Chapter - 3

HEALTH PROGRAMMES OF THE CENTRE AND STATE:

AN OVERVIEW

Section - 1 : Health Programmes of the Centre and State

Section - H : Millennium Development Goals of Health in

India by 2015 Reduce Child Mortality

Cluipter-3 = HeaCth (Programmes of the Center and State: Jin Overview = =

Chapter - 3

HEALTH PROGRAMMES OF THE CENTRE AND STATE: AN

OVERVIEW

3.1. Background

India was one of the pioneers in health service planning with a focus on

primary healthcare. In 1946, the Health Survey and Development Committee,

headed by Sir Joseph Bhose recommended establishment of a well- structured and

comprehensive health service with a sound primary healthcare infrastructure.

Social development through improvement in health status can be achieved through

improving access to and utilization of health, welfare and nutrition services with

special focus on the underserved and under privileged segments of the population.

The Central Government can intervene to assist the state governments in the area

of control / eradication of major communicable and non-communicable diseases,

bread policy formulation, medical and paramedical education combined with

regulatory measures, drug control and prevention of food adulteration. Child

Survival and Safe Motherhood (CSSM), and immunization programme. The

"Health for AH" strategy is bemg re-oriented towards "Health for Under­

privileged". National Health Policy (1983), states that the demographic and health

scenario of the country still constitutes a cause for serious and urgent concern. To

provide accessible, affordable, and equitable healthcare the Government has

launched a large number of programmes and schemes. This chapter has been

divided into two sections. Section -1 explains the health programmes of the Centre

and State, and section II gives millennium development goals of health in India,

by 2015.

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Section - 1

HEALTH PROGRAMMES OF THE CENTRE AND STATE

Janani Suraksha Yojana (JSY) Karnataka

This cent per cent centrally sponsored scheme was launched with a focus

on demand promotion for institutional deliveries in states and regions where these

are low. It targeted lowering of the Maternal Mortality Rate (MMR) by ensuring

that deliveries were conducted by skilled birth attendants. The increase in

institutional deliveries coupled with improvement in infrastructure manpower and

training has resulted in significant improvement of institutional deliveries. Janani

Suraksha Yojana is a safe motherhood intervention under the National Rural

Health Mission implemented with the objective of reducing maternal and infant

mortality by promoting institutional delivery.

The beneficiaries are pregnant women falling in the BPL category aged 19

years and above, and also, SC/ST categories opting deliveries in public or

accredited private health institutions. The Yojana was launched on 12* April 2005.

It identified the Accredited Social Health Activist (ASHA) as an effective link

between the Government and poor pregnant women in 10 low performing states

like Uttar Pradesh, Uttaranchal, Bihar, Jharkand, Madhya Pradesh, Chhattisgarh,

Assam, Rajasthan, Orissa, and Jammu and Kashmir. While these states have been

named as Low Performing States (LPS), the remaining states have been named as

High Performing States (HPS).

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Pradhan Mantri Swasthya Suraksha Yojana (PMSSY)

The Pradhan Mantri Swasthya Suraksha Yojana (PMSSY) was launched

with the objective of correcting regional imbalances in the availability of

affordable / reliable tertiary healthcare services and to augment facilities for

quality medical education in the country. The PMSSY has two components in its

first phase.

Setting up of six All India Institute of Medical Science (AIIMS) like

institutions under the first phase of the PMSSY. The Government has decided to

set up six AIIMS like institutions, one each in the states of Bihar (Patna),

Chattisgarh (Raipur)^ Madhya Pradesh (Bhopal), Orissa (Bhubaneshwar),

Rajasthan (Jodhpur), and Uttaranchal (Rishikesh). These states were identified on

the basis of their socio-economic vulnerabilities (or) upgradation of 13 existing

Government medical colleges / institutions in ten states.

National Vector Borne Disease Control Programme (NVBDCP)

During the XI Plan period, the existing strategies for prevention and control

of vector borne diseases would be continued and further strengthened with special

emphasis on surveillance, human resource development, behaviour change

communication, supervision and monitoring, quality assurance and quality control

of diagnostics, and drugs and operational research. The programme aims to

maintain annual blood smear examination rate over 10% and bring down the

annual parasite incidence to 1.3 or less so as to accomplish 25 per cent reduction

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in malaria mortality by 2010 and 50 per cent by 2012. The main objective of

NVBDCP initiated in 2003-04 through convergence of three programmes on

malaria, Kalaazar and the inclusion of Japanese Encephalitis and Dengue, is

prevention and efficient control of vector borne diseases. In tandem with goals set

under the NHP 2002, the mission of NVBDCP is integrated and accelerated action

towards reducing mortality on account of malaria, dengue, Japanese encephalitis

by a half and elimination of Kalaazar by 2010 and elimination of Lymphatic

Filariasisby 2015.

National Leprosy Eradication Programme (NLEP)

During the XI Plan, the programme will aim at further reducing the leprosy

burden in the country,'while providing high quality leprosy services for all persons

affected by leprosy to the general healthcare system. The National Leprosy

Eradication Programme (NLEP) was launched in 1983 as cent per cent centrally

sponsored schemes with the availability of Multi Drug Therapy (MDT). It became

possible to cure leprosy cases within a short period (6-24 months of treatment).

The NLEP programme was initially taken up in endemic districts and was

extended to all over the country from 1994 with World Bank assistance.

National Tuberculosis Control Programme (NTCP)

The Revised National Tuberculosis Control Programme (RNTCP) was

launched in the country on March 1 ', 1997. The Revised National Tuberculosis

Control Programme (RNTCP) using directly observed treatment short course (dots)

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strategy is being implemented in the country in a phased manner since 1997, with

assistance from the World Bank, Danish International Development Agency

(DANIDA), Department for International Development (DFID), United States

Agency for International Development (USAID), Global Drugs Facility (GDF),

and Global Funds for Aids TB and Malaria (GFATM). By November 2005, 1065

million (95 per cent) of the country's population in 607 districts / reporting units

were covered under the programme.

The programme covers a population of 92 million and has placed more than

251akhs patients on treatment, averting more than 6 lakhs deaths. Overall, the

performance of RNTCP has been excellent with cure / treatment completion rate

consistently above 85 per cent and death rate reduced to less than 5 per cent.

