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Healthcare
Powering rural healthcare
http://www.thehindu.com/opinion/op-ed/powering-rural-healthcare/article21419655.ece
Providing solar-powered systems across primary health centres can improve health outcomes
Around 38 million Indians rely on health facilities without electricity. Without access to
regular power supply, numerous life-saving interventions cannot be undertaken.
Ground report
A study, ‘Powering Primary Healthcare through Solar in India: Lessons from Chhattisgarh’,
published recently by the Council on Energy, Environment and Water (CEEW) and
supported by Oxfam India, evaluated 147 primary healthcare centres (PHCs) across 15
DAILY NEWS BULLETINLEADING HEALTH, POPULATION AND FAMILY WELFARE STORIES OF THE DayTuesday 20171212
districts in Chhattisgarh. It highlights the role of solar energy in bridging the gaps in
electricity access in rural healthcare facilities. In rural India, PHCs provide the last-mile
delivery of healthcare services. The Rural Health Statistics 2016 data find that India has
around 25,000 PHCs, and of the functional PHCs, 4.6% are not electrified. Further, the fourth
round of District Level Household and Facility Survey data indicates that one in every two
PHCs in rural India is either unelectrified or suffers from irregular power supply.
The use of renewable energy sources such as solar could help PHCs augment or even
substitute traditional grid-based power systems. This would also help the transition towards a
low-carbon, climate-smart healthcare system. Moreover, solar systems can facilitate reliable
and uninterrupted electricity supply critical for 24/7 emergency services, deliveries and
neonatal care, as well as inpatient and outpatient services.
In order to augment electricity supply across PHCs in power-surplus Chhattisgarh, the
Chhattisgarh Renewable Energy Development Agency (CREDA), between 2012 and 2016,
installed off-grid solar photovoltaic (PV) systems of 2kW each in 570 PHCs. Districts in
Chhattisgarh with a higher share of power-deficit PHCs (with less than 20 hours of electricity
supply per day from the grid), showed a higher infant mortality rate, a higher under-five
mortality rate, and a lower proportion of fully immunised children. The CEEW study found
that the solar-powered PHCs in Chhattisgarh admitted over 50% more patients and conducted
almost twice the number of child deliveries in a month compared to the power-deficit PHCs
without a solar system.
The ability of solar-powered PHCs to maintain cold chains to store vaccines and drugs and
operate new-born care equipment has significantly improved. Almost one-fourth of the
power-deficit PHCs in Chhattisgarh relied exclusively on solar as a backup to run cold chain
equipment. Continuous electricity supply must be ensured to cold chains at PHCs, especially
in rural Chhattisgarh, which has an infant mortality rate that is higher than the average for
rural India. Further, patients showed more willingness to get admitted for treatment at the
solar-powered PHCs due to facilities like running fans. Also, 90% of PHCs with solar
systems reported cost savings due to lower electricity bills or reduced expenditure on diesel.
Can solar systems be scaled up?
Scaling-up solar-powered systems across PHCs in rural India is dependent on three factors.
The first is to recognise the critical nature of electricity access in the entire health system
infrastructure. The Indian Public Health Standards has set minimum service-level
benchmarks for all activities of PHCs, indicating that every PHC should have power supply
with a back-up option. The National Health Policy 2017 reiterates the commitment to
improve primary healthcare by strengthening infrastructure. The second is the ability to adapt
solar systems around the local needs and considerations of PHCs including the burden of
disease, weather, terrain, and power availability. For example, disaster-prone areas that need
blood storage units and other health services could invest in higher capacity systems or
greater storage capacity. Third, there must be a focus on making ‘Solar for Health’ a national
priority. Scaling solar systems (5kW) across PHCs to power healthcare services could
contribute to about 160 MW of decentralised energy capacity. Solar power can be extended
to cover subcentres (1kW systems) and community health centres (8kW systems), where the
total potential would be around 415 MW.
Significant opportunities exist to simultaneously address the multisectoral goals of energy
access, energy security, resource management, and health outcomes, often competing for
resources and political attention. Solar power for healthcare in Chhattisgarh is a crucial
opportunity, with evidence that scaling this initiative can meet national and regional
ambitions for energy access and improved health outcomes.
Sunil Mani is Research Analyst and Hem H. Dholakia a Senior Research Associate at CEEW
Positive thinking
Positive thinking and wheatgrass (The Hindu: 20171212)
http://www.thehindu.com/opinion/open-page/positive-thinking-and-
wheatgrass/article21381855.ece
The secret of overcoming disease spells and running on hope and courage — and antioxidants
I was in my mid-teens, running on hormones, sarcasm and teenage angst. There were regular
showdowns at home, and the sound of my room door being banged shut resonated as often as
the doorbell.
