1. Health planning in India
By - Dr Pranali
Moderator - Dr Ashwini Kalantri

2. Framework Introduction Planning commission Historical background
Five year plans
National Health policy
NITI Aayog
Responsibility of centre, state and district
SWOT analysis of Health planning in India
References

3. Introduction Health planning is part of national development planning.
necessary for the economic utilization of material, manpower and financial resources.
National Health Planning has been defined as the orderly process of
defining community health problems
identifying unmet needs
surveying the resources to meet them
establishing priority goals that are realistic and feasible, and
projecting administrative action to accomplish the purpose of the proposed programme. (*WHO)

4. Planning commission
After independence in 1950 Planning Commission was established, which launched first five year plan in 1951
It was set up to make an assessment of the material, capital and human resources, and to draft developmental plans for the most effective utilization of resources addressing the needs of the community and country
29 divisions in the Planning Commission
like agriculture, health, nutrition, education, environment, family welfare, housing, water supply, manpower, rural development, multilevel planning and monitoring, etc
In 1957, the Planning Commission was provided with a Perspective Planning Division which makes projections into the future over a period of yrs

5. Planning commission cont..
The membership of the planning commission is highly distinguished and the Prime Minister was the chairman
It consists of Chairman, Deputy Chairman and 5 members
It works through 3 major divisions –
Programme Advisors
General Secretariat
Technical Divisions
Reviewed the progress made in various directions and makes recommendations to Govt on problems and policies relevant to rapid and balanced economic development

6. Planning commission- health sector
The PC gave considerable importance to health programmes in overall development
A Bureau of Planning was constituted in 1965 in the Ministry of Health to have better coordination between Centre and State Governments.
The health sector is divided into the following subsectors –
Water supply and sanitation
Communicable diseases
Medical education, training and research
Curative services i.e., Hospitals, PHCs, etc.
Public Health Services
Family Planning
Indigenous Systems of Medicine
The working of the national plans is reviewed time to time by National Development Council, which decides the social and economic policy affecting national development

7. Bhore committee, 1946
The most comprehensive health policy and plan document
Health Survey and Development Committee Report
appointed in 1943 with Sir Joseph Bhore as its Chairman
It made comprehensive recommendations for remodeling of health services
broad survey of the present position in regard to health conditions and health organization in British India, and recommendations for future development
Its secretary
was Dr. KCKE Raja and one of the joint secretaries Dr. K.T. Jungalwala.
Some of the well-known members included Dr. J.B. Grant, Dr. B.C. Roy,
Pandit P.N. Sapru and Dr. A.L. Mudaliar.

8. Recommendations by Bhore committee
Integration of preventive and curative services of all administrative levels
Major changes in medical education which includes three months training in preventive and social medicine to prepare social physicians
Development of Primary Health Centers in 2 stages :
Short‐term measure
One PHC for a 40,000 population
Secondary health center provide support, coordinate and supervise PHC
A long‐term programme of setting up
primary health units with 75 bedded hospitals for 10,000 to 20,000 population
secondary units with 650 bedded hospital, regionalized around district hospitals with 2500 beds
2 doctors, 1 nurse, 4 PHN, four midwives, four trained dais, two SI, two HA, one pharmacist and 15 class IV employees.
minimum
requirement recommended by the Bhore Committee was:
• 567 hospital beds per 100,000 population
• 62.3 doctors per 100,000 population
• nurses per 100,000 population (Bhore, 1946: III.3-4)
What existed at that time (1942) in India was:
• 24 beds per 100,000 population
• doctors per 100,000 population
• 2.32 nurses per 100,000 population (Bhore, 1946: I.13)

9. First five year plan (1951-1956)
The social sectors like health, education, water supply and housing have received only residual resources
The sectors that have received over 55% of plan resources are industry, power, and transport and communication (which constitute the basic economic infrastructure of an industrial economy)