National Aids Control Programme (NACP)

It was estimated that there were 2.31 million persons living with HIV/AIDS

in India in 2007. While the prevalence of HIV in general population is estimated

to be 0.34 per cent (Sentinel Surveillance, 2007), the National AIDS Control

Programme Phase-Ill (NACP) is being implemented for the period 2007-12 with

an investment of Rs. 11,585 crore. During the financial year 2008-09, out of a

budgetary provision of Rs. 1,123 crore, Rs. 1,037 crore was spent. Major

achievements during 2008-09 include scaling up targeted interventions for high

risk groups to 1,271, counselling and HIV testing, 101 lakh persons of which 41.5

lakh were pregnant women and providing ARV treatment to more than 2.17 lakh

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patients. New strategies that were initiated include setting up the District AIDS

Prevention and Control Unit (DAPCU) scheme of link workers in rural areas of

category AandB districts [Based on sentinel surveillance, 156 districts have been

identified as category-A districts, where prevalence of HIV amongst ANC

attendees (proxy for general population) is greater than 1 per cent).

Collaboration with NRHM and other national health programmes, public-

private partnership for treatment of sexually transmitted infections, and setting up

link ART centres to facilitate ARV drug dispensing red ribbon express and media

campaigns across the country to make the public aware about prevention of

HIV/AIDS are other initiatives. The first phase of the project on AIDS was

launched in 1992. Encouraged by the progress achieved, a second phase was

formulated by the Government in 1999 with two key objectives: i) to reduce the

spread of HIV infection in India, and ii) strengthen India's capacity to respond to

HIV/AIDS on a long-term basis. These objectives are being achieved through

prevention interventions among high risk groups and among the general

population, and by providing care and support services for people living with HTV

and AIDS. The total outlay for the second phase of the National AIDS Control

Programme (NACP-II) was Rs. 2,064,65 crore. The programme has five

components, viz.,

i. Priority targeted intervention for population at high risk,

ii. Preventive intervention for the general population.

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iii. Low-cost care for people living with HIV/AIDS,

iv. Institutional strengthening, and

V. Inter-sectoral collaboration.

Non-communicable diseases

The focus of the health sector programmes so far has been largely on

control of communicable diseases. Some programmes for non-communicable

diseases such as blindness, iodine deficiency, and cancer are also under

implementation. However, prevalence of non-communicable diseases like

cardiovascular diseases, mental disorder, cancer and trauma due to various factors

has been rising. There are national programmes for cancer, blindness, mental

health, and iodine deficiency disorders.

National cancer control programme

The national task force that had been set up under the programme has made

a series of recommendations for cancer control during the XI Plan. The strategies

proposed include prevention and early detection of cancer through district cancer

control activities, strengthening lEC, promoting centres of excellence in the field

of cancer management, augmenting cancer care facilities across the country,

development of early diagnostic capabilities and increasing capacity for palliative

care in cancer, etc. The cancer control programme was initiated in 1975-76 as cent

per cent centrally funded centre sector project. It was renamed as National Cancer

Control Programme in 1985.

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The objectives of the programme are:

1. Primary prevention of tobacco related cancers.

2. Secondary prevention of cancer cervix.

3. Extension and strengthening of treatment facilities on a national scale.

National Programme for Control of Blindness

The national blindness control programme was started in 1976 as 100 per

cent centrally sponsored programme with the objective of providing

comprehensive eye care services at primary, secondary, and tertiary healthcare

level, and achieving substantial reduction in the prevalence of eye disease in

general, and blindness in particular. Various activities of the programme include

establishment of Regional Institute of Ophthalmology, upgradation of medical

colleges and district hospitals and block level primary health centres, development

of mobile units and recruitment of required ophthalmic manpower in eye care

units for provision of Various ophthalmic services.

Prevalence and cause of blindness have undergone a distinctive change

since launching of the national programme for control of blindness as shown

below:

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Clmpter-3- HeaCth (Programmes oftHe Center and State :Jln Overview

Year

1971-74

1986-89

2001-04

2007

2010

2020

Prevalence (%)

1.38

1.49

1.10

0.8

0.5

0.3

Remarks

Cataract leading cause (75%)

Cataract blindness increased to 80%, Trachoma and vitamin A related blindness reduced

Cataract reduced to 63%, refractive error second leading cause (20%), Glaucoma and diabetic retinopathy emerging causes

Goal for 10*''Plan

Goal indicated in National Health Policy

Goal under "vision 2020 initiative"

The working group has recommended setting up an eye care management

information and communication network project to support access to quality and

affordable eye care services for prevention of blindness and sight restoration to the

underserved population.

The national network will comprise the district blindness control societies,

private hospitals, regional institutes of ophthalmology, and centres of excellence.

The latter centres would provide specialty services under one roof with highly

trained and motivated professionals. The new initiatives proposed includes

construction of dedicated eye wards and operation theatres in district hospitals in

the north-eastern states, Bihar, Jharkhand, Jammu and Kashmir, Himachal Pradesh,

Uttaranchal, and other states on demand. Telemedicine in ophthalmology is also to

be promoted.

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chapter-3 •• 'Kedth (Programmes of the Center and State: Jin Overview

National Mental Health Programme (NMHP)

The Govemmfent of India has launched the National Mental Health

Programme (NMHP) in 1982, keeping in view the heavy burden of mental ilbess

in the community, and the absolute inadequacy of mental healthcare infrastructure

in the country to deal with it.

Aims

1. Prevention and treatment of mental and neurological and their associated

disabilities.

2. Use of mental health technology to improve general health services.

3. Application of mental health principles in total national development to

improve quality of life.

Objectives

1. To ensure availability and accessibility of minimum mental healthcare for

all in the foreseeable future, particularly to the most vulnerable and

underprivileged sections of the population.

2. To encourage application of mental health knowledge in general healthcare

and in social development.

3. To promote community participation in mental health services development

and to stimulate efforts towards self-help in the community.

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Strategies

1. Integration mental health with primary healthcare through the NMHP.

2. Provision of tertiary care institutions for treatment of mental disorders.

3. Eradicating stigmatization of mentally ill patients and protecting their rights

through regulatory institutions like the central mental health authority and

state mental health authority.

Mental healthcare

1. The mental morbidity requires priority in mental health treatment.

2. Primary healthcare at village and sub-centre level.

3. At primary health centre level.

4. At the district hospital level.

5. Mental hospital and teaching psychiatric units.

District mental health programme

1. Training programmes for all workers in the mental health team at the

identified nodal institute in the state.

2. Public education in mental health to increase awareness and reduce stigma.

3. For early detection and treatment, OPD and indoor services are provided.

4. Providing valuable data and experience at the level of community to the

state and centre for future planning. Improvement in service and research.