My mother was a worry-wart. If ever news of a fire or an explosion reached her, which,
sadly, was not very rare, my outings to crowded places such as a cinema hall — the only
release those pre-cafe days — would stop. There would be an immediate clampdown on my
already scatty social life, and it wasn’t fun.
In addition to these frequent denials, I was rarely allowed out at night. On the few occasions
my parents caved in, they would insist my friends ride up in the lift and drop me off at my
doorstep on the 23rd floor, despite the fact that dropping someone at the lift lobby inside the
building gates was the norm. My friends, well aware of the tigress my mother was, asked no
questions; this was a minor compromise. It just mirrored her paranoia.
One evening my mother and I had a particularly harsh fight. A friend’s older sister was
having a huge party for her birthday at a nightclub, and I had been invited. We were
breathless with excitement, never having been inside one before. I had borrowed someone’s
dress since I didn’t possess any nightclub-worthy clothes, and tentatively broached the
subject with my mother. I knew permission would not be easily granted, but was unprepared
for this sudden and immediate denial, this blank refusal to discuss it further.
I threw a fit. My brother had just returned from a nightclub the previous weekend smelling of
cigarette smoke. “The fumes hang in the air,” my brother had informed us, swearing he
hadn’t touched a cigarette. I was eager to test this theory, but my mother was not about to
give me that chance. Anger spilled out of me, and as I started to rant about how unfair it was
that my parents gave in to sexist societal pressures, my mother raised a hand.
“I have cancer.”
Instantly, without even fully processing what she had just said, I burst into tears. My mother
had developed a lump in her breast, which had been discovered to be malignant. She
underwent a mastectomy. The good news is, she recovered, remarkably well.
Nevertheless, back then, none of us knew how things would turn out, and the fear was
crushing.
But my mother was a fighter. She fought her cancer with a good diet, exercise, positive
thinking, and wheatgrass, which grew in abundance in pots all over the house, the juice of
which my brother and I were also, under protest, forced to swallow. Life bounced back to
normal soon enough, but I found I couldn’t talk about my mother’s cancer, not even with my
best friend. I tried to broach the subject with her many times, but at every attempt I felt my
throat tighten, my head pound with the pressure of containing my tears. I gave up.
Days, packed with studies, exams, family vacations, and a lot of laughter, slipped by. I tried
to be a better daughter, to reduce her stress levels, which I was convinced had contributed to
her cancer.
The disease was soon relegated to the background. Before long, but for the ever-green
wheatgrass pots, there were no visible reminders of the scars it had left behind.
One day I stumbled upon an article on breast cancer, which detailed the prognosis and the
percentage of women who survive post-five years. I started calculating how many years had
passed. It had been more than five.
“What does this mean,” I had asked my mother, wondering if she had reached the end of her
rope. My mother explained how if it hadn’t returned in so many years, chances were she was
cancer-free. “If it doesn’t return in 10 years, consider me completely cured!” It didn’t return
in 10 years, it didn’t return in 15. The wheatgrass pots vanished.
A little over 20 years later, she was diagnosed with another lump in her breast, which also
turned out to be malignant. She had been going for regular check-ups, and thankfully, caught
it early. It hadn’t spread. Out came the wheatgrass pots.
It has been close to seven years since she had her second mastectomy, and her blood-work
has been perfect.
Over the years, countless people have called on my mother for support. She has given many
hope, courage and strength. Today she is over 70. She grows stronger and more beautiful,
inside and out, every day.
“What is your secret,” people often ask.
“Positive thinking,” she says. “A daily walk and…” she pauses (for effect or emphasis, I’ll
never know), “wheatgrass.”
Misleading Hunger Index
Flawed economics? (The Hindu: 20171212)
http://www.thehindu.com/opinion/op-ed/flawed-economics/article21419055.ece
Hunger is not related as much to food production as to access and distribution
The article “A misleading hunger index” (Dec. 4) could have been ignored for its wrong
understanding of both epidemiology and nutrition if it wasn’t for the fact that its authors are
members of the NITI Aayog. The authors, unhappy about the Global Hunger Index (GHI) put
out by the International Food Policy Research Institute, ranking India 100 out of 119
countries, said we should have been somewhere around 77, as though that would make India
proud.
