11 Chapter 2

CHAPTER 2
RURAL HEALTH CARE IN INDIA

2. Rural Health Care in India
Rural Health Care services in India is mainly based on Primary health care, which
envisages attainment of healthy status for all. Also being holistic in nature it aims to
provide preventive, promote curative and rehabilitative care services. The different
Health Policies and Programmes of the country aim at achieving an acceptable standard
of health for the general population of the country. Keeping in line with this broad
objective, a comprehensive approach was advocated, which included improvements in
individual health care, public health, sanitation, clean drinking water, access to food and
knowledge of hygiene and feeding practices. Importance was accorded to reduce
disparities in health across regions and communities by ensuring access to affordable
health, especially to the weaker and underprivileged like women and children, the older
persons, disabled and tribal groups. An assessment of the performance of the country‟s
health related indicators depicts that significant gains have been made in them e.g. life
expectancy at birth, child and maternal mortality, morbidity. This chapter attempts to
review the progress of primary health care services in India, especially in rural areas. It
deals with the origin and evolution of health care in India, where it covers the details of
the different stages of primary health care in India starting from Bhore committee (1946)
to Alma Ata Declaration (1978) to current NRHM (2005-2012). It briefly reviews -
1. Different committee reports / recommendations, policies and programmes to

assure health care facility in India, values and principles adopted in achieving the
same like Equitable distributions, Universal access to care and coverage on the
basis of the need, Community participation and Coordination & convergence with
the other health related sectors.
2. Primary health care resources in India- in terms of infrastructure, manpower and
financial resources needed to implement the primary health.
3. The current situation, progress made and programmatic response in respect to
different components of primary health care in India – Maternal and Child health
(Maternal Health, Infant and Children under5 years) including immunization,
nutrition, safe water and basic sanitation and health education
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2.1 Origin and Evolution of Primary Health Care in India
Primary Health Care is a vital strategy which is a backbone of Health Service delivery for
our country. India was one of the first few countries to recognize the importance of
Primary Health Care Approach. PHC was conceptualized in 1946, three decades before
the Alma Ata declaration, when Sir Joseph Bhore made recommendations, which laid the
basis for organization of basic health services in India. Over the past decades, several
Committees and Commissions have been appointed by the Government to examine issues
and challenges facing the health sector. The purpose of these committees formed from
time to time is to review the current situation regarding health status in the country and
suggest further course of action in order to accord the best of healthcare to the people.
The earliest committees included, the Health Survey and Development Committee (Bhore
Committee) and Sokhey Committee. Other main Committees in the Post Independence
period, included Mudaliar Committee, Chadha Committee, Mukherjee Committee,
Jungalwalla Committee, Kartar Singh Committee; Mehta Committee, Bajaj Committee
amongst others. Some of the recent Committees include the Mashelkar Committee and
the National Commission on Macroeconomics and Health. The committees and
commissions have been headed by eminent public health experts, who have studied the
issues in an in-depth manner and provided overarching recommendations for various
aspects of the health care system in India. The areas covered by them related to
organization, integration and development of health care services / delivery system across
levels; health policy and planning; national programmes; public health; human resources;
indigenous systems of medicine; drugs and pharmaceuticals. An examination of these
reports reveals the options, lessons and challenges for strengthening India‟s health
system.
2.1.1 Bhore Committee on Health Planning and Development
The Bhore committee report is the first health report, i.e. the Health Planning and
Development Committee's Report, 1946. It was a plan equivalent to Britain's National
Health Service. The Report was based on a countrywide survey in British India. It is the
first organized set of health care data for India. It considered that the health programme in
India should be developed on a foundation of preventive health work and proceeds in the
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closest association with the administration of medical relief. The Committee strongly
recommended a health services system based on the needs of the people, the majority of
whom were deprived and poor. It felt the need for developing a strong basic health
services structure at the primary level with referral linkages. It emphasized the social
orientation of the medical practice and high level of public participation. The
recommendations of the Bhore Committee report were1
 the integration of preventive and curative services at all administrative levels

 short term Primary Health Centre for 40000 population
 long term (3 million plan) – Primary Health Centers with 75 beds for each 10000
– 20000 population
 formation of Village Health Committee
 provision of Social doctor; inter-sectoral approach to health servicers
development
 Three months training in preventive and social medicine to prepare social
physicians for better health status of the citizens
2.1.2 Sokhey committee report on National Health
The National Planning Committee (NPC) set up by the Indian National Congress in 1948
under the chairmanship of Colonel S. Sokhey stated that the maintenance of the health of
the people was the responsibility of the State, and the integration of preventive and
2,3
curative functions in a single state agency was emphasized . The Sokhey Committee
Report was not as detailed as the Bhore Committee Report, but endorsed the
recommendations of the Bhore Committee Report and commented that it was „of the
utmost significance'.
1
Report of the Health Survey and Development Committee, Volume II and Volume IV, Government of India, New Delhi, 1946.
2
Banerji D., Health and family planning services in India: An epidemiological, socio-cultural and political analysis and a
perspective. Lok Paksh, New Delhi, 1985.
3
Report of National Planning Committee – Sub Committee on National Health, Government of India, 1948.
2-3
2.1.3 Community Development Programme
With the beginning of First Five Year Plan (1951 – 55) and Health Planning in India,
Community Development Programme (CDP) was launched in 1952 for all the
development of rural areas in all dimensions, where 80% of the population lived. The
Community Development Programme inaugurated on October 2, 1952, was an important
landmark in the history of the rural development. Community development was defined
as “a process designed to create conditions of economic and social progress for the whole
community with active participation and the fullest possible reliance upon the
community‟s initiative”. CDP was envisaged as a multipurpose programme covering
health and sanitation (Through the establishment of Primary Healthcare Centers and Sub
Centers) and other related sectors including agriculture, education, transport, social
welfare and industries. Each Community Development Block (CDB) consists of 100
villages with an approximate total population of 100000. For one CDB, one PHC was
created 4.
2.1.4 Mudaliar Committee on Health Survey and Planning
By the close of second Five Year Plan (1956 -61), “Health Survey and Planning
Committee”, headed by Dr. D.L.Mudaliar, was appointed by the Government of India to
review the progress made in the health sector after submission of Bhore Committee
report. This committee found the conditions in PHCs to be unsatisfactory and suggested
that the PHC, already established should be strengthened along with the strengthening of
sub divisional and district hospital. The major recommendation of this committee report
was to limit the population served by primary health centers to 40,000 with the
improvement in the quality of health care provided by these centers. Also provision of
one basic health worker per 10,000 population was recommended 5.
4
Bhattacharya S.N., Community Development– An Analysis of the Programme in India, Community Development Journal, 1971,
6(1), 51-52.
5
Report of the Health Survey and Planning Committee, Ministry of Health, Government of India, New Delhi, 1961.
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2.1.5 Mukherji Committee Reports on Basic Health Services
The Mukherji Committee headed by the then Secretary of Health Shri Mukherji, was
appointed to review the performance in the area of family planning. The committee
observed that the multiple activities of the mass programmes like family planning, small
pox, leprosy, trachoma, National Malaria Eradication Programme (maintenance Phase)
were making it difficult for the states to undertake these effectively because of the
shortage of funds and recommended to delink the malaria activities from family planning
so that the latter would receive undivided attention of its staff. The committee however,
does visualize that at later stage not long from how, there can and should be a much
greater integration between the Family Planning and Maternity and Child Health
Programme and the basic health services. The committee also worked out the
composition and organization of basic health services, which should be provided at the
Block level. Also strongly it recommended that Importance must be given to due
strengthening of the supervisory levels to correspond to the strengthening of the base
organization 6. This is particularly necessary for the basic health services since the quality
of the performance of the functionaries at the base level, who have to be comparatively
more numerous but cannot be so well paid nor of very high caliber nor technically so well
equipped, will determine greatly the quality of the whole service and the benefits derived
there from by the rural people. Supervision of their work has, therefore, to be particularly
strong and continues. This supervision must be both administrative and technical must be
adequate both in degree and quality and must not be confined only to exercise of control
but must extend also to providing help and guidance.
2.1.6 Jungalwalla Committee on Integration of Health Services
The Jungalwalla committee on Integration of Health Services was set up in 1964 under
the chairmanship of Dr. N Jungalwalla, the then Director of National Institute of Health
Administration and Education (currently National Institute of Health and Family
Welfare). It was asked to look into various problems related to integration of health
services, abolition of private practice by doctors in government services, and the service
6
Report of Mukerji Committee on Basic Health Services, Government of India, New Delhi, 1966.
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conditions of doctors. The committee defined “integrated health services” as “a service