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Agencies like the World Bank and WHO have been contacted to support

various components of the programme. Funds are provided by the

Government of India to the state governments and the nodal institutes to

meet the expenditure on staff, equipments, vehicles, medicine, stationary,

contingencies, training, etc., for initial 5 years, and thereafter, they should

manage themselves. The Government of India has constituted Central

Mental Health Authority to oversee the implementation of the Mental

Health Act, 1986. It provides for creation of State Health Authority alse to

carry out the functions.

The National Human Rights Commission also monitors the conditions in

the mental hospitals along with the Government of India, and the states are

currently actmg on the recommendation of the joint studies conducted to ensure

quality in delivery of mental care.

National Iodine Deficiency Disorders Programme (NIDDP)

Iodine Deficiency Disorders (IDD) affects a large number of the population

living in all the continents of our planet. Iodine is an essential micro nutrient,

which is required 100-150 micrograms daily for normal human growth and

development. It is proposed to bring down prevalence of IDD below 10% in the

entire country by AD 2015, and ensure 100% consumption of adequately iodated

salt at the household level through IDD surveys through state govemments/NGOs

established IDD control cells and IDD monitoring labs, quality control of iodated

salt at the consumer level training programmes production, and distribution of

iodized salt.

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The Multi Purpose Health Workers Scheme (MPHWS)

Towards remedying the situation as mentioned a door delivery oriented

nationwide health scheme called the multipurpose health workers scheme was

launched. The main objective of the MPHW scheme was to ensure atleast a

minimum availability of public health facilities, which include preventive

medicine, family welfare, nutrition and curative and referral services. The MPHW

scheme was launched in the year 1974 with the objective of establishing a

healthcare delivery system in rural areas through a team of multipurpose health

workers. One male and one female, in every sub-centre of the Primary Health

Centre (PHC) were set up. The specific objectives of the MPHW scheme were:

i. To increase the accessibility of healthcare services in rural areas.

ii. To reduce the area and allotted per health worker to improve the quality of

health services delivered through the trained paramedical personnel and to

extend the services at the periphery.

iii. To help develop a good rapport with the rural community.

iv. To convert all existing unpurposed workers at different levels into

multipurpose workers after reorientation training, and

v. To integrate organization and structure of various health and family welfare

programmes at the levels of primary health centre, district, and state.

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National Scheme for Prevention of Nutritional Blindness and National

Nutritional Anaemia Prophylaxis Programme

In India, the National Programme for Prevention of Nutritional Blindness

(NPPNB) due to vitamin A deficiency was initiated in the year 1970 under which

mega doses of vitamin A solution were distributed every six months to children

1-5 years of age. The National Nutritional Anaemia Prophylaxis Programme

(NNAPP) was also initiated in 1970, and under this programme, 100 tablets of

iron and folic acid (IFA) containing 60 mg of elemental iron and 500 mg of folic

acid were given per years one hundred IFA tablets containing 20 mg elemental

iron and 100 mg folic acid) are given per year. For every young child in the age

groups of 1-2 years, who carmot swallow tablets, IFA liquid is distributed. Both of

the national health programmes are funded by the Government of India and

implemented by the respective state governments through their health

infrastructures.

National Programme for Control of Blindness (NPCB)

Prevention and control of blindness is one of the important healthcare

programmes in India. The national health policy document of Government of India,

1983 stipulates that one of the basic human rights is the right to see. National

Programme for Control of Blindness (NPCB) was launched in the year 1976 as

cent per cent centrally sponsored vertical public heart programme.

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Objectives

The objectives to be attained under the National Programme for Control of

BUndness are as follows :

a. Developing eye care infrastructure throughout the country.

b. Increase institutional capacity for eye care.

c. Expand coverage to underserved areas.

d. Decentralization at the district level.

e. Human resource development for eye care at all levels

f. Improvement in the quality of eye care far better visual outcome and

g- Secure participation of non-government and private sector in the

programme.

Rashtriya Arogya Nidhi (RAN)

Rashtriya Arogya Nidhi was set up under the Ministry of Health and

Family Welfare in 1997. The scheme provides for financial assistance to patients

living below poverty line, who are suffering from major life threatening diseases

to receive medical treatment at any of the super speciality hospitals / institutes or

other government hospitals. The financial assistance to such patients is released in

the form of "One time grant" to the medical superintendent of the hospital in

which the treatment is being received. For providing financial assistance to the

needy patients, an advance of Rs. 10 to 40 lakhs is kept with the Medical

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Superintendents under the scheme. Central government also provides grant- in- aid

to states/union territories to set up state illness fund to the extent of 50% of

contribution made by state/union territories. Financial assistance is given to

patients living in their respective states/union territories under state illness fund

upto 1.5 lakhs in an individual case. However, in cases where the quantum of

financial assistance is likely to exceed Rs. 1.5 lakh, these are referred to RAN for

consideration.

Ayurveda, Yoga, Unani, Siddha, and Homeopathy (AYUSH)

AYUSH which includes Ayurveda, Yoga, Unani, Siddha Homeopathy, and

Naturopathy can play an important role in the prevention and management of

certain non- communicable diseases and lifestyle related disorders. A vast

infi-astructure has been created under AYUSH, which includes 3100 hospitals,

66366 beds, and 20811 dispensaries. Mainstreaming of AYUSH under the NRHM

received topmost priority during the year. AYUSH facilities were co-located with

1834 PHCs, 128 CHCs, and 29 District Hospitals. Keeping in view the strengths

of the AYUSH systems, new public health campaigns including control of

maternal anaemia through ayurveda, yoga for health, and unani for skin diseases

have been launched. Further, a National Yoga School Programme has been

launched in more than 100 schools in the country. The government has also given

priority to implementing the National Mission on Medicinal Plants. A National

Campaign on Amata was launched recently. Eight states have been covered so far

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under this programme. The govenmient has also taken steps to accredit hospitals

and educational institutions to improve their standards in collaboration with the

Quality Council of India (QCI). To improve the quality, safety, and efficacy of

ayurveda, siddha, and unani drugs, a programme for voluntary certification was

launched from 1 ' October 2009 in collaboration with the QCI. In order to

promote the AYUSH as well as provide employment opportunities to people,

especially women in rural areas of the country, ten AYUSH industrial clusters

have been taken up at a proposed investment of Rs. 100 crore in different parts of

the country.

