherence to quality assurance standards at all
levels of service delivery.
• Ensure equitable access to health facilities in urban areas
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HUMAN RESOURCES FOR HEALTH:
This recommendation has two implications. More equitable distribution of human resources Potential to generate around 4 million new jobs (including over
a million community health workers) over the next ten years.
• Recommendations: Ensure adequate numbers of trained health care providers
and technical health care workers at different levels bya) Giving primacy to the provision of primary health care b) Increasing HRH density to achieve WHO norms of at least 23
health workers per 10,000 populations (doctors, nurses, and midwives).
More specifically the following is proposed:• Community Health workers:
– Two community health workers (CHW's or Accredited Social Health Activists (ASHAs)) population in rural and tribal areas.
– At least one female– Similarly trained CHW for every 1000 population among low-
income vulnerable urban communities.
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• Rural Health Care Providers: Bachelor of Rural Health Care (BRHC) • Nursing staffs• AYUSH• Allied Health Professionals• Allopathic Doctors• Finally the manpower at different level
– Village and community level: • Two health worker (1 ASHA and 1 AWW with helper)• Similarly 1 CHW in vulnerable urban area
– Sub centre• At least 2 ANM and one male health worker• Supplementation with Rural Medical Practitioners
--Primary Health Centre• In addition to IPHS, AYUSH Pharmacist, dentist, additional
doctor and Male health worker– Community Health Centres level:
• Increase no. of staff nurse to 19 and additional male health worker, Physiotherapist.
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• Enhance the quality of HRH education and training by
introducing competency-based, health system-connected
curricula and continuous education.
• Invest in additional educational institutions
• Establish District Health Knowledge Institutes (DHKIs).
• Strengthen existing State and Regional Institutes of Family
Welfare
• Establish a dedicated training system for Community
Health workers
• Establish State Health Science Universities.
• Establish the National Council for Human Resources in
Health (NCHRH).
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COMMUNITY PARTICIPATION AND CITIZEN ENGAGEMENT
COMMUNITY PARTICIPATION AND CITIZEN ENGAGEMENT:
• Transform existing Village Health Committees or Health and
Sanitation Committees into participatory Health Councils.
• Organize regular Health Assemblies.
• Enhance the role of elected representatives as well as Panchayati Raj
institutions (in rural areas and local bodies in urban areas).
• Strengthen the role of civil society and non-governmental
Organizations.
• Institute a formal grievance redressal mechanism at the block level.
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ACCESS TO MEDICINES, VACCINES AND TECHNOLOGY:
• Current Scenario: Almost 74% of private out-of-pocket expenditures.
Millions of Indian households have no access to
medicines.
Drug prices have risen sharply in recent decades.
India's dynamic domestic generic industry is at risk of
takeover by multinational companies.
The market is flooded by irrational, nonessential, and
even hazardous drugs.
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Recommendations:• Enforce price controls and price regulation especially on
essential drugs.• Revise and expand the Essential Drugs List.• Strengthen the public sector to protect the capacity of
domestic drug and vaccines industry to meet national needs.• Ensure the rational use of drugs.• Set up national and state drug supply logistics corporations.• Protect the safeguards provided by the Indian patents law
and the TRIPS Agreement against the country's ability to produce essential drugs.
• Empower the Ministry of Health and Family Welfare to strengthen the drug regulatory system.
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MANAGEMENT AND INSTITUTIONAL REFORMS Managerial reforms: • Recommendations:• Introduce All India and state level Public Health Service
Cadres & specialized state level Health Systems Management Cadre.
• Adopt better human resource practices and assure career tracks for competency-based professional advancement.
• Develop a national health information technology network
• Ensure strong linkages and synergies between management and regulatory reforms and ensure accountability to patients and communities.
• Establish financing and budgeting systems to streamline fund flow.
• Invest in health research
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• The committee recommend the establishment of the following agencies:– National Health Regulatory and Development
Authority (NHRDA): The main functions of the NHRDA will be to regulate and monitor public and private health care providers, with powers of enforcement and redressal.
Three Units:• The System Support Unit (SSU):• The National Health and Medical Facilities Accreditation
Unit (NHMFAU):• The Health System Evaluation Unit (HSEU):
– National Drug Regulatory and Development Authority (NDRDA):
– National Health Promotion and Protection Trust (NHPPT):
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Actual framework for 12th Plan
• A Renewed Commitment to Public Health:• Review of the health system during the previous
Plan:• Identifying Structural Problems: • Goals for Health Systems: National Health Outcome Goals for the 12th Plan:
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Maternal Mortality Ratio
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Infant Mortality Rate
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Total Fertility Rate
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Underweight Children
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Prevalence of Anaemia
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Child Sex Ratio ( 0 t0 02 Year)
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Out of Pocket Expenditure
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National Health Programmes:
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Health Information System:
A composite HIS should incorporate the following:
• Universal registration of births, deaths and cause of death. Maternal and infant death reviews.
• Nutritional surveillance, in women in the reproductive age group and under six children, linked to the ICDS Programme.
• Disease surveillance• Out-patient and in-patient information through Electronic
Medical Records (EMR).• Data on Human Resource within the public health system.• Financial management in the public health system. • Use of Communication and Information Technology (ICT)
in medical education• Tele-medicine and consultation support
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• Nation-wide registries of clinical establishments,
manufacturing units, drug-testing laboratories, licensed
drugs and approved clinical trials.
• Access of public to their own health information and
medical records.
• Programme Monitoring support for National Health
Programmes
• A computer with internet connectivity in every PHC and
all higher health facilities .
• M-Health, the use of mobile phones to speed up
transmission of data and reduce burden of work.