with a unified approach for all problems instead of a segmented approach for different
problems”. The committee recommended integration from the highest to lowest level in
the services, organization and personnel. That is Medical Care and Public Health
Programmes should be put under charge of a single administrator at all levels of
hierarchy by adopting - The Unified Cadre, Common Seniority, Recognition of extra
qualifications, equal pay for equal work, special pay for special work, abolition of
private practice by government doctors, improvement in their service conditions 7.
2.1.7 Kartar Singh Committee on Multipurpose workers
The Kartar Singh Committee, 1973 headed by the Additional Secretary of Health named
“committee on multipurpose workers” to laid down the norms about health workers to
form a framework for integration of health and medical services at peripheral and
supervisory levels. For ensuring proper coverage the committee recommended the
amalgamation of peripheral workers into a single cadre of multipurpose workers. Also it
recommended the organizational change of with respect to PHCs and SCs - one PHC to
be established for every 50,000 population. Each PHC to be divided into 16 SCs each for
a population of 3000 – 3500. Each SC to be staffed by a team of one male and one
female health worker. The work of 3-4 health workers to be supervised by one Health
Assistant. 8
2.1.8 Shrivastav Committee on Medical Education & Support Manpower
The Shrivastav Committee was set up in 1974 as “Group on Medical Education and
Support Manpower” to determine the steps needed to (i) reorient medical education in
accordance with the national needs and priorities and (ii) develop a curriculum for health
assistants who were to function as a link between medical officers and MPWs. The
committee recommended
7
Report of the committee on Integration of Health Services, Directorate General of Health Services, New Delhi, March 1967.
8
Report of the Committee of Multipurpose Workers under Health and Family Planning Programme Ministry of Health and Family
Planning, New Delhi, 1973.
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(a) Creation of bands of paraprofessional and semi-professional health workers from

within the community (like school teachers, post masters etc) itself.
(b) The establishment of 3 cadres of health workers between the community level
workers and doctors at PHC.
(c) The development of “Referral Service Complex” by establishing linkages
between the primary health centre and higher level referral and service centers viz
taluka, district, regional and medical college hospitals.
(d) Establishment of a medical and Health Education Commission for planning and
implementing the reforms needed in health and medical education on the lines of
University Grants Commission.9
2.1.9 Rural Health Scheme: Community Health Volunteer Scheme-Village Health

Guides
Acceptance of the recommendations of the Shrivastav Committee report led to the

launching of Rural Health Scheme in 1977, wherein training of community health
workers, reorientation training of multipurpose workers and linking medical colleges to
rural health was initiated. Also to initiate community participation, the Community
Health Volunteer – Village Health Guide (VHG) scheme was launched on 2nd October
1977. According to the VHG Scheme the village community selects a volunteer was to be
a person from the village, mostly women, who was imparted short term training and
small incentive for the work. VHG acts as a link between the community and the
Government Health System.10,11 He / She mainly provides health education and creates
awareness of Maternal and Child Health and Family Welfare Services. He / She has to
keep a track of communicable and treat minor ailments and provide first aid to the
patients.
9
Report of the group on Medical Education and Support Manpower, Health Services and Medical Education –A programme for
immediate Action, Ministry of Health and Family Planning, Government of India, New Delhi, 1975.
10
D.G. Satihal, K.E.T. Rajarama, Evaluation of Village Health Guide Scheme, Belgaum District, Karnataka, Report prepared for the
Ministry of Health and Family Welfare, Government Of India, New Delhi, 2000.
11
Report of the National Commission on Macroeconomics and Health (Chapter 7), Ministry of Health and Family Welfare,
Government of India, 2005.
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Exhibit 2.1: Major miles stones in evolution of Primary Health Care in India
Pre Alma Ata Declaration
1946 Bhore Committee Report on Health Survey and Development
1948 Sokhey Committee Report on National Health
1952 Community Development Programme
1962 Mudaliar Committee Report on Health Survey and Planning
1966 Mukheree Committee Reports on Basic Health Services
1967 Jungalwalla Committee Report on Integration of Health Services
1973 Kartar singh Committee report on Multipurpose Health Workers
1975 Shrivastav Committee Report on Medical Education and Support

manpower
1977 Rural Health Scheme: Community Health Volunteer Scheme-Village Health

guides
Alma Ata Declaration and beyond
1978 Alma Ata Declaration – Health For All by 2000
1980 ICSSR and ICMR Report – “Health for all- An alternate Strategy”
1983 Mehta Committee on Medical Education Review
1983 First National Health Policy
1987 Bajaj Committee on Health Manpower Planning, Production and