10. Second five year plan (1956-1961)
During the first two Five Year Plans the basic structural framework of the public health care delivery system remained unchanged
Urban areas continued to get over three-fourth of the medical care resources whereas rural areas received special attention under the Community Development Program (CDP).
Under CDP, primary health unit/per development Block (70,000 population spread over 100 villages) and supported by a Secondary health unit (hospital with mobile dispensary) for every three such primary health units.
The aim of this health organization was: the improvement of environmental hygiene, including provision and protection of water supply, proper disposal of human and animal wastes, control of epidemic diseases, provision of medical aid along with appropriate preventive measures, and education of the population in hygienic living and in improved nutrition.
According to govt own evaluation report, The CDP was failing even before the Second Five Year Plan began

11. Second five year plan cont..
Health care facilities were far below any acceptable human standard
Even the targets set out by the Bhore Committee were nowhere close to being achieved
Curative health care services in the country are mostly provided by the private sector and preventive and promotive services are almost entirely provided by the State sector
Major focus – manage epidemics
Vertical programmes e.g. The National Malaria Eradication Programme
malaria, smallpox, tuberculosis,
Leprosy, filaria, trachoma and cholera

12. Mudaliar committee, 1962 Health Survey and Planning Committee
headed by Dr. Mudaliar, was set up in 1959
To assess the performance in health sector since the submission of Bhore Committee report
To evaluate the progress made in the first 2 plans
To make recommendation for the future path of development of health services
This committee found the conditions in PHCs to be unsatisfactory
only 2800 PHCs existing by the end of 1961
Most of the PHC's were understaffed, large numbers of them were being run by ANM's or public health nurses in charge.
disease control programmes had some substantial achievements in controlling certain virulent epidemic diseases, malaria, cholera, smallpox (morbidity and mortality reduced)

13. Recommendations of Mudaliar committee
Strengthening of the district hospitals with specialists services
Regional organizations in each state between the headquarters organization and the district in charge of a Regional Deputy or Assistant Directors – each to supervise 2 or 3 district medical or health officers
Each PHC not to serve more that population
To improve the quality of health care provided by PHC
Integration of medical and health services
Constitution of an All India Health service on the pattern of Indian Administrative Services

14. Third ( )
For rural area: one Primary Health Unit/140,000 population, one hospital/320,000 population, one bed/7000 population
In sharp contrast urban areas had one hospital/36,000 population and one hospital bed/440 urban residents
directed attention to the shortage of health personnel, delays in the construction of PHCs, buildings and inadequate training facilities in the rural areas
But, no mention was made of any specific steps to reach this goal
new short term course for the training of medical assistants should be instituted and after these assistants had worked for 5 years at a PHC they could complete their education to become full fledged doctors and continue in public service
Family planning became an independent department in the Ministry of health – active efforts for population control
The Medical council and the doctors lobby opposed this and hence it was not taken up seriously.

15. Chadah committee, 1963
was appointed under chairmanship of Dr. M.S. Chadah, to advise about the necessary arrangements for the maintenance phase of National Malaria Eradication Programme
recommended the integration of health and family planning services
suggested basic health workers who would function as multipurpose workers:
one per 10,000 population,
would perform, in addition to malaria work, the duties of family planning and vital statistics data collection
under supervision of family planning health assistants.
The recommendations of the Chadah Committee, when implemented, were found to be impracticable the basic health workers, with their multiple functions could do justice neither to malaria work nor to family planning work.

16. Mukherjee committee, 1965
headed by the then Secretary of Health Shri Mukherjee
was appointed to Review the Staffing Pattern and Financial Provision under Family Planning
Recommendations –
Separate staff for the family planning programme
The basic health workers were to be utilized for purposes other than family planning
Delink the malaria activities from family planning so that the latter would received undivided attention of its staff
The family planning assistants were to undertake family planning duties only

17. Mukherjee committee, 1966
Due to shortage of funds, it was difficult for the states to undertake multiple activities of the mass programmes effectively E.g family planning, small pox, leprosy, trachoma, NMEP etc.
The committee worked out the details of –
The Basic Health Service at the Block level
Some consequential strengthening required at higher levels of administration.
NMEP (maintenance phase),

18. Jungalwalla committee, 1967
Committee on Integration of Health Services, was set up in 1964
under the chairmanship of Dr. N Jungalwalla, the then Director of National Institute of Health Administration and Education
Steps recommended for the integration at all levels of health organization –
Common Seniority
Recognition of extra qualifications
Equal pay for equal work
Special pay for special work
Abolition of private practice by government doctors
Improvement in their service conditions
(currently NIHFW).
The committee defined Integrated health services as –
A service with a unified approach for all problems instead of a segmented approach for different problems.
Medical care and public health programmes should be put under charge of a single administrator at all levels of hierarchy.