Central Government Health Scheme (CGHS)

Central Government Health Scheme (CGHS) established in 1954, covers

employees and retirees of the central government and certain autonomous,

semi-autonomous, and semi-government organizations. It also covers members of

parliaments, governors, accredited journalists, and members of the general public

in some specified areas. The families of the employees are also covered under the

scheme. Total beneficiaries stand at 43 lakh (10.4 lakh card holders, 2003) across

24 cities with membership in Delhi being the highest with total of 9.12 lakh

cardholders and 33.01 lakh beneficiaries (as on 31 * March 2006). About 72.5%

cardholders are serving employees, 25.4% are pensioners, and the rest belong to

categories such as freedom fighters, members of parliament (MPs), ex- MPs,

journalists, and others. Central Government Health Scheme (CGHS) include

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CHapter- 3 = HeaCtfi (Programmes of the Center and State: Jin Overview

hospitalization, out-patient consultation and treatment, diagnosis, drugs, etc. For

these services, there are 247 polyclinics and 65 laboratories in the cities . For

hospitalization, the services are largely outsourced to selected private hospitals

and all government hospitals are included. Out Patient Department (OPD) and

diagnostic services are also partly outsourced to selected private hospitals and

diagnostic centres. Benefits under the scheme include medical care at all levels

and home visits/care as well as free medicines and diagnostic services. These

services are provided through public facilities (including CGHS exclusive

allopathic, ayurvedic, homeopathic and unani dispensaries) with some specialized

treatment (with reimbursement ceilings) being permissible at private facilities. Of

the total expenditure, about a third is spent on wages and salaries of the CGHS

staff.

Employees State Insurance Scheme (ESIS)

Employees State Insurance Scheme (ESIS) was established in 1948. It is an

insurance system, which provides both cash and medical benefits. It was

conceived as a compulsory social security benefit for workers in the formal sector.

The Employees State Insurance Corporation (ESIC) manages the scheme and is a

corporate semi-government body headed by the Union Minister of Labour as

Chairman and a Director General as the Chief Executive. Its members are

representatives of central and state governments, employers, employees, medical

profession, and members of parliament. The scheme applies to power using

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chapter- 3 HeaCth (Programmes of the Center and State: J?n Overview

factories employing 10 persons or more, and non-power and other specified

establishments employing 20 persons or more with employees earnings upto

Rs. 7500 per month being covered along with their dependents. The benefit

package is quite comprehensive in its coverage of health related expenses going

beyond the cost of medical care to include cash benefits (sickness, maternity,

permanent disablement of self and dependents) as well as other benefits such as

funeral expenses and rehabilitation allowance. However, the actual package of

benefits available is determined more by the type of facility accessed rather than

the type of cover. Medical care comprises out-patient care, hospitalization or

specialist treatment as well as services of the Indian systems of medicines. These

services are provided through a network of ESIS facilities, public care centres,

non-governmental organization (NGOs), and empanelled private practitioners. The

ESIS is financed by a three- way contribution from employers, employees, and the

state government. Between 1993-94 and 1997-98, the income of the scheme grew

substantially, while medical benefits have actually fallen, and as a result, the net

excess transferred to the ESIS fund went up from 14% to 30%. Significantly, the

cost of administering the scheme has been steadily increasing as a proportion of

expenditure on the revenue account.

National Rural Health Mission (NRHM)

National Rural Health Mission (NRHM) was launched on 12* April 2005

to provide accessible, affordable, and accountable quality health services to the

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Cluipter-3 HeaCth (Programmes oftHe Center and State: J\.n Overview

poorest households in the remotest rural regions. The thrust of the mission was on

establishing a fully functional, community owned, decentralized health delivery

system with intersectoral convergence at all levels to ensure simultaneous action

on a wide range of determinants of health like water, sanitation, education,

nutrition, social and gender quality. Under the NRHM, the focus was on a

functional health system at all levels from village to the district.

Objectives of NRHM

1. Reduction in maternal and child mortality

2. Universal access to affordable and quality health care services.

3. Prevention and control communicable and non- communicable diseases.

4. Access to integrated comprehensive primary healthcare.

5. Population stabilization.

6. Promotion of healthy lifestyle.

The union health and family welfare ministry has demonstrated 227

iimovative schemes being implemented by states and union territories under

NRHM.

Accredited Social Health Activities (ASHA)

One of the important goals of the National Rural Health Mission is to

provide access to improved healthcare at household levels through female

Accredited Social Health Activities (ASHA), who act as an interface between the

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community and the public health system. ASHA acts as a bridge between the

Auxiliary Nurse Midwife (ANM) and the village, and she is accountable to the

Panchayat. She helps promote referrals for universal immunization, escort services

for RCH, construction of household toilets, and other healthcare delivery

programmes. One of the key strategies under NRHM is a community health

worker, i.e., Accredited Social Health Activities (ASHA) forever at a norm of

1000 population. The role of ASHA vis-a-vis that of Anganawadi worker (AWW)

and Auxiliary Nurse Midwife (ANM) is also clearly laid dovm. Under the

implementation framework for the NRHM, the scheme of ASHA has now been

extended to all the 18 high focus states. Besides, the scheme would also be

implemented in the tribal districts of the other states.

Anganawadi Karyakarti Bima Yojana

Anganawadi Karyakatri Bima Yojana to Anganawadi workers and

Anganawadi helpers was launched with effect from April 2004 under the Life

Insurance Corporation's Social Security Scheme. In order to motivate Anganawadi

workers and give recognition to good voluntary work, a scheme of award has been

introduced both at the national and state levels. The award comprises of Rs. 25000

cash and a citation at central level and Rs. 5000 cash and a citation at state level.

Navjat Shishu Suraksha Karyakram

A new programme in basic new bom care and rescue citation, a two- day

training module for care provider at health facilities has been developed, and

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training programme to train master trainees at state and district levels has been

rolled out with the support of the Indian Academy of Neonatal Forum of India.

Auxiliary Nurse Midwives (Female Health Worker) Training Programme

Each sub- centre is manned by one male health worker and one female

health worker. In order to train the required number of ANMs in the rural areas,

there are 464 ANMs training schools functioning in the country with an annual

admission capacity of 20312 (1997). The duration of the training is 18 months.

Female Health Assistant Training Programme (LHV)

One female health assistant has to supervise the work of six sub- centres in

the rural areas. She provides technical guidance and supervision to the ANMs with

a minimum of 5 years working experience and are trained for 6 months to take up

the post of LHV, which is a promotional post. 44 LHV training schools with an

admission capacity of 2568 are functioning in the country.