Management
1996 Bajaj Committee on Public Health Systems
2000 National Population Policy
2002 Second National Health Policy
2005 National Rural Health Mission (NRHM)
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2.1.10 Alma Ata Declaration – Health for all by 2000
The Alma Ata declaration of 1978 launched the concept of Health For All by year 2000.
It was signed by 134 governments (including India) and 67 other agencies. The Alma Ata
Declaration in 1978 gave an insight into the understanding of primary health care. It
viewed health as an integral part of the socioeconomic development of a country. It
provided the most holistic understanding to health and the framework that States needed
to pursue to achieve the goals of development. The Declaration recommended that
primary health care should include at least: education concerning prevailing health
problems and methods of identifying, preventing and controlling them; promotion of food
supply and proper nutrition, and adequate supply of safe water and basic sanitation;
maternal and child health care, including family planning; immunization against major
infectious diseases; prevention and control of locally endemic diseases; appropriate
treatment of common diseases and injuries; promotion of mental health and provision of
essential drugs.12 It emphasized the need for strong first-level care with strong secondary-
and tertiary-level care linked to it. It called for an integration of preventive, promotive,
curative and rehabilitative health services that had to be made accessible and available to
the people, and this was to be guided by the principles of universality,
comprehensiveness and equity. In one sense, primary health care reasserted the role and
responsibilities of the State, and recognized that health is influenced by a multitude of
factors and not just the health services.13 At the same time, the Declaration emphasized
on complete and organized community participation, and ultimate self-reliance with
individuals, families and communities assuming more responsibility for their own health,
facilitated by support from groups such as the local government, agencies, local leaders,
voluntary groups, youth and women's groups, consumer groups, other non-governmental
organizations, etc. The Declaration affirmed the need for a balanced distribution of
available resources (WHO 1978). The declaration asserted “PHC is essential health care
based on practical, scientifically sound and socially acceptable methods and technology
12
Declaration of Alma-Ata International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978, accessed from
www.who.int/hpr/NPH/docs/declaration_almaata.pdf
13
Joy E Lawn, Jon Rohde, Suson Rifkin, Miriam Were, Vinod K Paul, Mickey Chopra, Alma-Ata 30 years on: revolutionary,
relevant, and time to revitalize, The Lancet 2008; 372: 917 -27.
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made universally accessible to individuals and families in the community through their
full participation at every stage of their development in the spirit of self-reliance and self-
determination.”
Several critical efforts outlined Government of India‟s commitment to provide health for
all of its citizens after Alma Ata declarations, which are briefly discussed below.
With a view of evolving a national strategy for securing the objectives of Health For All
and to identify specific programmes for the VI Five Year Plan, The working group on
Health was constituted by the Planning Commission with Shri Kripa Narain, Secretary,
Ministry of Health and Family welfare as its Chairman to review the current health status
keeping in view the physical and qualitative implementations of plan programmes, short
falls and deficiencies and measures for rectifying them. The report of the working Group
on “Health for All by 2000 AD” examined the contextual issues in providing health care.
The report contains a variety of inter-related recommendations, setting out objectives,
strategies and operational goals which are considered feasible in the obtaining conditions.
It is basically set down the parameters of the problem and set out the specific health tasks
and targets to the state in the simplest terms but with full belief, that the goal of Health
For All as spelt out here is an achievable one, given the sustained will and the supporting
efforts to implement the indicated tasks by 2000 AD.14
2.1.11 ICSSR and ICMR Reports on “Health for all - An Alternate Strategy”
The report of Study Group on „Health for All – an alternate Strategy” commissioned by
ICSSR and ICMR (1980) under the chairmanship of Dr. V. Ramalingaswami indicated
that most of the health problems of a majority of India‟s population were amenable to
being solved at the primary health care level through community participation and
ownership. The report of ICSSR / ICMR report “Health for All : An Alternative
Strategy” offered a viable alternative strategy to reach most of the Indians who are in
need of such services. The report recommended an alternative health care system that was
accessible, culturally acceptable and cost effective for all citizens accountable to the
14
Report of the Working Group on HEALTH FOR ALL by 2000 AD, Ministry of Health and Family welfare, Government of India,
1981.
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people it served. It advocated - 1) encouraging people to utilize their age-old health

culture and practices together with the best of all available systems provided in a simple
and effective manner. 2) With the support of the community, this decentralized system
could devise a graded training and referral system from the village to community‟s own
hospital and training complex. This would meet almost 95% of all requirements of
preliminary health and medical care. Broad-based medical and surgical specialty level
within a 30000 population level would be serviced by the government Primary health
Center.15 The report was set in the context the failures of the imported, top heavy,
centralised, elite-oriented model of health care delivery that characterised the first 30
years of Indian independence. It was a move beyond merely reproducing Western social
institutions, services and values in the area of health to creating a health care delivery
system that was more relevant to India.16 The report also recommended the formulation
of a comprehensive national health policy through an inter-sectoral approach that
includes environment, nutrition, education, socio-economic, preventive and curative
dimensions.
2.1.12 Mehta Committee on Medical Education Review, 1983
The Mehta committee mainly reviewed the medical education in all its aspects and
specifically discussed about lack of availability of Health manpower data in India. Also
committee recommended to establish Universities of Medical Sciences and Medical and
Health Education Commission; method for updating the manpower data and projections
for doctors , nurses and pharmacists.17
2.1.13 First National Health Policy, 1983
The responsibility of the state to provide comprehensive primary health care to its people
as envisioned by the Alma Ata declaration led to the formulation of India‟s First National
health Policy (NHP) in 1983. The major goal of policy was to provide of universal,
comprehensive primary health services. The policy emphasized the role that could be
15
Noshir Anita, Seema Deodhar, Neges Mistry, Developing an Alternative Strategy for Achieving Health for all, The ICSSR/ ICMR
Model – The FRCH Experience, Foundation for Research in Community Health, Pune, 2004.
16
ICMR and ICSSR , Health For All: An Alternate Strategy, Published by Indian Institute of Education, 1981.
17
Report of the Medical Education Review Committee, Ministry Of Health and Family Welfare, Government of India, 1983.
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played by private and voluntary organizations working in the country to support

government for integration of health services. It stressed the creation of an infrastructure
for primary healthcare; close co-ordination with health-related services and activities like
nutrition, drinking water supply and sanitation; the active involvement and participation of
voluntary organisations; the provision of essential drugs and vaccines; qualitative
improvement in health and family planning services; the provision of adequate training; and
medical research aimed at the common health problems of the people. 18
Meanwhile, A selective approach as an “interim” measure to the long term process of