19. Fourth five year plan (1969-1974)
most poorly written plan document
No comment on the social, political and economic upheaval during the plan Holiday period ( )
Again the poor progress made in the PHC programme and recognized again the need to strengthen it
FP continued to get even a more greater emphasis with 42% of health sector plan allocation going to it
water supply and sanitation was separated and allocations were made separately under the sector of Housing and Regional development
It pleaded for the establishment of effective machinery for speedy construction of buildings and improvement of the performance of PHCs by providing them with staff, equipment and other facilities.
Malaria burden

20. Fifth five year plan (1974-1978)
Govt acknowledged that despite advances in terms of reduced infant mortality rate, increased life expectancy, the number of medical institutions, beds, health facilities etc, were still inadequate in the rural areas
Had accepted that the urban health structure had expanded at the cost of the rural sectors
Highest priority to minimum development prog - integrated packaged approach to the rural areas
Another major innovation was launched in 1977 by creating a cadre of village based, Community Health workers
These were part time workers selected by the village, trained for 3 months in simple promotive and curative skills both in allopathy and indigenous systems of medicine.
They were to be supervised by MPWs, and the programme was started in 777 selected PHCs where MPWs were already in place

21. Fifth five year plan cont..
Objectives
Increasing the accessibility of health services to rural areas through the Minimum Needs Programme (MNP)
Referral services to be developed further
Intensification of the control and eradication of communicable diseases
Affecting quality improvement in the education and training of health personnel

22. Kartar singh committee, 1973
headed by the Additional Secretary of Health
Committee on multipurpose workers under Health and Family Planning
was constituted to form a framework for integration of health and medical services at peripheral and supervisory levels
Recommendations –
Various categories of peripheral workers should be amalgamated into a single cadre of multipurpose workers (male and female)
One PHC should cover a population of 50,000 and should be divided into 16 sub centers, staffed by a male and a female health worker
ANM – MPW(F)
Basic health workers – MPW(M)
LHV – Female health supervisor
The work of 3‐4 MPWs was to be supervised by one health supervisor

23. Shrivastav committee 1975
Group on Medical Education and Support Manpower
to determine steps needed to –
reorient medical education with national needs and priorities
develop a curriculum for health assistants
Recommendations
Creation of bands of paraprofessional and semi professional health workers from the community itself e.g. school teachers, postmasters etc
Establishment of two cadres of health workers – MPWs and health assistants
Development of a Referral Services
Establishment of a Medical and Health Education Commission for planning and implementing the reforms needed
Acceptance of the recommendations of the Shrivastava Committee in 1977 led to the launching of the Rural Health Scheme.

24. Sixth five year plan (1980-1985)
Influenced by the Alma Ata declaration of Health For All by 2000 AD (WHO, 1978)
emphasized that horizontal and vertical linkages had to be established among all the interrelated programmes, like water supply, environmental sanitation, hygiene, nutrition, education, family planning and MCH
They no longer had talked of targets. The keywords were efficiency and quality and the means to realize them is privatization.
The strategies advocated
provision of health services to the rural areas on a priority basis
the training of community health worker
No further linear expansion of curative facilities in urban areas
Rolling plan
The objective of achieving a net reproduction rate of 1

25. National Health Policy 1983
Until 1983, No formal or official National Health Policy
Prior to that, health activities were formulated through the Five year Plans and recommendations of various Committees
formulated, in the background of the global agreement of Health for All
first time after the Bhore Committee, the govt. had talked about universal comprehensive health care
As regards targets, only crude death rate and life expectancy had been achieved, fertility, immunization and related to national health programme were much below expectation