Village Health Guide Scheme

The Village Health Guide Scheme was initially started as community health

workers scheme on 2"** October. The scheme was renamed as Village Health

Guide Scheme in 1981, when it was made cent per cent centrally sponsored

scheme under the family welfare programme. According to the scheme, the village

community selects a volunteer as VHG, who after training acts as a link between

the community and the Governmental Health System. VHG mainly provides

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health education and creates awareness on MCH and family welfare services.

VHG has to keep track of communicable diseases and treat minor ailments and

provide first aid to the patients.

Multi Purpose Worker (Male)

As per the norms, each sub- centre is required to be manned by a trained

female health worker (ANM) and a trained male health worker knovm as Multi

Purpose Worker (Male). The Government of India had initiated a scheme of

training, and thereby, converting the uni-purpose workers under various

programmes to Multi Purpose Workers. However, because of the shortage of

MPWs (Male) at sub- centre levels, a scheme of basic training for MPW (Male)

was initiated during 7* plan period. The basic training of MPW (M) was initiated

in 47 health and family welfare training centres throughout the country as cent per

cent centrally sponsored scheme.

Orientation Training of Medical and Paramedical Personnel

This is a centrally sponsored scheme under the family welfare programme.

It was started in 1984 with the objective to train medical and paramedical

personnel working at PHCs and sub- centres. Each category is placed to be

imparted training in the same institution where they had their basic training. The

duration of the training is two weeks.

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Health and Family Welfare Training Centres (HFWTC)

Health and Family Welfare Training Centres (HFWTC) were established in

the country with the objective of giving in-service training to health personnel in

the rural health sector. These training centres are set up with cent per cent financial

assistance fi-om the central government.

Training of ISM Practitioners on Family Welfare Programme

The scheme relates to the involvement of the practitioners of Indian System

of Medicine (ISM) in the various Family Welfare Programmes presently in

operation in the country. It was envisaged that it would cover various aspects of

the family welfare programme with a view to motivate the practitioners of ISM to

popularize small family norm, encourage use of contraceptives, assist in

information and attitude building for higher age at marriage, and to inform them of

the demographic changes and impact of population explosion. The Department of

Family Welfare had started a scheme for involving ISM practitioners with the

family welfare programme from 1992-93 in the state sector on an experimental

basis. Under the scheme, Rs. 50000 per seminar was provided to the states for

sensitization of private ISM practitioners only.

Karnataka Health System Development and Reform Project

Kamataka Health System Development and Reform Project is a World

Bank assisted five years project launched on 11-01-2007 at a cost of Rs. 897.77

crore with IDA credit of US $141.83 million and state share of US$ 64.65 million.

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Under project finance, IDA share is disbursed at 90% of actual expenditure on

certain new initiatives to faster result- based orientation in the department and test

certain new approaches to service delivery and health financing. Under

programme finance, IDA credit is disbursed at 50% of increase in the actual

expenditure incurred ongoing state sector programmes and activities.

Progress achieved upto November 2009 under project components are -

1. Organization Development

About 233 personnel at various levels commencing from HOD to Group D

have been trained in various aspects of Health Care and Hospital Management.

2. Service Improvement Challenge Fund

a. Construction Facilities

Out of the target of creating new facilities, 35 PHCs, 161 ANM sub training

centres, 13 drug warehouses, 16 PHCs, and 144 ANM sub-training centres have

been completed during the year. Out of repair/modification of 54 existing facilities

20 are completed.

b. 19 mobile health clinics are operating and more than 2000 camps conducted

and about 75000 patients checked/treated.

c. 6 citizen help desks at various district hospitals are operationalized.

d. 13 specialist doctors are contracted at various PHCs for improving

healthcare.

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3. Public Health Competitive Fund

1. Selection of 31 organizations (at least one per district) for imparting

training to 4.50 lakh members of the VHSC and ARS is in the final stages.

2. Process of selecting 29 HCMW officers for hospitals with more than 100

beds is in the final stage. Health establishments generate huge quantities of

healthcare and liquid waste. Series of steps are proposed for safe and

effective disposal of the waste by training and creating facilities for

treatment of the biomedical waste.

4. Health Financing

Helped to create and establish Suvama Arogya Raksha Trust plan to

supplement the proposed Suvama Arogya Raksha Trust for implementing health

insurance schemes for BPL families.

Thayi Bhagya

This scheme 'Thayi Bhagya' envisages a basket of interventions funded by

GOI (under NRHM components and State Government) to manage and support

the programme implementation. All vertical National Health Programmes are

merged both at the state and district levels.

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The inventions broadly have the following objectives:

a. Janani Suraksha Yojana (Safe Delivery)

This cent per cent centrally sponsored scheme was launched with a focus

on demand promotion for institutional deliveries in states and regions where these

are low. It targeted lowering of the MMR by ensuring that deliveries were

conducted by skilled birth attendants. The increase in institutional deliveries

coupled with improvement in infrastructure man power and training has resulted

in significant improvement of institutional deliveries.

The goals of JSY are reduction in maternal mortality rate and infant

mortality rate as well as to increase the institutional deliveries in BPL and SC/ST

families. Under this Yojana, besides insuring maternity services like 3 antenatal

checkups and referral transport, cash assistance is given. In rural areas, the cash

assistance to the mother for institutional delivery is Rs. 700 per case, whereas in

the urban areas, the cash assistance to mother is Rs. 600 for institutional delivery.

The cash assistance is also available for women delivering at home and the

amount given is Rs. 500 per case. If in case of government run health centres or

hospitals, specialists are not available, the institution can hire such specialists to

manage complications or for caesarean section. Assistance up to Rs. 1500 per

delivery could be utilized by the health institution for hiring services of specialists.

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Private hospitals accredited under JSY are also eligible for JSY funds. Total

deliveries conducted during the year upto the end of November 2009 is 632623

and JSY incentives was paid to 245054 mothers.

b. Prasuthi Araike Yojana

Financial support for nutritious diet and incentive to seek antenatal check

up was introduced in 7 districts in the state in the year 2007-08. This scheme

consists of giving a cash incentive of Rs. 2000 in cash (in two instalments of Rs.