comprehensive primary health care implementation was introduced in many countries,
including India as resource constraints made it ”not possible” to achieve Alma Ata goals
within the committed time limit. Thus the focus shifted from the development of health
systems and infrastructure for primary health care and ensuring health equity to several
vertical interventions based on technical justifications and cost effectiveness analysis.
UNICEF also suggested its selective approach, GOBI-FFF (Growth monitoring, Oral
dehydration, Breast feeding, Immunization, Female literacy, Family planning, Food
supplement) for improving child survival.19 By the turn of the millennium, despite some
gains in health outcomes and vast improvements in the availability of health
infrastructure through a three-tier network, India had yet to achieve most of the goals
enshrined in its first national health policy.
2.1.14 Bajaj Committee on Health Manpower Planning, Production and
Management, 1987
An “Expert Committee for Health Manpower Planning, Production and Management”

was constituted in 1985 under Dr. J.S. Bajaj, then professor at AIIMS. The committee
discussed in details the different components of primary health care, manpower
requirement at different levels and catering the demand by vocational training and
managing the manpower. The major recommendations are20
18
First National Health Policy, Ministry of Health and Family Welfare, Government of India, New Delhi, 1983.
19
The World Health Report 2002 – Reducing risks, Promoting Healthy life, (Chapter 5), World Health Organization, Geneva, 2002.
20
Report of the Expert Committee on Health Manpower Planning, Production and Management, Ministry of Health and Family
Welfare, Government of India, New Delhi, 1987.
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1. Formulation of National Medical and Health Education Policy.

2. Formulation of National Health Manpower Policy.
3. Establishment of an Educational Commission for Health Sciences (ECHS) on
the lines of UGC.
4. Establishment of Health Science Universities in various states and union
territories.
5. Establishment of Health manpower cells at centre and in all states.
6. Vacationalisation of education at 10 +2 levels as regards health related fields
with appropriate incentives, so that good quality paramedical personnel may
be available in adequate numbers.
7. Carrying out a realistic health manpower survey.
2.1.15 Bajaj committee on Public Health System, 1996
The Ministry of Health and Family Welfare, constituted a Expert Committee on Public
Health Systems under the chairmanship of Dr. J.S. Bajaj, to comprehensively review the
public health system in the country and to offer appropriate recommendations. After the
detailed deliberations the committee exhaustively reviewed the current status of public
health system, epidemiological surveillance system, status of control strategies for
epidemic diseases, existing health schemes, environmental health and sanitation, role of
state and local health authorities in epidemic remedial measures, health manpower
planning and health management information system. A series of short term and long
term recommendations along with action plan are proposed to impart a greater degree of
responsiveness in the public health system.
Key recommendations are Policy initiatives with respect to review National Health
Policy, Establishment of health impact assessment cell, surveillance of critically polluted
areas, search for alternative strategy / strengthening of health services / system research,
uniform adoption of public health Act by the local health authorities, establishing
National Notification System / National Health Regulations, Joint Council of Health,
Family Welfare and ISM and Homeopathy, Establishing an Apex Technical Advisory
Body, Constitution of Indian Medical and Health Services, Administrative restructuring
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of department of Health and Family welfare and DGHS, strong Health Manpower
Planning division under DGHS, opening of Regional Schools of Public Health along with
the emphasis on implementation of recommendation of committee recommendations of
manpower planning, production and management of 1987. 21
2.1.16 National Population Policy, 2000
The National Population Policy was announced in the year 2000, the overarching policy
framework for family planning and maternal and child health goals, objectives and
strategies. The immediate objective of NPP was to address the unmet needs of
contraception, health care infrastructure and health personnel and to provide integrated
delivery for basic reproductive and child care services. It envisaged development of one-
stop integrated and coordinated service delivery at the village level for basic reproductive
and child health services through a partnership of the government with voluntary and
non-governmental organizations.22
2.1.17 Second National Health Policy, 2002
Nearly twenty years after the first health policy, the Second National Health Policy, 2002
was presented. The NHP 2002 recognized as the noteworthy successes in health since the
implementation of the First NHP 1983. These successes included the eradication of small
pox and guinea worm, the near eradication of polio and the progress towards the
elimination of leprosy and neonatal tetanus. The NHP sets out a new policy framework to
achieve public health goals 23 in the socio-economic circumstances currently prevailing in
the country. The approach aims at increasing access to the decentralized public health
systems by establishing new infrastructure in deficient areas and upgrading the
infrastructure of existing institutions. It sets out an increased sectoral share of allocation
out of total health spending to primary health care. The major goals set by this policy are
as below listed
21
Report of the Expert Committee on Public Health System, Ministry of Health and Family Welfare, Government of India, New
Delhi, 1996.
22
National Population Policy 2000, Ministry of Health and Family welfare, Government of India, New Delhi, 2000.
23
National Health Policy 2002 (India), Ministry of Health and Family Welfare, Government of India, New Delhi 2002.
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Exhibit 2.2: Major Goals of National Health Policy 2002
National Health Policy 2002
Major Goals to be achieved Year
Eradication of Polio and Yaws 2005
Eliminate Leprosy 2005
Eliminate Kala Azar 2010
Eliminate Lymphatic Filariasis 2015
Achieve zero level growth of HIV/AIDS 2007
Reduce Mortality by 50% on account of TB Malaria, other 2010

vector and water borne diseases
Reduce IMR to 30/100 and MMR to 100 per 1 Lakh 2010
Increase the utilization of public health facilities from <20% to >75% 2010
Increase health expenditure by Govt as a %GDP from existing 0.9% to 2% 2010
Establish an integrated system of surveillance,

2005
National Health Accounts and Health Statistics
2010
Increase share of central grants to constitute at least 25% of total health spending
Increase the state sector health spending from 5.5% to 7% of the budget 2005
Further increase to 8% of the budget 2010

