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:

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

Vision for UHC

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

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 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.

• 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

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 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

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