The first flaw in the article is the assumption that, with a 26% increase in per capita food
production in the last decade, and a doubling in the last 50 years, hunger must have
automatically come down. In reality, hunger is not related as much to the production of food
as to access and distribution. Do the urban poor, who depend predominantly on PDS, have
the same access as the urban rich? There is also a gender, caste, religion, regional variation in
access.
The authors say that the GHI is neither appropriate nor representative of hunger since more
weightage (70.5%) is assigned to children less than five years, who constitute only a minor
population. Children’s requirement for calories is 2-3 times (80 calories/kg/day for children
versus 35-45 calories/kg/day for adults) the adult requirement. This makes them more
vulnerable to undernutrition and its consequences.
The statement that “weight and height of children are not solely determined by food intake
but are an outcome of a complex interaction of genetics, environment, sanitation and
utilisation of food intake” is mischievous at best and dangerous at worst. The role of genetics
in determining adult height is significant only after two or three generations of adequate food
availability. When children have deficits of 600 calories (they are recommended 1200-1500
calories), neither can the argument for wholesome food be ignored nor the fact that these
children are more vulnerable to infections due to lowered immunity and possibly
malabsorption.
For data to be comparable, representative indicators are chosen. The nutrition status of
children under five is a sensitive measure of the overall nutrition of a country. Similarly,
maternal mortality rate as an acceptable indicator of health system function does not mean
that pregnant women constitute the largest share of the population. The authors need to
understand the difference between bias and representation before they level charges of bias
against the GHI.
They claim that “there is still inconclusive debate on the cut-off for minimum energy
requirement calculation” and suggest that a lower Food and Agriculture Organisation norm of
1,800 kcal should suffice for calculating hunger. Why should India settle for a ‘minimum’
energy requirements when it has worked out a recommended dietary allowance that addresses
the energy needs of all populations based on gender, occupation, weight and special
conditions like weight gain during pregnancy and growth of children?
Veena Shatrugna is a clinical nutritionist and former deputy director of the National Institute
of Nutrition and Sylvia Karpagam is a public health doctor and researcher
Pollution
For clean air, India needs a policy leap(The Hindu: 20171212)
http://www.thehindu.com/opinion/op-ed/for-clean-air-india-needs-a-policy-
leap/article21419755.ece
The way to curb pollution is to tax carbon. Only then will households look for greener
substitutes
It wouldn’t be an exaggeration to say that air pollution is one of the biggest public concerns
in India today. Its implications are many but just two will suffice here. A report of the Lancet
Commission on pollution and health states that around 19 lakh people die prematurely every
year from diseases caused by outdoor and indoor air pollution. A study by the Indian Journal
of Pediatrics shows that the lungs of children who grow up in polluted environments like
Delhi are 10% smaller compared to the lungs of children who grow up in the U.S. This is
nothing short of a public health emergency. What is needed, therefore, is a comprehensive
policy to curb pollution. We need to act now.
At the heart of the problem of pollution are carbon dioxide (CO2) emissions. About 75% of
all greenhouse gas emissions are CO2 emissions produced through burning fossil fuels — oil,
coal and natural gas — to generate energy. Since the early 2000s, carbon emissions have
increased because of high growth in the Indian economy. In 2014, India’s total carbon
emissions were more than three times the levels in 1990, as per World Bank data. This is
because of India’s heavy dependence on fossil fuels and a dramatically low level of energy
efficiency.
Remodel the energy mix
Emissions can be curbed only if people are persuaded to move away from fossil fuels and
adopt greener forms of energy. But how do we achieve that? Tax carbon, period.
A part of the carbon revenue thus generated can be used for a systemic overhaul of the energy
mix, which, to a large extent, would address the pressing problem of environmental
degradation. The Indian economy’s energy mix needs to be remodelled through investments
in clean renewable sources of energy like solar, wind, hydro, geothermal and low-emissions
bioenergy, and by raising the level of energy efficiency through investments in building
retrofits, grid upgrades, and industrial efficiency. According to our estimates, this energy mix
overhaul requires an additional 1.5% of GDP (to the current annual level of 0.6%) annually
over the next two decades. Assuming that the Indian economy grows at 6% per annum and
the population is likely to rise from 1.3 billion to 1.5 billion over the next two decades, the
per capita emissions will still fall as a result of this policy, from the International Energy
Agency’s 2035 Current Policy Scenario of 3.1 metric tonnes to 1.5 metric tonnes — a 52%
decline. Since this expenditure is financed by the carbon tax revenue, it will be a revenue-
neutral policy with no implications on the fiscal deficit.