Source: National Health Policy – 2002, Ministry of Health and Family welfare, GOI, New Delhi
2.1.18 National Rural Health Mission (NRHM, 2005-2012)
Recognizing the importance of Health in the process of economic and social development
and improving the quality of life of our citizens, the Government of India has launched
the National Rural Health Mission (NRHM) in April 2005 to carry out necessary
architectural correction in the basic health care delivery system. The Mission adopts a
synergistic approach by relating health to determinants of good health viz. segments of
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nutrition, sanitation, hygiene and safe drinking water. It also aims at mainstreaming
the Indian systems of medicine to facilitate health care. The mission envisages a
primary health care approach for decentralized health planning and implementation at
the village and district level.24 The mission was made operational from April 2005
throughout the country with special focus on 18 states having weak demographic
indicators and infrastructure. The Plan of Action includes increasing public expenditure
on health, reducing regional imbalance in health infrastructure, pooling resources,
integration of organizational structures, optimization of health manpower,
decentralization and district management of health programmes, community participation
and ownership of assets, induction of management and financial personnel into district
health system, and operationalizing community health centers into functional hospitals
meeting Indian Public Health Standards in each Block of the Country.
The Goal of the Mission is to improve the availability of and access to quality health
care by people, especially for those residing in rural areas, the poor, women and
children.24
NRHM is visualized as an architectural correction of the Indian Public health system to

enable it to effectively handle increased allocations and promote policies that strengthen
public health management and service delivery in the country. It envisages appropriate
health personnel to be placed at different levels starting from village level in fully
functioning health centers with adequate linkages amongst different levels. An illustrative
structure model is depicted in below Figure showing health structures functioning at
different levels with a set of key health personnel performing adequate functioning in
coordination with other sectors.
24
National Rural Health Mission Document, 2005- 12, Ministry of Health and Welfare, Government of India, New Delhi, April 2005.
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Exhibit 2.3 : NRHM - Illustrative Structure
Source : NRHM, Framework for implementation, 2005-12, Ministry of Health and Family Welfare, GOI, New Delhi
NRHM has as its key components as provision of a female health activist in each village
called ASHA to promote access to improved health care at household level: a Village
Health Plan formulation through a local team headed by the health and sanitation
committee of the Panchayat: strengthening of rural hospitals for effective curative care
and making them measurable and accountable to the community through Indian Public
Health Standards (IPHS); integration of vertical health and family welfare programmes:
strengthening of primary health care through optimal utilization of funds, infrastructure
and available manpower. NRHM works on five key approaches – communitization
emphasizing community involvement, flexible financing for increased monetary
autonomy at different levels, capacity building to empower multiple stakeholders for
efficient health delivery and human resource management to generate more manpower
and equipping health personnel with adequate multiple skills.
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Exhibit 2.4 : NRHM Goals and Approaches
Source : NRHM, Framework for implementation, 2005-12, Ministry of Health and Family Welfare, GOI, New Delhi
The key core strategies under NRHM are 25
 Train and enhance capacity of Panchayat Raj Institutions (PRIs) to own, control
and manage public health services.
 Promote access to improved health care at household level through the village
level worker , ASHA
 Health plan for each village through Village Health Committee of the Panchayat.
 Strengthening sub centers through better human resource development, clear
quality standards, better community standards, better community support and an
untied fund to enable local planning and action and more multipurpose workers.
 Strengthening existing Primary Health Centers through better staffing and human
resource development policy, clear quality standards, better community support
and an untied fund enable the local management committee to achieve these
standards.
25
National Rural Health Mission, Frame work for implementation, 2005-12, Ministry of Health and Family Planning, New Delhi,
April 2005.
2-18
 Provision of 30 – 50 bedded CHC per lakh population for improved curative care
to a normative standard. (Indian Public Health Standards defining personnel,
equipment and management standards)
 Preparation and implementation of an inter-sector district plan prepared by district
health mission, including drinking water supply, sanitation, hygiene and nutrition.
 Integrating vertical health and family welfare programmes at national, state,
district and block levels.
 Technical support to national, state and district health mission for public health
management.
 Strengthening capacities for data collection, assessment and review for evidence
base planning, monitoring and supervision.
Supplementary Strategies under Mission
 Regulation for private sector including the informal Rural Medical Practitioners
(RMPs) to ensure availability of quality service to citizens at reasonable cost.
 Promotion of Public Private Parternership for achieving public health goals.
 Mainstreaming the Indian System of medicine (AYUSH) revitalizing local health
traditions.
 Reorienting medical education to support rural health issues including regulation
of medical care to medical ethics.
 Effective and viable risk pooling and social health insurance to provide health
security to the poor by ensuring accessible, affordable, accountable and good
quality hospital care.
2.2 Principles and Values of Primary Health Care in India
2.2.1 Equitable distribution
The first key principle in the primary health care strategy is equity or equitable
distribution of health services. i.e. Health services must be shared equally by all people
irrespective of their ability to pay, and all (rich or poor, urban or rural) must have access
2-19
to health services.26 A commitment to health equity focuses not only on ensuring