1000 each to be paid by cheque to all BPL women who deliver in government

hospitals and identified hospitals).

c. Madilu

Promotion of institutional delivery and hygiene under this scheme,

assistance is provided to BPL pregnant women delivering in government

institutions. The assistance is in the form of Madilu kits consisting of requirements

for baby and mother is provided after delivery.

d. Chiranjeevi

Financial assistance for simple complicated deliveries and post- natal care

through direct payment. Under this scheme, private hospitals will be empanelled

in the identified districts to provide cashless treatment for deliveries conducted at

such hospitals for BPL women. This covers normal as well as complicated

deliveries. Private providers are reimbursed for every 100 deliveries (Rs. 3 lakh

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for 100 deliveries with 10% advance payment). During 2009-10, 15731 deliveries

were conducted in government and 5289 deliveries were conducted in private

hospitals. There is an improvement in the institutional delivery rate from 60-70%

Self Help Groups like Sthree Shakti Groups have been involved in providing

basic healthcare knowledge to the rural poor and also to distribute drugs for

common ailments.

Drug Distribution Management System (SSMS) is an integrated system

covering various ftinctions involved in the effective monitoring of procurement

and distribution of drugs, medicines, suture and surgical equipments to all

government hospital institutions in the state.

Important State Interventions during 2009-10

1. Arogya Kavacha

To provide Emergency Management Response Services like Arogya

Kavacha is implemented under the public private partnership. Ambulance service

is provided for emergencies such as delivery, accident, etc. at free of cost within

30 minutes when call is received from dedicated toll free telephone number 108.

During the year, 258 ambulances have been added into service and in all 408

ambulances have been inducted. During the year 2009-10 (upto November 2009),

73.80 lakh calls were received and cases have been shifted to nearby hospitals.

Total number of lives saved is 5493.

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2. Arogya Sanjeeviiii Scheme

This scheme provides free health facilities to SC and ST population who

are coming under BPL families. This scheme is implemented in existing

'Yeshaswini' Health Insurance Scheme, which is being implemented through

cooperative department.

3. Special Development Plan

About 53 Community Health Centre buildings were taken up during 2008-

09 and are nearing completion. Around 52 taluk headquarters hospital buildings

(100 beds), 42 community health centre buildings, and 3 district hospital buildings

are under various stages of construction.

4. Arogya Bandhu

Under Public Private Partnership (PPP), private institutions like medical

colleges, trusts, and charitable institutions have been launched over primary health

centres for maintenance and to provide free medical facilities under contract for a

period of 5 years. The entire cost will be borne by the state government. During

the current year, 9 PHCs were included and total 51 PHCs have been handed over

to medical colleges and NGOs.

5. During the year 2009-10, 21000 ASHA health workers were trained and

their services are being utilized.

6. Citizen Help Desk

In order to make hospitals user friendly and to address the patients'

problems. Citizen Help Desks have been established in 20 District Hospitals.

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Nutritional Programmes in Karnataka

Nutrition programmes have generally been focused on improving the

nutritional status of children, particularly those who are attending Anganawadis

and Government Primary Schools. National Nutrition Supplement Programme,

Supplementary Nutrition Programme, Akshara Dasoha Programme and Supply of

Food grains to the poor at subsidized rates under the Public Distribution System.

The Yeshaswini Health Insurance Scheme

The Yeshaswini Health Insurance Scheme introduced by the Government

of Karnataka in 2003, is a success story of partnership between the government,

insurance company, and an NGO to offer low cost health cover, particularly to the

poor in Karnataka. Under this programme, members of various cooperatives

receive an insurance cover against an extensive list of surgical procedures for a

nominal premium of Rs. 60 per annum. Yeshaswini Cooperative Farmers Health

Care Scheme (YCFHCS) is a great boon to the cooperative farmers of Karnataka.

This scheme has for the first time addressed the major health concerns of rural

people who typically have no health insurance. The scheme was put into operation

with effect from 1'* June 2003. To state it empathetically, Karnataka has become

a role model state with the introduction of Yeshaswini Scheme. Now, any farmer

who is a member of a cooperative society in Karnataka can get the necessary

treatment and have access to expense medical procedures by becoming a member

of this scheme. In 2003, this programme was introduced throughout rural

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Kamataka and in its first year of operation, the scheme had enrolled 1.6 million

rural farmers and peasants dispersed throughout the state. This scheme was

initiated by Narayana Hrudayalaya, Bangalore and implemented with suitable

modifications by the principal secretary to the Government of Kamataka, the co­

operation department, and a group of officers of the Co-operation Department with

the Family Health Plan Ltd., as the implementing agency.

The scheme aims to provide cost effective quality healthcare facilities to the

co-operative farmers spread across the state of Kamataka. It operates under the

agencies of the Kamataka State Co-operative Department. This scheme offers a

low priced product for a wide surgical cover to the co-operative farmers and their

dependent family members.

Arogya Raksha Yojana

ARY is a comprehensive scheme that goes beyond surgeries and

encompasses hospitalization, free medical consultation, and low cost medicines

for a premium of Rs. 120 per annum. Both these schemes (in case of the

Yashaswini prograrrmie) and private hospitals and clinics (in the Arogya Raksha

Model) provide quality healthcare.

Rashtriya Swasthya Bima Yojana

Rashtriya Swasthya Bima Yojana or RSBY started rolling fi"om 1* April

2008. RSBY has been launched by the Ministry of Labour and Employment,

Government of India to provide health insurance coverage for Below Poverty Line

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(BPL) families. The objective of RSBY is to provide protection to BPL

households from financial liabilities and the beneficiaries are entitled to

hospitalization coverage upto Rs. 30,000/- for most of the diseases that require

hospitalization. The government has even fixed the package rates for the hospitals

for a large number of interventions. Pre-existing conditions are covered from day

and there is no age limit. Coverage extends to five members of the family, which

includes the head of household, spouse, and upto three dependents. Beneficiaries

need to pay only Rs. 30/- as registration fee, while the central and state

governments pay the premium to the insurer selected by the government on the

basis of a competitive bidding.

Features of the scheme

i. Contribution by Government of India, 75% of the estimated annual

premium of Rs. 750, subject to a maximum of Rs. 565 per family per

annum. The cost of smart card will be borne by the Central Government.

ii. Contribution by respective State Governments, 25% of the annual premium

as well as any additional premium.

iii. The administrative and other related cost of administering the scheme

would be borne by the respective State Governments.

iv. The beneficiary would pay Rs. 30 per annum as registration / renewal fee.

