The Approach Paper to the 12th Plan sees the projected 32% increase in India’s labour force in the next two decades as a demographic dividend. But is the 12th Plan focusing sufficiently on the health, nutrition and education of the children who will form this labour force in the coming decades, asks Alex George
The draft Approach Paper of the 12th Plan was approved by the cabinet and presented to the National Development Council on October 22, 2011. The paper, which projects a growth rate of 9% for the 12th Plan, envisages that inclusiveness, an idea carried over from the 11th Plan, should lead to poverty reduction, increase in health outcomes and universal access of children to schools. It further states that inclusiveness should include providing opportunities for wage employment and livelihoods, and improved provision of water, sanitation and housing. All these have implications for improving child health and reducing childhood poverty.
Health
The observation of the paper that the National Rural Health Mission (NRHM) focused on child health and pre-natal care and that it was now necessary to expand to a wider range of conditions gives the impression that targets in child health have already been achieved and therefore we can move on. Though offering a broader set of services is important given our changing epidemiological profile, the focus on child health cannot be diminished as India still accounts for the highest proportion of child deaths in the world.
The Approach Paper states that central and state government expenditure on health has increased to 1.4% of GDP in 2011-12 from less than 1% at the beginning of the 11th Plan. This calculation is based on Budget Estimates of 2011-12, whereas actual expenditures would be lower. Even otherwise, the estimated increased expenditure on health mentioned in the paper is way below the UPA government’s commitment to raise it to 3% of GDP. The paper agrees only to a rise of up to 2.5% of GDP, that too by the end of the 12th Plan, ie 2017.
The paper mentions the High Level Expert Group (HLEG) on Universal Health Coverage constituted by the Planning Commission but does not give any clear commitment on the provision of universal healthcare. It says instead that the recommendations of this group will be an input for defining a “comprehensive health strategy for the next 10 years”.
The accountability matrix defining the responsibilities of functionaries of the health, women and child development, water and sanitation departments at the block and habitation levels is a welcome step towards convergence of health and related services. However, to make it functional there must be a convergence in the performance of various functions at the state and district levels also.
On the positive side, the 12th Plan does envisage a convergence of health and childcare services; but it is aimed at the lower levels of health and nutrition services, ie the anganwadi centre and sub-centre. In operational terms it will amount to having one Accredited Social Health Activist (ASHA) positioned at every anganwadi centre (AWC), who will connect the AWC to the Auxiliary Nurse Midwife (ANM) at the sub-centre. The idea to have a sub-centre in every panchayat does not appear to be offering anything new as a sub-centre is anyway supposed to exist for every 5,000 population in the plains and for every 3,000 population in the tribal and hilly areas, which works out to one for every panchayat already.
The paper also promises to set up sub-centres and Integrated Child Development Services (ICDS) centres in all slums to provide primary healthcare to the urban poor, which is lacking at present. This step is welcome, but the provision of primary healthcare in urban areas requires a broader urban primary healthcare system and not just sub-centres and ICDS centres.
The Approach Paper promises to make healthcare delivery more consultative and inclusive of the community by increasing users’ participation through institutionalised audits, again a welcome move. But we should not forget that the community monitoring exercise under NRHM in the 11th Plan was carried out only in a few areas with strong civil society presence.
A reduction of regional disparities in maternal and child health, in particular in the 264 high-focus districts, is also a programme focus already. The offer to provide funds for upgradation of primary healthcare centres (PHCs) and community healthcare centres (CHCs) to IPHS norms is also an already existing commitment of the government.
The Approach Paper also mentions making district hospitals district knowledge centres for training health workers like nurses, mid-level health workers and offering courses like Bachelor of Rural Healthcare/Primary Practice. This would help provide a cadre of qualified health professionals to attend to a defined set of basic healthcare services. This is one way to get qualified practitioners in allopathy to reach India’s remote rural areas. Several examples of NGOs providing community healthcare using trained rural health workers have shown the effectiveness of such an approach.
The paper’s emphasis on local production of drugs is a very important measure as public sector drug companies have not been given encouragement for several years. Drug self-sufficiency is important in the context of the IPR regime and a declining public sector in this field, coupled with the fact that several Indian private sector giants have been taken over by foreign multinationals.
The paper also deals with training and hiring women from marginalised communities in the healthcare workforce. But this approach should not be only for ASHAs, ANMs and AWWs. It should be implemented across the spectrum for all levels of health functionaries including medical professionals and applied to men from these communities also.