program inputs such as services and personnel based on need but also reducing
differences in health outcomes. An equitable health system ensures that the groups or
individuals with most compromised health conditions receive more health services.
There is a clear urban-rural, rich-poor division in India. In the 42nd (1986 -87), 52nd
(1995-96), 60th (Jan-Jun 2004) and 66th (Jul2009–Jun2010) rounds of National Sample
Survey Organisation (NSSO),27,28 the percentage of ailing persons who got their
ailments treated is found to be higher in the urban areas than in the rural areas. Affluent
sections, urban populations and those working in the organized sector are covered under
some form of social security such as Employees State Insurance Scheme and Central
Government Health Services. The rural population and those working in the unorganized
sector have only the tax-based public facilities to depend upon for free or subsidized
care, and private facilities depending on their ability to pay. It was observed in 60th
round of NSSO that more reliance was to public care provider than private provider by
the scheduled castes in both rural and urban areas. Both in rural and urban areas, it was
observed in 42nd. 52nd and 60th rounds of NSSO, percentage of people citing financial
reason as an attribute for not attending to last spell of ailment are increased over time (in
rural areas, 15% to 24% to 28% and in urban areas 10% to 20% to 28% from 42nd round,
52nd round to 60th round NSSO). According to 66th round NSSO, spending on medical
care in hospitals increased by 38% in rural areas and by 31% in urban areas. Spending
on non-institutional medical care – medicines, tests, fees etc – jumped up by 60% in
rural areas and 102% in urban areas,29 a decline of about 12% in rural areas – possibly
an effect of the National Rural Health Mission – and a modest increase of 12% in urban
areas.
26
Report of the Health Survey and Development Committee, Volume II, and Volume IV, Government of India, New Delhi, 1946.
27
World Health Organisation, Select Health Parameters: A comparative analysis across the National Sample Survey Organisation
(NSSO) 42nd, 52nd and 60th rounds, 2007, Ministry of Health and family Welfare, Government of India, in collaboration with WHO,
country office India,
28
Report of 66th NSSO Survey, Census of India, Office of the Registrar General and Census Commissioner, India.
29
country office India.
2-20
This inequity, described as the “inverse care law” has been captured through numerous
studies on health status differentials between various groups and regions. According to
NFHS-3, IMR in the lowest wealth index group (70 per 1000 live births) is more than
twice the IMR in the highest group (29 per 1000 live births).30 Similarly IMR in the
states like Uttar Pradesh, Chattisgarh, Bihar and Jharkand is much higher than the
southern states. Only one in five women from the poorest quintile has deliveries assisted
by a skilled provider as compared to the national average of 47%. Visits to a public
health facility or camp were also higher by women from the highest quintile (42%) as
compared to women from the lowest quintile (29%).30 The in-patient days, outpatient
usage and obstetric care favours the rich whereas immunization and ante/post natal is
more equitably distributed.31 The poor have cited poor quality of services and financial
implications as primary reasons for underutilization of public health services.
Indian health care plans and policies have stressed on making conscious and consistent
efforts to deliver health services for “underprivileged” as a strategy for reaching “Health
for all”. While highlighting the continued health inequities across various groups and
regions, NHP 2002 sought to craft a policy structure to allow for even access to public
health services by disadvantaged groups.32 Suggested measures included the
involvement of the private sector as well as the engagement of practitioners of the Indian
System of Medicine and Homeopathy (AYUSH) in public health function.
NRHM and equity
The NRHM addresses equity concerns in a number of forms. The mission promotes the
health of weaker sections of the society. ASHA being women is believed to improve
access to health care by women and children.33 Making all peripheral health facilities to
become fully functional is one of the most basic ways in which social protection for the
poor is provided and the health sector reaches out to underserved areas. NRHM also
promotes delivering services to even more remote areas through the mobile medical
30
International Institute of for Population sciences (IIPS) and Macro International 2007, National Family Health Survey (NFHS-3),
India: Mumbai: IIPS.
31
Peters, D., Yazbeck, A.S., Sharma R., Ramana, G.N.V., Pritchett, L,Wagstaff, A., Better Health Systems for India’s Poor. Findings,
Analysis and Options, 2002, Economic Research, World Bank, Washington DC.
32
33
2-21
units and holding outreach sessions. It also seeks to exempt below BPL families from all
charges ensuring access.
2.2.2 Universal access to care and coverage on the basis of need
Accessibility and availability of health services reflect the reach and coverage of primary
health care facilities. According to NFHS-3, private health facilities are preferred for
health care by a majority of the urban households (70%) as well as rural households
(63%). However, the use of public health facilities by the lowest wealth quintile (39%) is
comparatively more than the highest wealth quintile (34%). At the same time, a very
negligible proportion of the sampled population (1.4%) access health care from the sub
centre. Non usage of public health facilities varies greatly across states, ranging from 8%
in Sikkim to 93% in Bihar. The most common reason for not using the government
facilities is the poor quality of care (58%) followed by lack of nearby facility (47%), long
waiting period (25%), inconvenient timings (13%) and provider absenteeism.29
The role of the grass root health worker such as ANM, LHV, AWW, ASHA and MPW in
providing health services at the community level is at the heart of the primary health care
system employed by India.34 However, as per NFHS-3 only 17% of the women reported
any contact with health workers in the three months preceding the NHFS-3 survey. Rural
women reported higher contact (21%) with health workers compared to urban women
(10%) and women from the lowest quintile had the maximum exposure to health workers
(22%).35 Pervasive absenteeism by health providers contributes to the ineffectiveness in
delivery of primary health care services. A study revealed that 40% of the health workers
were absent from their facility in India at the time of a random unannounced spot check.
Similar studies quote the lack of regularity in terms of the time of day or day of the week
by absentee health providers, which further serves as a disincentive to seek health care.
34
April 2005.
35
2-22
NRHM and universal Coverage
The National Rural Health Mission aims to restructure the health delivery systems
towards providing universal access to equitable, affordable and quality health care
responsive to the health needs of the community. Human resource requirement under
NRHM has stepped up drastically, in view of renewed commitment to universal
coverage.36 The challenges involved in training, recruitment, placement and motivation
of health workers across the country cannot be overemphasized if universal coverage is to
be attained. Several alternatives are being explored to address the existing and anticipated
shortfall of human resources. These include increasing retirement age to 65 years,
decentralization of recruitment to district level, contractual employment of doctors on
attractive salaries, incentive for rural postings, posting junior / post graduate students and
doctors at PHCs / CHCs for a fixed period, incentives for financial and career
advancement, enabling work environment and residential facilities / allowances, and
educational incentives for children of doctors in rural areas, etc.
2.2.3 Community Participation
The primary Health Care approach lays emphasis on health care provision by the people.
It centers on people‟s participation in their own activities. Community involvement in
health programmes has been tried through various approaches in India.
Health care delivery in the country has utilized community volunteers from time to time
in different forms to link the community with the health care system. Community based
volunteers called Village Health Guides during 1977 were involved in giving health
education, Maternal and Child Health and family welfare services, management of
minor ailments and first aid.37 Mahila Swasthya Sangh were working as community
health volunteers during 1990-91 assisting ANM in educating and motivating
community in MCH services.
36
April 2005.
37
D.G. Satihal, K.E.T. Rajarama, Evaluation of Village Health Guide Scheme, Belgaum District, Karnataka, Report prepared for the
Ministry of Health and Family Welfare, Government Of India, New Delhi, 2000.
2-23
NRHM and Community Participations
As part of NRHM, a cadre of Accredited Social Health Activities (ASHA), an honorary

volunteer who is accountable to the community, acts as an interface between the
community and the public health care system. ASHA facilitates preparation and
implementation of Village Health Plan along with AnganaWadi Worker, other
community workers and ANM under the leadership of the Panchayat Health Samiti. She
receives performance based incentives for promoting construction of household toilets,
universal immunization, referral and escort services for RCH and other health care
delivery programmes.38
The Village Health and Sanitation Committees (VHSC) are another key strategy of
communalization planned under NRHM.38 The village committee is being given a small
fund of Rs 10000 to utilize for variety of local needs. These committees could play
multiple roles including IEC, household survey, preparation of health register,
organization of meetings at the village level, promoting household toilet and school
sanitation programme.
The Rogi Kalyan Samitis (RKS)(Patient Welfare Society / Hospital Development