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Benefits of Scheme

The beneficiary shall be eligible for such in-patient healthcare insurance

benefits as would be designed by the respective State Governments based on the

requirement of the people / geographical area. However, the State Governments

are advised to incorporate atleast the following minimum benefits in the package /

scheme.

• The unorganized sector worker and his family will be covered, total sum

insured would be Rs. 30,000/- per family per annum on a family floater

basis.

• Cashless attendance for all covered ailments.

• Hospitalization expenses, taking care of most common illnesses with as few

exclusion as possible.

• All pre-existing diseases to be covered.

• Transportation costs (actual with maximum limit of Rs. 100 per visit)

within an overalU limit of Rs. 1000.

Vajapayee Arogyasri Scheme

To provide financial protection to families living below poverty line for the

treatment of major ailments, requiring hospitalization and surgery. In order to

bridge the gap in provision of tertiary care facility and the specialist pool of

doctors to meet the state- wide requirement for the treatment of such diseases,

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particularly in rural areas, the Government of Kamataka has taken the initiative in

this direction. Heath insurance could be a way of removing the financial barriers

and improving accessibility to quality medical care by the poor. The Government

of Kamataka intends to implement the health insurance scheme under the name

Vajzayee Arogyashree for the BPL families of Kamataka in a phased manner.

The scheme is intended to benefit below poverty line (BPL) families, both

in urban and mral areas in Kamataka, in a phased manner. Identification of these

families are based on a BPL ration cared issued by the Food and Civil Supplies

Department. All eligible (family of 5 members) in the proposed districts are

provided with BPL cards issued by the Department of Food and Civil Supplies.

These BPL ration cards will be basis for identification of beneficiary under the

scheme until Biometric Health Cards are issued.

Objectives

To improve access of BPL families towards quality tertiary medical care for

treatment of identified diseases involving hospitalization, surgery and therapies

through an identified network of healthcare providers.

• To cover catastrophic illnesses.

• Universal coverage of BPL (Rural and urban).

• Catastrophic illnesses can wipe out decades of savings of BPL families.

• To protect the lifetime savings of BPL families which could be wiped out in

case of a catastrophic illness.

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Types of services

• Cardiovascular diseases

• Cancer treatment

a) Surgery

b) Chemotherapy

c) Radiotherapy

Neurological diseases

Renal diseases

Bums

Poly trauma cases

Neo-natal cases of services will be available for the beneficiaries under this

scheme.

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chapter- 3 'Keatth (Programmes of the Center and State: Jin Overview =^=^=

Section - II

MILLENNIUM DEVELOPMENT GOALS OF HEALTH IN INDIA

BY 2015 REDUCE CHILD MORTALITY

The Under-Five Mortality Rate is the probability (expressed as a rate per

1000 live births) of a child bom in a specified year dying before reaching the age

of five if subjected to current age specific mortality rates. Under-five mortality rate

at the national level has declined during the last decade. SRS based Under-Five

Mortality Rate in India for the year 2010, stands at 59 and it varies from 66 in

rural areas to 38 in urban areas. Maternal and child mortality are in decline,

although the pace of decline is not sufficient to attain Millermium Development

Goals (MDGs) 4 and 5 for 128/137 developing countries. Due to slow progress in

reducing infant and maternal mortality and the moral urgency of reinvigorating

efforts to tackle slow in 2010, India recorded 56 000 maternal and 1.3 million

infant deaths, the highest for any country. 5, 6, 7 India's MDG target is to reduce

IMR by two-thirds between 1990 and 2015, i.e., from 80 infant deaths per 1000

live births in 1990 to '28' by 2015. Under MDG, another target is to improve the

proportion of one-year-old children immunized against measles from 42% in

1992-1993 to 100% by 2015. India's main MDG target is to reduce MMR by three

quarters between 1990 and 2015, i.e., from 437 maternal deaths per 100 000 live

births to'109', while it has also committed to improve the 'proportion of births

attended by skilled health personnel'. With only three years left to achieve MDGs

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Cfiapter- 3 = HeaCth (Programmes of the Center and State: ^n Overview =^^=

4 and 5 targets, there is a need to understand the progress made by India as well as

its 15 most populous states. To a large extent, India shapes the global MDGs 4 and

5 targets, because of its share of the global burden of child (23%) and maternal

mortality (19%).l, 3 Moreover, during the past two decades, the 15 most populous

states, which account for 95% of India's population, have made variable progress

on infant and/or maternal mortality reduction efforts. India's IMR would be 42 per

1000 live births by 2015.

Infant Mortality Rate

Infant Mortality Rate (IMR) is defined as the deaths of infants of age less

than one year per thousand live births. Though IMR for the country as a whole

declined by 33 points in the last 20 years at an annual average decline of 1.65

points, it declined by six points between 2008 and 2010 with IMR at national level

being 47 in 2010. With the present improved trend due to sharp fall during

2008-09, the national level estimate of IMR is likely to be 44 against the MDG

target of 27 in 2015. This projected IMR level for 2015 therefore shows an

improvement over the projected IMR given in the last report based on data upto

2008.

Proportion of one year old children immunize against measles

The national level measure of the proportion of one-year old (12-23

months)children immunized against measles has registered an increase from

42.2% in 1992-93 to 74.1% in 2009 (UNICEF and GOI- Coverage Evaluation

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chapter - 3==^^= HeaCth (Programmes of the Center and State :^n Overview = ^ = ^

Survey 2009). At-this historical rate of increase, India is expected to cover about

89% children in the age group 12-23 months for immunization against measles by

2015. Thus, India is likely to fall short of the universal immunization of one year

olds against measles by about 11 percentage points in 2015.

Improve Maternal Health

Maternal Mortality Ratio (MMR)

The Maternal Morality Ratio reduced by three- quarters between 1990 and

2015. The Maternal Mortality Ratio ((MMR) is the number of women who die

from any cause related to or aggravated by pregnancy or its management

(excluding accidental or incidental causes) during pregnancy and childbirth or

within 42 days of termination of pregnancy, irrespective of the duration and site of

the pregnancy, per 100,000 live births. SRS6 data indicates India has recorded a

deep decline in MMR by 35% from 327 in 1999-2001 to 212 in 2007-09 and a fall

of about 17% happened during 2006-09. The decline in MMR from 1990 to 2009

is 51% from an estimated MMR level of 437. Based on SRS estimates for the

period 1988-1992, Under-Five Mortality Rate for 1990 has been taken as 125 per

1000 live births; thus, giving the 2015 target for the estimate as 42 per 1000 live

births (=l/3rd of 1990 value).6 SRS -Sample Registration System 19 per 100,000

live births in 1990/1991, India is required to reduce the MMR to 109 per 100,000

live births by 2015. At the historical pace of decrease, India tends to reach MMR

of 139 per 100,000 live births by 2015, falling short by 30 points. However, the

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bright line in the trend is the sharp decline, i.e., 17% during 2006-09 and 16%

during 2003-06 compared to 8 % decline during 2001-2003.