In terms of financing healthcare, the paper acknowledges the high out-of-pocket health expenses of Indians and offers a two-pronged approach of expanding public provisioning of healthcare and public financing of care using the private sector, but subject to appropriate regulations and oversight. Once the government becomes a buyer of a set of services from the private sector it will be in a commanding position to ensure that the private sector functions according to state regulations.
In addition to expanding public provisioning and bringing publicly financed private players under a regulatory regime, the paper also envisages establishing a health insurance plan for every citizen. The details in this regard are likely to emerge from the report of the HLEG which is due in November.
Nutrition
The need to restructure the ICDS focusing on the 0-3 age-group, promoting decentralisation of administration, ensuring quality, participation of women’s/mother’s groups and strengthening convergence with related schemes is clearly articulated in the paper, though the roadmap is not spelt out. The paper states that the recommendations of the inter-ministerial working group on ICDS constituted under the PM’s Nutrition Council are awaited.
A shift towards family- and community-based interventions such as breastfeeding is also mentioned. In this regard a national campaign on universal breastfeeding linked to a programme for wider and enhanced provision of nutrition to breastfeeding mothers, should be taken up on a scale comparable to the erstwhile family planning programme, as this intervention is crucial for the survival of 0-6-month- old children.
Conclusion
The paper points out that India’s labour force will increase by 32% in the next two decades, while that of industrialised countries and China will decline by 4% and 5% respectively and that therefore we should reap the benefits of this demographic dividend. This would however demand that we ensure the health, nutrition and education of children who will form the labour force for the coming decades. On the contrary we find that the Infant Mortality Rate, a key indicator of health status, is at 50/1,000 live births according to Sample Registration Survey (SRS) 2009, published in early-2011 and is still higher at 70 and 66 respectively in UP and MP according to the recent Annual Health Survey (AHS) 2010-11. The AHS was conducted in the nine states of Rajasthan, Uttar Pradesh, Uttarakhand, Bihar, Jharkhand, Orissa, Madhya Pradesh, Chhattisgarh and Assam. These states alone account for 70% of infant deaths, 75% of under-5 deaths and 62% of maternal deaths in India, which demand urgent attention.
The draft Approach Paper of the 12th Plan was approved by the cabinet and presented to the National Development Council on October 22, 2011. The paper, which projects a growth rate of 9% for the 12th Plan, envisages that inclusiveness, an idea carried over from the 11th Plan, should lead to poverty reduction, increase in health outcomes and universal access of children to schools. It further states that inclusiveness should include providing opportunities for wage employment and livelihoods, and improved provision of water, sanitation and housing. All these have implications for improving child health and reducing childhood poverty.
Health
The observation of the paper that the National Rural Health Mission (NRHM) focused on child health and pre-natal care and that it was now necessary to expand to a wider range of conditions gives the impression that targets in child health have already been achieved and therefore we can move on. Though offering a broader set of services is important given our changing epidemiological profile, the focus on child health cannot be diminished as India still accounts for the highest proportion of child deaths in the world.
The Approach Paper states that central and state government expenditure on health has increased to 1.4% of GDP in 2011-12 from less than 1% at the beginning of the 11th Plan. This calculation is based on Budget Estimates of 2011-12, whereas actual expenditures would be lower. Even otherwise, the estimated increased expenditure on health mentioned in the paper is way below the UPA government’s commitment to raise it to 3% of GDP. The paper agrees only to a rise of up to 2.5% of GDP, that too by the end of the 12th Plan, ie 2017.
The paper mentions the High Level Expert Group (HLEG) on Universal Health Coverage constituted by the Planning Commission but does not give any clear commitment on the provision of universal healthcare. It says instead that the recommendations of this group will be an input for defining a “comprehensive health strategy for the next 10 years”.
The accountability matrix defining the responsibilities of functionaries of the health, women and child development, water and sanitation departments at the block and habitation levels is a welcome step towards convergence of health and related services. However, to make it functional there must be a convergence in the performance of various functions at the state and district levels also.