26. National Health Policy 1983, cont..
The salient features of the 1983 health policy were:
It was critical of the curative-oriented western model of health care
It emphasized a preventive, promotive and rehabilitative primary health care approach
It recommended a decentralized system of health care, the key features of which were low cost, use of volunteers and paramedics, and community participation
It called for an expansion of the private curative sector which would help reduce the government's burden
It set up targets for achievement that were primarily demographic in nature
Not free health care services
As regards the demographic and other targets set in the NHP, only crude death rate and life expectancy have been on schedule.
The others, especially fertility and immunization related targets were much below expectation
Those related to national disease programs were also much below the expected level of achievement.

27. Seventh five year plan (1985-1990)
After1983 NHP, rural health care received special attention and a massive program of expansion of primary health care facilities to achieve the target of one PHC/30,000 population and one SC/5000 population.
This target has more or less been achieved in most of the states
But were grossly under utilized because of poor facilities, inadequate supplies, poor managerial skills of doctors, faulty planning of the mix of health programs and lack of proper monitoring and evaluation
System failed to work because of the mismatch of training and the work allocated to health workers, inadequate transport facilities, non-availability of appropriate accommodation for the health team and an unbalanced distribution of work-time for various activities
Child Survival and Safe Motherhood

28. Seventh five year plan (1985-1990) cont..
This plan also talks of improvement and further support for urban health services, biotechnology and medical electronics and non- communicable diseases
Enhanced support for population control activities also continues
The special attention that AIDS, cancer, and coronary heart diseases are receiving

29. Bajaj committee, 1986
Expert Committee for Health Manpower Planning, Production and Management, was constituted in 1985 under Dr. J.S. Bajaj
Major recommendations are :‐
Formulation of National Medical & Health Education Policy
Formulation of National Health Manpower Policy
Establishment of an Educational Commission for Health Sciences, Health Science Universities and health manpower cells
Vocationalization of education at 10+2 levels as regards health related fields Carrying out a realistic health manpower survey
the then professor at AIIMS.

30. Eighth ( )
The Plan got pushed forward by two years due to massive economic crisis
No new thinking went into this plan
Only adopted a new slogan – instead of Health for All by 2000 AD it chose to emphasize Health for the Underprivileged
Continued the support to privatization
Annual plans

31. Ninth five year plan (1997-2002)
provides a good review of all programs and has made an effort to strategize on achievements and learn from them
reference is once again being made to the Bhore Committee
Basic Minimum Services programme: strengthening of PHCs and SCs and assuring that the requirements for its proper functioning are made available
Plan suggests creating part time positions which can be offered to local qualified private practitioners and/or offer the PHC and CHC premises for after office hours practice against a rent

32. Ninth five year plan (1997-2002) cont..
concerned for urban health care, especially the absence of primary health care and complete reliance on secondary and tertiary services even for minor ailments
This needs to be changed through provision of primary health care services, especially in slums, and providing referral linkages
Reviewed population policy and the family planning program. It goes back to the Bhore Committee report and says that the core of this program is maternal and child health services
More focus on Child Survival Safe Motherhood prog
National Population Policy was announced
It is an improvement but the underlying element remains population control

33. National health policy 2002
9th Plan also reviewed the 1983 National Health Policy in the context of its objectives and goals and concludes that a reappraisal and reformulation of the NHP is necessary
formulated during the initiation of the economic liberalization policy of India and adoption of the MDGs as a target of achieving the HFA
Integration of vertical program activities with general health service for sustainability
For decentralization- Role of Local Self Government Institutions has been defined
There is passing comment on strengthening primary health care but how this can be achieved policy has not specified. No comment on village health workers.

34. National health policy 2017
Draft of NHP 2015 – to achieve the MDGs the United Nations reviewed the progress made so far and suggested two strategies of Health for All - concept implying health as an integral part of development and universal health coverage - Draft NHP formulated and placed it in the public domain in December 2014
NHP 2017 – The socio-economic and epidemiological changes since last NHP call for the formulation of a New Policy to address the current and emerging challenges.