Proportion of births a(ttended by skilled health personnel: Still more gaps left

to be bridged for safer motherhood

Safe motherhood depends mainly on delivery by trained professional

personnel, particularly through institutional facilities. The rate of increase in

coverage of institutional deliveries in India is rather slow. It increased from 26%

in 1992-93 to 47% in 2007-08. As a result, the coverage of deliveries by skilled

personnel has also increased almost similarly by 19 percentage points from 33% to

52% during the same period. With the existing rate of increase in deliveries by

skilled personnel, the likely achievement by 2015 is only to 62%, which is far

short of the targeted universal coverage.

Combat HIV/AIDS, Malaria and other Diseases

The estimated adult HIV prevalence in India was 0.32 per cent (0.26% -

0.41%) in 2008 and 0.31 per cent (0.25% - 0.39%) in 2009. The aduh prevalence

is 0.26 per cent among women and 0.38 per cent among men in 2008, and 0.25 per

cent among women and 0.36 per cent among men in 2009. Among pregnant

women of 15-24 years, the prevalence of HIV has declined from 0.86% in 2004 to

0.48% in 2008.

India has contributed to approximately 24% of the total global new cases

detected during the year 2009 as per the WHO Global Report, 2010. There has

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been an increase in the number of TB patients registered for treatment from

1.29 million in 2005 to 1.52 million in 2010. Prevalence of all forms of TB has

been brought down from 338 lakh population (1990) to 256 lakh population in

2010 and TB mortality in the country has reduced from over 42 lakh population in

1990 to 26 lakh population in 2010 as per the WHO global report 2011. Repeat

population surveys conducted by TRC7 indicate an aimual decline in prevalence

of the disease by 12%.

The total malai ia cases have consistently declined from 2.08 million to 1.6

million during 2001 to 2010. Malaria is a public health problem in several parts of

the country. About 95% population in the country resides in malaria endemic areas.

80% of malaria cases are reported from areas consisting of 20% of population

residing in tribal, hilly, difficult and inaccessible areas. Directorate of National

Vector Borne Disease Control Programme (NVBDCP) has framed technical

guidelines/ policies and provides most of the resources for the programme.

Indicators have been developed at the national level for monitoring of the

programme, and there is uniformity in collection, compilation, and onward

submissions of data. Passive surveillance of malaria is carried out by PHCs,

Malaria Clinics, CHCs, and other secondary and tertiary level health institutions

that patients visit for treatment. Apart from that, ASHA-a village volunteer is

involved in the programme to provide diagnostic and freatment services at the

village level as a part of introduction of intervention like Rapid Diagnostic Tests

and use of Artemisinin Combination Therapy (ACT) for the treatment of Pf cases.

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Tuberculosis

The Revised National TB Control Programme (RNTCP) based on the

internationally recommended directly observed treatment short course (DOTS)

strategy has been expanded to cover the entire country with a view to achieve and

maintain a cure rate of at least 85% among new sputum positive patients and at

least70% success rate in case detection. Prevalence of all forms of TB has been

brought down from 338 lakh population (1990) to 256 lakh population in 2010,

and TB mortality in the country has reduced from over 42 lakh population in 1990

to 26 lakh population in 2010, as per the WHO Global Report, 2011.

India has not been successful in achieving some of the most important

Millennium Development Goal (MDG) targets like reduction in maternal and child

deaths, and increase in child immunization rates by 2015. The World Health

Organization (WHO) has for the first time aired its views that India will miss its

targets, some by a big margin. "The MDG targets will expire in 2015 and not all

goals will be achieved by India." WHO admits that India has been effectively

reducing its infant and maternal mortality figures, but experts say the pace has not

been satisfactory enough, especially when it comes to infant and maternal deaths.

One of the MDG goals is to reduce under-five mortality rate to 42 per 1,000 live

births by 2015. India w ll reach 52 by that year missing the target by 10 percentage

points. The national level estimate of infant mortality rate is likely to be 44 against

the MDG target of 27 in 2015. Some of the largest states like Madhya Pradesh

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(62), Odisha (61), Uttar Pradesh (61), Assam (58), Meghalaya (55), Rajasthan (55),

Chhattisgarh (51), BiHar (48), and Haryana (48) still have IMR above the national

estimates.

The national level measure of the proportion of one-year old (12-23

months) children immunized against measles has registered an increase from

42.2% (1992-93) to 74.1% (2009). India is, however, expected to cover about 89%

children in the age group 12-23 months for immunization against measles by

2015, which is short of the universal immunization of one-year olds against

measles by about 11 percentage points. India will reach maternal mortality rate

(MMR) of 139 per 100,000 live births by 2015, falling short by 30 percentage

points.

The rollout of the Universal Health Coverage (UHC) programme, entitling I

essential primary, secondary, and tertiary healthcare services guaranteed by the

central government to all citizens, will help India achieve its unfinished MDG

targets only after 2015. Nearly 50 countries have attained universal or near-

universal coverage. Escalating healthcare costs, inadequate public spending, and

weak healthcare delivery systems in low and middle income countries have been

barriers to UHC.

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Cfiapter-3 • Heakh (Programmes of tfie Center and State: ^n Overview ^^^=

Conclusion

Healthcare should be within the reach of every citizen. For providing basic

health facilities to all people, the government has introduced and implemented

various health schemes and programmes. The health progranmies are expected to

bring significant improvement to the entire health system, and in particular, to

rural areas, especially to the vulnerable groups (such as mothers and children).

Many programmes and schemes are in process, to provide health services, in order

to bridge the gap of inadequacies in the infrastructure, including shortage of

personnel and provide accessible, affordable, equitable healthcare, to provide

financial protection to families living below poverty line for the treatment of major

ailments, requiring hospitalization and surgery particularly in rural areas. However,

tertiary medical care provided by multi-speciality hospitals and medical colleges

are located almost exclusively in urban areas. Hence, the government should take

necessary steps, to provide financial assistance for the people, especially those

who are living in the remotest regions of the rural areas, to access healthcare

services.

115