Committee) introduced in NRHM is a form of communitisation / public participation
adopted as a part of a strategy to improve the quality of management and therefore
facility outcomes and as a form of providing flexible funds for facility improvement.38
Decentralization through involvement of PRIs: Panchayati Raj Institutions with

enhanced empowerment is planned at each level in NRHM. Involvement of local
government representatives is envisaged in different local health committees to facilitate
improved functioning at grass root level. Greater leadership, autonomy and
accountability is accorded to the Gram Panchayat through a local committee with
representation of VHSCs. Rogi Kalyan Samitis, with representation from Panchayat
38
April 2005.
2-24
members, will oversee the management of the PHCs. NRHM recommends organizing
“Jan Samvad”‟ or “Jan Sunwai” at regular intervals at PHC, block and district level.
A number of efforts and coalitions, spearheaded by the Jan Swasthya Abhiyan39 or the
People‟s Health Movement, are underway in the country to synergistic momentum
towards operationalizing the “right to health” in India. The Jan Swasthya Abhiyan (JSA)
is the India regional circle of the People‟s Health Movement, a growing coalition of
people‟s organizations, civil society organizations, NGOs, social activists, health
professionals, academics and researchers that endorse the Indian People‟s health Charter
and the People‟s Charter for Health-consensus documents that arose out of the Jan
Swasthya Sabha (National Health Assembly) and the first People‟s Health Assembly
held in December 2000 at Kolkata, when concerned networks, organizations and
individuals met to discuss the „Health for all‟ challenge. Also Second National Health
Assembly (NHA 2) in February 2007 at Bhopal, where the overarching theme for
discussion was “Defending the health of people in the era of Globalisation”.40 There are
21 major national networks that constitute the Jan Swasthya Abhiyan. After the launch of
NRHM, to monitor the progress of NRHM and whether NRHM is functioning as per
desired objectives, Rural People‟s Health Watch (RPHW) has been formed.
2.2.4 Inter-sectoral coordination and convergence of programmes
Simply expanding and developing the health services cannot achieve improvements in
the health status of a population. The linkage between health and development has been
amply demonstrated globally. Health development is increasingly becoming part of a
strategy aiming at satisfying the basic needs of the population by giving the poor, access
to resources and economic opportunities, raising education levels, ensuring availability
and distribution of food, improving the status of women, providing the basic
infrastructure of transportation, improving the nutritional status and sanitation. GOI is
committed to achieve inter-sectoral coordination and convergence at multiple levels in
following ways.
39
http://phm-india.org/
40
http://www.phmovement.org/en/node/302
2-25
NRHM and Convergence with different health related sectors
Common District Health society is created under NRHM to promote the convergence
within the health department of various different disease related activities. The indicators
of health depend as much on drinking water, female literacy, nutrition, early childhood
development, sanitation, women‟s empowerment etc. Realizing the importance of wider
determinants of health, NRHM sought to adopt a convergent approach for interventions
under the umbrella of the District Plan. The Anganwadi Centre under the ICDS41 and
Village Health and Sanitation Committees at the village level would be the principal hub
for the health action. Panchayat Raj Institutions would be fully involved in this
convergent approach so that the gains of integrated action can be reflected in district
Plans.42
Convergence with Indian System of Medicine (AYUSH)
India enjoys the distinction of having medical pluralism with traditional medical systems
contributing to a large extent in providing health care to the rural population. Both
codified and non-codified forms of traditional medical knowledge are equally popular in
this country. The officially recognized codified traditional medical systems are
Ayurveda, Yoga & Naturopathy , Unani, Siddha and Homeopathy. Homeopathy,
though not a traditional medical system but enjoys equal status and is assimilated in the
country‟s health delivery network. AYUSH is the Government approved acronym used
to represent these systems. Mainstreaming and integration of indigenous medicines and
therapies in to the national health delivery system is one of the strategies that is being
implemented under NRHM since April 2005. The NRHM, which aims at vertical and
horizontal strengthening of the health delivery system with increased public health
spending, envisages provisioning of traditional medicine facilities in the primary health
network. Financial support is provided to the states to create AYUSH treatment facilities
41
http://wcd.nic.in/icds.htm
42
(D)
2-26
at PHC, CHC and District Hospital levels.43 Till 2008-09 District Hospitals, 1569 CHCs
and 6323 PHCs35 were reported to have set up AYUSH treatment facilities. Drugs
belonging to AYUSH have been included under the list of essential medicines to be
made available at different health facilities.
2.2.5 Partnership with the Private Health Care Providers
Currently private sector health services range from those provided by large corporate
hospitals, smaller hospitals / nursing homes to clinics/dispensaries run by qualified
personnel and services provided by unqualified practitioners. A majority of the private
sector hospitals are small establishments with 85% of them having less than 25 beds
with average bed strength of 10 beds. Private tertiary care institutions providing
specialty and super specialty care account for only 1 to 2 % of the total number of
institutions while corporate hospitals constitute less than 1 percent. 44 It is very well
known that large population of total ailments were treated from the private sources –
78% in the rural areas and 81% in the urban areas, while the overall proportion of
treated ailments to all ailments was 82% in the rural and 89% in the urban areas in 2004.
According to 60th round of NSSO, reasons for preferences to the private sector for
treatment as compared to the government are as shown below.
Exhibit 2.5 : Reasons for preferences of private sector for treatment of aliments
Share of Non- Spells of ailment receiving from Non-Govt. sources by reasons for
Govt. sources not using Govt. sources
Sector per 1000
treated spells Govt Not satisfied with Long waiting Others including
doctor/facilities too far medical non availability
treatment by govt of services
doctor/facilities
Rural 777 210 407 83 300
Urban 808 135 447 161 257

Source: NSSO 60th Round
43
April 2005.
44
country office India,
2-27
Also it is observed from the trend in the hospitalization from 1986 to 2004 that the
private institutions dominate the field in treating the inpatients and thus it is very
pertinent to utilize resources available in private sector in achieving the public health
goals through Public Private Partnership.
Partnership with Rural Medical Practitioners
There is a large pool of formally or informally qualified Rural Health Practitioners

(RHPs) who meet the day-to-day health care needs of people in almost 6.5 lakh villages,
on round the clock basis. These RMPs also can be trained in variety of interventions and
their services can be utilized as part of NRHM. They being key people with whom
generally local people make their first contact in case of illness, their services in the
mission would play a very pertinent role to enhance service delivery.
Partnership with Non-Governmental and Civil Organisations
The Government of India envisages collaboration with NGOs and civil organizations
particularly to supplement the role to that of the government health care delivery. NGOs
are involved in ASHA‟s training, national disease control programmes and service
delivery in addition to health education and awareness programmes. NRHM encourages
non-governmental partnerships that improve service guarantees in the health sector for
the poor households.
2-28
2.3 Rural Health Care System in India – The structure
The health care infrastructure in rural areas has been developed as a three tier system (see
Chart) and is based on the following population norms.45
Table 2.1: Population Norms for Different Health Care Facilities