35. NITI Aayog
NITI Aayog, National Institution for Transforming India is a GOI policy think- tank established by the BJP government, in 2014
to replace the Planning Commission
The Prime Minister serves as the chairman
The governing council consists of all state Chief Ministers, chief ministers of Delhi and Puducherry, Governor of Andaman and Nicobar, and vice chairman nominated by the Prime Minister
In addition to full members, there are two part-time members and four ex-officio members and a chief executive officer
The temporary members are selected from the leading universities and research institutions
Website –
Arvind Panagariya, Vice Chairman
Bibek Debroy, Member
V. K. Saraswat, Member
Ramesh Chand, Member
Amitabh Kant, CEO

36. Responsibilities of centre
Defense
Central Bureau of Intelligence and Investigation
Foreign affairs
United Nations Organization
Foreign jurisdiction
Railways
Posts and telegraphs, telephones, wireless, broadcasting and other like forms of communication
Constitution, organisation, jurisdiction
Inter-state migration; inter-State quarantine
Taxes
Inquiries, surveys and statistics for the purpose of any of the matters in this List
Currency, foreign exchange
Reserve Bank of India
Post Office Savings Bank
Banking
Insurance
Stock exchanges
Regulation and development of oilfields and mineral oil resources
Regulation of mines
Ancient and historical monuments and records
Census
Election Commission.

37. Responsibilities of state
Public order
Police
Prisons
Local government
Public health and sanitation; hospitals
Intoxicating liquors
Relief for the disabled and unemployable
Communications, roads, bridges
Agriculture
water supplies, irrigation, drainage
Land
Salaries and allowances of Ministers for the State
State public services; State Public Service Commission
Treasure
Land revenue
Taxes on agricultural income
Taxes on lands and buildings
Taxes on the consumption or sale of electricity
Taxes on goods and passengers carried by road or on inland waterways
Taxes on vehicles

38. Concurrent list Criminal law and procedures
Marriage and divorce; infants and minors; adoption; wills, intestacy and succession
Transfer of property other than agricultural land
Evidence and oaths; recognition of laws, public acts and records, and judicial proceedings.
Lunacy and mental deficiency
Prevention of cruelty to animals
Adulteration of foodstuffs and other goods
Drugs and poisons
Economic and social planning
Population control and family planning
Education, including technical education, medical education and universities
Charities and charitable institutions
Prevention of the extension from one State to another of infectious or contagious diseases or pests
Vital statistics including registration of births and deaths
Price control
Newspapers, books and printing presses
Commercial and industrial monopolies
Social security and social insurance; employment and unemployment
Welfare of labour
compensation, invalidity and old age pensions and maternity benefits

39. Responsibility of centre and state for health
At the Central
policy making
planning, guiding, assisting, evaluating and coordinating the work of the State Health Ministers
At the State
The state is ultimate Authority responsible for all the health services.
At present there are 29 states in India with each state having its own health
administration.
In all the states the management sector comprises the State Ministry of Health and a Directorate of Health.
Historically, the first mile stone in State Health Administration was the year 1919, when the states obtained autonomy, under the Montague – Chelmsford
reforms from the Central government in matters of public health. The Government of
India act 1935 gave further autonomy to the states. The position has largely remained the
same even after the new constitution of India came into force in 1950.

40. Responsibility of district
The principal unit of administration in India is the district under a Collector.
Within each district again, there are six types of administrative areas
Sub–divisions.
Tehsils
Community Developments Blocks: unit of rural planning and development, and comprises approximately 100 villages (about to population) In- charge - Block Development Officer
Municipalities and Corporations: Municipal Boards – in areas with population ranging between and 2 lakhs, In-charge - Municipal chairman of Municipal Board. Corporations with population above 2 lakhs and above, In-charge - Mayor
Villages
Panchayat - institutions of rural local self government
Most districts in India are divided into two or more sub-divisions, each in-charge of an Assistant Collector or Sub-Collector. Each division is again divided into tehsils (taluks), in-charge of a Tehsildar. A tehsil usually comprises from 200 to 600 villages..