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Convergence with other Social Sector Programmes (Specially ICDS)
At the National and State Levels:• National Mission Steering Group,• Empowered Programme Committee, • National Programme Consultative Committee,
and• State level corresponding institutional
mechanisms (State Health Mission and State Health Society) as nodal institutions to undertake convergence initiatives.
District levels and below:• Local Self Government Bodies
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Some areas of Convergence between ICDS and HealthSuggested mechanism to achieve inter-sectoral
coordination and convergence with ICDS • Harmonization of ICDS and Health Blocks. • Roles of grass root workers clearly delineated.
AWC for health and nutrition and ASHA for her outreach activities.
• Development of joint field operational plans.• Ensuring effective and efficient operation of
Village Health and Nutrition Days.• Creating a direct reporting relationship between
AWCs and Sub-Centres
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Public Health Management
The objective “fulfill society's interest in assuring conditions in which people can be healthy.”
• The three core public health functions are:– Assessment and monitoring in order to identify health
problems and priorities;– Formulation of public policies to solve local and national
health problems and to set priorities; and– To ensure that every person has access to appropriate
and cost-effective care.
• Recommendations:– Developing and deploying a Public Health Cadre.– Territorial responsibility of Public Health officials.– Training for Public Health functionaries at all
levels:
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• Decentralization of responsibilities by involving Local
Self-Government Bodies:
• Regular, institution based health checks:
• Attention to balanced nutrition:
• Health Education campaign:
• Standards, regulations and Acts for public health:
• Enhancing community participation in planning,
implementation, monitoring and evaluation
• Occupational health:
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Tertiary Care System:
Current Scenario:Total No. of medical colleges = 335 Annual Training Capacity (UG) = 41569 Annual Training Capacity (PG) = 20858 Bed Strength = 2 lac (approx.)Private hospitals .Target:• Doctor : Population = 1 : 2000 (approx.)• Nurse : Population = 1 : 1130• Nurse : Physician = 1.5 : 1
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Projected Scenario:
• Doctor –Population Ratio = 1:2000 (existing approx.)
• Registered doctors =7.5 lakhs
• Active =5.5 lakhs.
• Existing training capacity (MBBS) = 41569
• Targeted training capacity (MBBS) = 80,000 (By 2021)
• Existing training capacity (PG) = 20868
• Targeted training capacity (PG) = 45, 000 (By 2021)
• Doctor –Population Ratio = 1:1000 (Targeted)
• To achieve this, an additional 5.5 lakh doctors required
which will be available by 2020.
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Human resource for health:
• Estimated HR in Health care in rural area.
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Skilled health workers:
Four categories require expansion:• Medical Graduates:• Medical and Surgical Specialists:• Para-medical workers for health facilities:• Public Health professionals and community-based workers:Recommendations:• Expansion of Medical, Public Health, Nursing and
paramedical education• Central Cadre of Medical Teachers: • New category of mid-level health workers through a 3 year
training programme:• Orienting medical education to the needs of society:
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• Integrating of non-qualified practitioners into the
health system after suitable training:
• Mandate Continuing Medical Education to retain
license to practice:
• Better Information on Human Resource in
Health:
• Ensuring adequate human resource for key tasks
• Human Resources Regulatory Functions:
• Norms for Staffing of Public Facilities:
• Management system for human resource in
health:
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Regulation of Food, Drugs, Medical Practice and Public Health
• Regulation of Drugs:
• Regulation of Medical Practice:
• Pre-Conception and Pre-Natal Diagnostic
Techniques (Prohibition of Sex Selection) Act,
1994:
• Public Health regulation:
• General regulatory issues:
Quality Council of India (QCI)
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Promoting Health Research
The Department of Health Research (DHR) created on 5th October 2007
• The strategies for health research in the 12th Plan should be the following:
• Address national health priorities: • Maternal and child nutrition, health and survival;• High fertility in parts of the country;• Low child sex ratio and discrimination against girl child;• Prevention, early detection, treatment, rehabilitation to
reduce burden of diseases –• Communicable, non-communicable (including mental
illnesses) and injuries;• Sustainable health financing aimed at reducing household's
out-of-pocket expenditure;
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• HIS covering universal vital registration, community based
monitoring, disease
• Surveillance and hospital based information systems for
prevention, treatment and teaching;
• Measures to address social determinants of health and
inequity, particularly among marginalized populations;
• Suggest and regularly update Standard Treatment
Guidelines which are both necessary and cost-effective for
wider adoption;
• Public health systems and their strengthening; and
• Health regulation, particularly on ethics issues in
research.
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• Build Research Coordination Framework:
– Efficient research governance, regulatory and evaluation framework:
– Nurture development of research centres and labs:– Utilize available research capacity by promoting
Extramural research:– Build on strengths of Indian Systems of Medicine and
Homeopathy:– Develop Human Resources:– Cost-effectiveness studies to frame Clinical Treatment
Guidelines:
• AYUSH – Integration in Research, Teaching and Health Care
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Inclusive Agenda
To meet the special needs of the marginalized, the Steering
Committee recommends the following:
• Access to services:
• Special services for vulnerable populations:
• Disaggregated monitoring and evaluation systems:
• Including representatives of marginalized and
disadvantaged segments of the population in community
fora:
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References:
• History, Constitution of Planning commission in India: Available on URL: http://www.planningcommission.nic.in/index.php
• Planning commission. Report of High level Expert Group on
Health, Oct.2011.
• Planning Commission. Faster, sustainable and more inclusive growth, Approach Paper for 12th Five year plan. August 2011.
• Health Division, Planning Commission. Report of Steering
Committee on health for 12th five year plan (includes recommendation of all working group. February 2012