Vikash Keshri Moderated by: Dr. A. M. Mehendale 12th Five Year Plan Vikash Keshri Moderated by: Dr. A. M. Mehendale

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

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.

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.

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

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.

Organization: Chairman – Prime Minister of India Deputy Chairman Minister of state (Planning) Members Member Secretary Senior Officers Grievance officer

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)

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

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.”

Guiding Principles: Universality, Equity, Non-exclusion and non-discrimination, Comprehensive care that is rational and of good quality, Financial protection, Protection of patients' rights that guarantee appropriateness of care, Patient choice, Portability and continuity of care, Consolidated and strengthened public health provisioning, Accountability and transparency, Community participation and Putting health in People’s hands. Two critical factors to achieve and sustain UHC: Social determinants of health and Gender Issues

Vision for UHC

The New Architecture for UHC Health Financing and Financial Protection Health Service Norms Human Resources for Health Community Participation and Citizen Engagement Access to Medicines, Vaccines and Technology Management and Institutional Reforms

HEALTH FINANCING AND FINANCIAL PROTECTION:

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.

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.

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

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 by Giving primacy to the provision of primary health care 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.

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.

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).

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.  

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.

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.

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

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):

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:

Maternal Mortality Ratio

Infant Mortality Rate

Total Fertility Rate

Underweight Children

Prevalence of Anaemia

Child Sex Ratio ( 0 t0 02 Year)

Out of Pocket Expenditure

National Health Programmes:

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

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.

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

Some areas of Convergence between ICDS and Health Suggested 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

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:

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:

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

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.

Human resource for health: Estimated HR in Health care in rural area.

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:

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:  

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)

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;

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.

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

  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:

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