There is, however, a problem with carbon tax. It’s regressive in nature — it affects the poor
more than the rich. Fortunately, there’s a way out. Economists in the West have argued for a
‘tax and dividend’ policy according to which the revenue thus generated is distributed equally
across its citizens and as a result, the poor are more than compensated for the loss, since in
absolute amounts the rich pay more carbon tax than the poor. Such a policy of cash transfer,
which might work in the West, however, has a problem in the Indian context, which has been
discussed in the context of the Right to Food debate.
Instead of a cash transfer, the other part of the carbon revenue can be used for an in-kind
transfer of free electricity to the population that contributes less carbon than the economy
average, and universal travel passes to compensate for the rise in transport costs and to
encourage the use of green public transport. Such a policy justly addresses the widening
schism between Bharat, which bears the climate impact burden, and India, which is imposing
that burden because of its lifestyle choices.
As of 2014, more than 20% of India’s population did not have access to electricity. In July
2012, India experienced a blackout affecting roughly 70 crore people. Through this Right to
Energy programme, every household in India will have access to electricity, a feat that almost
all the governments since Independence have dreamt of but have failed to deliver. The free
entitlement of fuel and electricity for a household works out to 189 kWh per month based on
our calculations from the National Sample Survey data. Anything above this limit will be
charged in full to control misuse of this policy. Travel passes with a pre-loaded balance
amount of around ₹4,600 per household per annum, which can be used in any mode of public
transport — private and government alike — will be available for every household.
The level of carbon tax required for this policy to come into effect is ₹2,818 per metric tonne
of CO2. It will be levied upstream, namely, at ports, mine-heads, and so on. While the prices
of almost all the commodities will rise, the highest rise in price will be in fuel and energy
since the carbon content is the highest in this category. To give an idea about the pinch that
will be felt, the average price of electricity will rise from its current value of ₹3.73 to ₹4.67
per kWh.
Other benefits
This policy not only curbs emissions but also delivers on providing more employment since
the employment elasticity in greener forms of energy is higher than those in fossil fuel-based
energy. Higher prices of commodities according to their carbon content will induce
households, including the rich, to look for greener substitutes. They have the effect of
enticing even the poor to move away from traditional forms of energy consumption because
the price of energy will be zero for them (provided they consume less than the cut-off limit)
as compared to a shadow positive price in terms of the time used for collection of wood or
cow dung cakes. Availability of free energy also addresses the issue of stealing of electricity,
since there will be no incentive left for those who steal. In India, even in 2014, the value of
electricity stolen through corrupt means amounts to about 0.8% of GDP. It’s difficult to put a
figure on the health benefits that such a policy will entail, but as a rough measure, a
significant part of more than 3% of India’s GDP currently spent on pollution-induced
diseases will surely come down.
If we want to breathe to live, India needs to make such a policy leap.
Rohit Azad teaches economics at JNU, New Delhi, and Shouvik Chakraborty is a research
fellow at the Political Economy Research Institute, Amherst, U.S.
Abortions
1.6cr abortions a yr in India, 81% at home: Study (The Times of India:
20171212)
http://epaper.timesgroup.com/Olive/ODN/TimesOfIndia/#
Mumbai: A total of 1.56 crore abortions took place across India in 2015, 22 times the 7 lakh
figure that the government has been putting out every year for the last 15 years, according to
a research paper published in The Lancet Global Health medical journal on Monday.
Not only do a lot more Indian women than previously thought undergo abortions every year,
an overwhelming number — 81% — take medicines at home instead of going to hospitals,
the study has said.
“The government figure talked of surgical abortions carried out in its own hospitals. The
private sector was not counted, nor were medical abortions,” said the main author, Dr
Chandra Shekhar of International Institute of Population Sciences in Mumbai.
Overall, 1.27 crore (81%) abortions were medication abortions, 22 lakh (14%) were surgical,
and 8 lakh (5%) were through other methods, probably unsafe.
Medical abortions using mifepristone and mifepristone-misoprostol combipacks need a
doctor’s prescription.
‘50% of pregnancies unintended’
Doctors whom TOI spoke to said the revised number of abortions caried out in India wasn’t
asurprise. “Smaller studies done previously in Mumbai and Chennai indicated abortions were
higher than thought,” said a doctor with a government hospital. “Sale of medicines for
abortion also gave us an indication,” said gynecologist Dr Nozer Sheriar, who was a part of
the study.