On the positive side, the 12th Plan does envisage a convergence of health and childcare services; but it is aimed at the lower levels of health and nutrition services, ie the anganwadi centre and sub-centre. In operational terms it will amount to having one Accredited Social Health Activist (ASHA) positioned at every anganwadi centre (AWC), who will connect the AWC to the Auxiliary Nurse Midwife (ANM) at the sub-centre. The idea to have a sub-centre in every panchayat does not appear to be offering anything new as a sub-centre is anyway supposed to exist for every 5,000 population in the plains and for every 3,000 population in the tribal and hilly areas, which works out to one for every panchayat already.
The paper also promises to set up sub-centres and Integrated Child Development Services (ICDS) centres in all slums to provide primary healthcare to the urban poor, which is lacking at present. This step is welcome, but the provision of primary healthcare in urban areas requires a broader urban primary healthcare system and not just sub-centres and ICDS centres.
The Approach Paper promises to make healthcare delivery more consultative and inclusive of the community by increasing users’ participation through institutionalised audits, again a welcome move. But we should not forget that the community monitoring exercise under NRHM in the 11th Plan was carried out only in a few areas with strong civil society presence.
A reduction of regional disparities in maternal and child health, in particular in the 264 high-focus districts, is also a programme focus already. The offer to provide funds for upgradation of primary healthcare centres (PHCs) and community healthcare centres (CHCs) to IPHS norms is also an already existing commitment of the government.
The Approach Paper also mentions making district hospitals district knowledge centres for training health workers like nurses, mid-level health workers and offering courses like Bachelor of Rural Healthcare/Primary Practice. This would help provide a cadre of qualified health professionals to attend to a defined set of basic healthcare services. This is one way to get qualified practitioners in allopathy to reach India’s remote rural areas. Several examples of NGOs providing community healthcare using trained rural health workers have shown the effectiveness of such an approach.
The paper’s emphasis on local production of drugs is a very important measure as public sector drug companies have not been given encouragement for several years. Drug self-sufficiency is important in the context of the IPR regime and a declining public sector in this field, coupled with the fact that several Indian private sector giants have been taken over by foreign multinationals.
The paper also deals with training and hiring women from marginalised communities in the healthcare workforce. But this approach should not be only for ASHAs, ANMs and AWWs. It should be implemented across the spectrum for all levels of health functionaries including medical professionals and applied to men from these communities also.
In terms of financing healthcare, the paper acknowledges the high out-of-pocket health expenses of Indians and offers a two-pronged approach of expanding public provisioning of healthcare and public financing of care using the private sector, but subject to appropriate regulations and oversight. Once the government becomes a buyer of a set of services from the private sector it will be in a commanding position to ensure that the private sector functions according to state regulations.
In addition to expanding public provisioning and bringing publicly financed private players under a regulatory regime, the paper also envisages establishing a health insurance plan for every citizen. The details in this regard are likely to emerge from the report of the HLEG which is due in November.
Nutrition
The need to restructure the ICDS focusing on the 0-3 age-group, promoting decentralisation of administration, ensuring quality, participation of women’s/mother’s groups and strengthening convergence with related schemes is clearly articulated in the paper, though the roadmap is not spelt out. The paper states that the recommendations of the inter-ministerial working group on ICDS constituted under the PM’s Nutrition Council are awaited.
A shift towards family- and community-based interventions such as breastfeeding is also mentioned. In this regard a national campaign on universal breastfeeding linked to a programme for wider and enhanced provision of nutrition to breastfeeding mothers, should be taken up on a scale comparable to the erstwhile family planning programme, as this intervention is crucial for the survival of 0-6-month- old children.
Conclusion
The paper points out that India’s labour force will increase by 32% in the next two decades, while that of industrialised countries and China will decline by 4% and 5% respectively and that therefore we should reap the benefits of this demographic dividend. This would however demand that we ensure the health, nutrition and education of children who will form the labour force for the coming decades. On the contrary we find that the Infant Mortality Rate, a key indicator of health status, is at 50/1,000 live births according to Sample Registration Survey (SRS) 2009, published in early-2011 and is still higher at 70 and 66 respectively in UP and MP according to the recent Annual Health Survey (AHS) 2010-11. The AHS was conducted in the nine states of Rajasthan, Uttar Pradesh, Uttarakhand, Bihar, Jharkhand, Orissa, Madhya Pradesh, Chhattisgarh and Assam. These states alone account for 70% of infant deaths, 75% of under-5 deaths and 62% of maternal deaths in India, which demand urgent attention.
(Alex George is National Manager-Research
with Save the Children, India)
Infochange News & Features, November 2011