41. State Program Implementation Plans (PIPs)
To support the activities for effective and time bound implementation of NHM
approved by the National Program Coordination Committee
the strategies, budgetary requirements and expected health outcomes made by the Executive Committee of the State Health Society and approved by the State Govt
The EC implements the approved plan, with governance and oversight by the Governing Board and the State Health Mission.

42. State Program Implementation Plans (PIPs), cont..
The State PIP is appraised by the National Programme Coordination Committee, chaired by the Mission Director with representatives of MOHFW and the states.
National technical assistance and support agencies providing support to the respective states would provide their inputs.
These plans would also be shared with other departments- AYUSH, AIDS Control and Health Research- as well as those dealing with Drinking Water and Sanitation, School Education and the Women and Child Department, for their inputs.

43. Strengths of health planning in India
Have stared very earlier even before independence
There was a distinct policy and strategy for the health sector, not written one. This was reflected through the Five Year Plans of the Central government before NHP.
Reach of the health system
Efforts for decentralization and community participation
Medical advances
Practitioners of alternate systems of medicine - can be used

44. Weaknesses Unregulated private health sector
At the state government level, lack of any policy initiatives in the health sector
Inequity in health care
Limited access to preventive and curative health services
Lack of trained Human Resources
More expenditure on curative services
Inadequate coverage of health insurance (at least for a minimum standard of health care)
The Central government has shaped health policy and planning in India.through the Council of Health and Family Welfare and various Committee recommendations
A dark cloud, however, threatens to blot out the sun from this landscape. Almost everywhere, the poor suffer poor health and the very poor suffer appallingly.
In addition the gap in health between rich and poor remains very wide. Addressing this problem, both between countries and within countries, constitutes one of the greatest challenges of the new century. Failure to do so properly will have dire consequences for the global economy, for social order and justice, and for the civilization as a whole.

45. Opportunity Sustainable developmental goals International agenda
Swacchh Bhararat Abhiyan
WHO - Health in All Policies

46. Threats Health and health care development has not been a priority
Low level of investment and allocation of resources to the health sector
Population with large geographic area
Burden of both infectious and NCD
Some population – lack of education, poverty and gender inequity
Economical and urban rural inequity
lack of environmental sanitation and safe drinking water, under-nutrition, poor living conditions
political and bureaucratic interference

47. References
K. Park, Park’s Textbook of preventive and social medicine. 23th edition. Banarsidas Bhanot Publishers;
Bhalwar R, Vaidya R, Tilak R, Gupta R, Kunze R,editors. Text book of Public Health and Community Medicine. 1st edition. New Delhi: Dept of Community Medicine Armed Force Medical College Pune;
Green A, An Introduction to Health Planning in Developing Countries. 2nd edition. Oxford university press, New york; 1999.
Govt of India, Ministry of Health and Family Welfare. National Health Policy Document. New Delhi
Govt of India, Ministry of Health and Family Welfare. National Policy Document. New Delhi 1983.
Govt of India, Ministry of Health and Family Welfare. National Health Policy Document. New Delhi
Banerjee, D, 1973: Population Planning in India – National and Foreign Priorities, JNU, New Delhi.
Batliwala, Srilatha, 1978: The Historical Development of Health Services in India, FRCH, Bombay.

48. References cont..
Bhore, Joseph, 1946: Report of the Health Survey and Development Committee, Volume I to IV, Govt. of India, Delhi.
Chadha Committee, 1963: Special Committtee for NMEP Maintenance Phase, MoHFW, GOI, New Delhi.
Duggal, Ravi and S Amin, 1989 : Cost of Health Care, Foundation for Research in Community Health, Bombay.
Expert Committee on Public Health Systems, 1993, MoHFW, GOI, New Delhi.
Five Year Plan I – IX, various years: Five Year Plans – First to Ninth, Planning Commission, GOI, New Delhi.
Kutty VR. Health Planning in India. Current Science. 199; 60(4): 280.
Duggal R. Evolution of Health Policy in India. 2003; (April):1–56.
Ministry of Health and Family Welfare. Approval of State Programme Implementation Plan of NRHM : Maharashtra