The new study also estimated that half of the total 48.1 million pregnancies in India in 2015
were unintended. “Abortions accounted for one-third of all pregnancies, and nearly half of
pregnancies were unintended,” said the study, adding that India’s abortion rate is 47 per
1,000 women of reproductive age, which is similar to rates in Pakistan
(50), Nepal (42) and Bangladesh (39). Dr Shekhar said the unintended pregnancies pointed to
the need for better contraception and family planning programmes.
Around 53% Indians use modern contraception, but the expert said studies have shown that
half the couples surveyed didn’t know how to use the condom correctly. The study —
conducted jointly by IIPS, the Delhi-based Population Council and the New York–based
Guttmacher Institute — compiled national sales and distribution data of medical abortion
pills and conducted surveys of various public and private health facilities in six Indian states.
It estimated that close to three in four abortions are achieved using drugs from chemists and
informal vendors. WHO says abortion medicines are safe and effective when used correctly
and within a nineweek gestational limit.
Unfortunately, only a quarter of the abortions occur in the public sector, which is the main
source of healthcare for the poor. Dr Sheriar said abortions are the third leading cause for
maternal mortality in India. “The use of medicines for abortions has brought down this
number from 12% to 8% in recent years, but it is still huge,” he said, underlining the need to
make access to abortion easier for women. The results show abortions don’t need to take
place in hospitals, nor do they need highly trained doctors. The study proposed recommended
permitting nurses, AYUSH doctors (practitioners of indigenous medicine) and auxiliary nurse
midwives to provide abortion medicines. This would expand the number of providers—and
facilities—qualified to offer safe abortion services.
Immunotherapy (The Asian Age: 20171212)
http://onlineepaper.asianage.com/articledetailpage.aspx?id=9593123
Total Health Expenditure
INDIA’S HEALTH SPENDING (Hindustan Times: 20171212)
http://paper.hindustantimes.com/epaper/viewer.aspx
New National Health Accounts data reveals medicines are the biggest financial burden on
Indian households
Air quality
Air quality improves marginally with rain (Hindustan Times: 20171212)
http://paper.hindustantimes.com/epaper/viewer.aspx
THE IMPROVEMENT, BECAUSE OF THE RAIN, WAS REFLECTED BETTER IN THE
LEVELS OF PM10 AND PM2.5 WHICH STARTED DIPPING SOON AFTER THE
DRIZZLE
The air quality in Delhi, which spiked throughout Monday, showed signs of marginal
improvement from late Monday evening, as rain lashed the National Capital bringing down
the concentration of particulate matter – the dominant pollutants in Delhi’s air.
SANCHIT KHANNA/HT PHOTO
n Delhi received light rain on Monday. The meteorological department has forecast rain on
Tuesday as well. The rain helped bring down levels of particulate matters in Delhi’s air.
Experts said that pollution levels are likely to dip further on Tuesday as light rain and drizzle,
triggered by a western disturbance, is expected to continue till Tuesday morning.
The day’s average Air Quality Index (AQI) dropped to 361 on Monday from 377 on Sunday.
But this improvement was not because of the drizzle. The average AQI is calculated around 4
pm and the rain started around 6 pm.
The improvement, because of the rain, was reflected better in the levels of PM10 and PM2.5
which started dipping soon after the drizzle started. Till 8.30pm on Monday, Delhi received
2mm rain.
While PM10 concentration dropped from around 422 at 2 pm to around 400 around 9pm, the
level of PM2.5 also came down from around 245 at 5 pm to 238 at 9pm
“There will be further improvement on Tuesday as the rain will wash away some more
pollutants in the air. The layer of dust on the roads, trees and constructions sites will also be
washed away. The dust particles, which used to rise from these surfaces and mix with the air,
will not be able to do so, allowing Delhiites to breathe some cleaner air,” said D Saha head of
the air quality laboratory at CPCB.
But pollution levels could spike marginally once again from Wednesday and continue to
deteriorate till Friday because of the calm winds and high moisture levels left back by the
rains.
“We are expecting some shallow fog on Wednesday and Thursday morning as there would be
a lot of moisture in the air. The winds would be calm too,” said Kuldeep Srivastava, a senior
scientist with the RWFC.
MeT experts, however, said that the sky is likely to clear up from Friday as the cold and dry
north westerly winds are expected to pick up speed.
“Once we get a clear sky, a good sunshine and some strong winds from the north and
northwest, air quality would definitely improve,” said Saha.
The Indian Medical Association (IMA
IMA to form state-level panels to look at quality of healthcare (Hindustan
Times: 20171212)
http://paper.hindustantimes.com/epaper/viewer.aspx
The Indian Medical Association (IMA), the national voluntary organisation of doctors, has
announced the creation of a state-level Medical Redressal Commission that can look into the
quality and social and financial aspect of healthcare practices – either on demand or suo
moto.
The commission will be constituted of a prominent public figure, an IMA office bearer, one
former state medical representative and two subject experts.
The move came in the light of two private hospitals in the national capital region being
accused of negligence and overcharging. The association urged all doctors to follow the
ALERT policy (Acknowledge, Listen in detail, Explain, Review and Thank you) to develop
doctor-patient trust. “This will help in bringing down the increasing incidents of violence
against doctors,” said Dr KK Aggarwal, president of the IMA.
The IMA also urged doctors, hospitals and the healthcare industry to employ self-regulation
to increase the doctor-patient trust. Steps recommended by the IMA include doctors
preferably prescribing drugs from the National List of Essential Medicines, promoting the
Janaushadhi Kendras, transparent billings, provide options for cost-effective treatment at the
time of admission.
“Doctors should actively participate in ensuring that no hospital sells any item priced higher
than the MRP. No service charges should be added to procure drugs from outside. MRP shall
not be dictated by the purchaser,” said Dr Agarwal.
The organisation urged the state government to subsidise the cost of emergency care, even at
private hospitals.
Health insurance
Only 27 per cent Indians have health insurance: report(Indian Express:
20171212)
http://indianexpress.com/article/india/only-27-per-cent-indians-have-health-insurance-report-
4978687/
Thus, of India’s 135 crore people, 100 crore have no cover against catastrophic health
expenses.
The NDA government is “committed to UHC”, Health Minister J P Nadda asserted at an
event on Monday, the eve of Universal Health Coverage (UHC) Day. However, only 27 per
cent Indians or approximately 35 crore people have health cover, according to data from the
National Health Profile (NHP) released in April.
Thus, of India’s 135 crore people, 100 crore have no cover against catastrophic health
expenses.
“We are committed to advancing the agenda of Universal Health Coverage in the country,”
Nadda said. He was speaking at an event where he launched a mobile application to help
health workers in peripheral areas through complicated deliveries, a scheme for quality
certification of labour rooms and guidelines for critical obstetric care.
NHP data, which is compiled by the Central Bureau of Health Intelligence (CBHI) that
reports to the Union Health Ministry and, therefore, uses government figures to compile all
its reports, also says that between 2009-10 and 2014-15, public expenditure on health as a
percentage of GDP has remained constant at 0.98 per cent. Interestingly, a scheme that would
provide some health cover to 10 crore families requiring an annual government commitment
of Rs 6,000 crore, which was to be the precursor to a full-blown nationwide health protection
scheme, has been with the Union cabinet for more than a year now.
The 2017 NHP report on the CBHI website says: “Around 35 crore individuals were covered
under any insurance in 2015-16. This amounts to 27% of the total population of India. 77% of
them were covered by public insurance companies. Overall 80% of all persons covered with
insurance fall under government sponsored schemes… Compared to other countries that have
either Universal Health Coverage or moving towards it, India’s per capita public spending on
health is low.”
In 2014-15, average per capita public health expenditure ranged from Rs 940-2,532, the
spending being the highest in the northeastern states and lowest in what are known as the
Empowered Action Group states of Bihar, Jharkhand, MP, Chhattisgarh, Odisha, Rajasthan,
UP and Uttarakhand.
Health Care Services ( Dainik Gagaran: 20171212)
http://epaper.jagran.com/ePaperArticle/12-dec-2017-edition-Delhi-City-page_6-3450-4862-
4.html
Clinical establishment Act ( Dainik Gagaran: 20171212)
http://epaper.jagran.com/ePaperArticle/12-dec-2017-edition-Delhi-City-page_12-3436-4592-
4.html
Health (Hindustan: 20171212)
http://epaper.livehindustan.com/story.aspx?id=2412632&boxid=100409316&ed_date=2017-
12-12&ed_code=1&ed_page=7
Cauliflowers (Hindustan: 20171212)
http://epaper.livehindustan.com/story.aspx?id=2412641&boxid=99066332&ed_date=2017-
12-12&ed_code=1&ed_page=16
Imagery (Hindustan: 20171212)
http://epaper.livehindustan.com/story.aspx?id=2412641&boxid=99247380&ed_date=2017-
12-12&ed_code=1&ed_page=16
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