Centre Population Norms
Plain Area Hilly/Tribal/Difficult Area
Sub-Centre 5000 3000
Primary Health Care 30000 20000
Community Health Care 120000 80000
Exhibit 2.6: Three tier Rural Health Care System in India
Source: Rural Health Care System in India, MOHFW, GOI
45
Rural Health Care System in India, Ministry of Health and Family Welfare, Government of India.
2-29
2.4 Primary health care resources in India
2.4 Primary health care resources in India
2.4.1 Infrastructure
Health Infrastructure is an important indicator to understand the healthcare delivery

provisions and mechanisms in a country. Health Infrastructure indicators is subdivided
into two categories viz. educational infrastructure and service infrastructure.
Educational infrastructure provides details of medical colleges, students admitted to

M.B.B.S. course, post graduate degree/diploma in medical and dental colleges,
admissions to BDS & MDS courses, AYUSH institutes, Nursing courses and Para-
medical courses.
Medical education infrastructures in the country have shown rapid growth during the last
46
20 years. The country has 314 medical colleges with total admission of 29,263 (in 256
Medical Colleges), 289 Colleges for BDS courses and 140 colleges conduct MDS
47
courses 21547 and 2,783 respectively during 2010-11. There are 2028 Institutions for
General Nurse Midwives with admission capacity of 8033248 and 608 colleges for
Pharmacy (diploma) with an intake capacity of 36115 49 as on 31st March, 2010.
Service infrastructure in health include details of allopathic hospitals, hospital beds,

Indian System of Medicine & Homeopathy hospitals, Sub centers, PHC, CHC and blood
banks.
There are 12,760 hospitals having 576793 beds in the country. 6795 hospitals are in rural
area with 149690 beds and 3748 hospital are in Urban area with 399195 beds. Rural and
Urban bifurcation is not available in the States of Bihar and Jharkhand.50
46
Medical Council of India, http://www.mciindia.org/
47
Dental Council of India, http://www.dciindia.org/
48
Indian Nursing Council. http://www.indiannursingcouncil.org/
49
Pharmacy Council of India, http://www.pci.nic.in/
50
Directorate General of State Health Services, http://mohfw.nic.in/
2-30
Medical care facilities under AYUSH by management status i.e. dispensaries & hospitals
are 24,465 & 3,408 respectively as on 1.4.2010.51
There are 1,47,069 Sub Centers, 23,673 Primary Health Centers and 4,535 Community
Health Centers in India as on March 2010.52 Total No. of licensed Blood Banks in the
Country as on January 2011 are 2445. 53
Sub Centres (SCs)
The Sub-Centre is the most peripheral and first contact point between the primary health
care system and the community. Each Sub-Centre is required to be manned by at least
one Auxiliary Nurse Midwife (ANM) / Female Health Worker and one Male Health
Worker (for details of staffing pattern, and recommended staffing structure under Indian
Public Health Standards (IPHS) see Annexure I). Under NRHM, there is a provision for
one additional second ANM on contract basis. One Lady Health Visitor (LHV) is
entrusted with the task of supervision of six Sub-Centers. Sub-Centers are assigned tasks
relating to interpersonal communication in order to bring about behavioral change and
provide services in relation to maternal and child health, family welfare, nutrition,
immunization, diarrhoea control and control of communicable diseases programmes. The
Sub-Centers are provided with basic drugs for minor ailments needed for taking care of
essential health needs of men, women and children.54 The Ministry of Health & Family
Welfare is providing 100% Central assistance to all the Sub-Centers in the country since
April 2002 in the form of salary of ANMs and LHVs, rent at the rate of Rs. 3000/- per
annum and contingency at the rate of Rs. 3200/- per annum, in addition to drugs and
equipment kits. The salary of the Male Worker is borne by the State Governments. Under
the Swap Scheme, the Government of India has taken over an additional 39,554 Sub
Centers from State Governments / Union Territories since April, 2002 in lieu of 5,434
51
http://indianmedicine.nic.in/
52
Bulletin on Rural Health Statistics in India 2010, Infrastructure division, Ministry of Health and Family Welfare, Government of
India.
53
Drug Controller General(I), DGHS, Ministry Of Health and Family Welfare (Drug section). http://mohfw.nic.in/
54
2-31
Rural Family Welfare Centers transferred to the State Governments / Union Territories.
There are 1, 47,069 sub centers functioning in the country as on March 2010. 55
Graph 2.1: Progress of Primary Health Care System – Sub Centers
Source: Bulletin on Rural Health statistics in India 2010, MOHFW/ GOI.
Primary Health Centres (PHCs)
PHC is the first contact point between village community and the Medical Officer. The
PHCs were envisaged to provide an integrated curative and preventive health care to the
rural population with emphasis on preventive and promotive aspects of health care. The
PHCs are established and maintained by the State Governments under the Minimum
Needs Programme (MNP)/ Basic Minimum Services (BMS) Programme. As per
minimum requirement, a PHC is to be manned by a Medical Officer supported by 14
paramedical and other staff.56 Under NRHM, there is a provision for two additional Staff
Nurses at PHCs on contract basis. It acts as a referral unit for 6 Sub Centres. It has 4 - 6
beds for patients. The activities of PHC involve curative, preventive, promotive and
Family Welfare Services. There are 23,673 PHCs functioning as on March 2010 in the
country.57
55
India.
56
57
India.
2-32
Graph 2.2: Progress of Primary Health Care System - PHCs
Community Health Centres (CHCs)
CHCs are being established and maintained by the State Government under MNP/BMS
programme. As per minimum norms, a CHC is required to be manned by four medical
specialists i.e. Surgeon, Physician, Gynecologist and Pediatrician supported by 21
paramedical and other staff. It has 30 in-door beds with one OT, X-ray, Labour Room
and Laboratory facilities.58 It serves as a referral centre for 4 PHCs and also provides
facilities for obstetric care and specialist consultations. As on March, 2009, there are
4,535 CHCs functioning in the country. 59
Graph 2.3 : Progress of Primary Health Care System - CHCs
58
59
India.
2-33
First Referral Units (FRUs)
An existing facility (district hospital, sub-divisional hospital, community health centre

etc.) can be declared a fully operational First Referral Unit (FRU) only if it is equipped to
provide round-the-clock services for Emergency Obstetric and New Born Care, in
addition to all emergencies that any hospital is required to provide. It should be noted that
there are three critical determinants of a facility being declared as a FRU: i) Emergency
Obstetric Care including surgical interventions like Caesarean Sections; ii) New-born
Care; and iii) Blood Storage Facility on a 24-hour basis.60
2.4.2 Current Situation of the Infrastructure compared to 2005 (Before NRHM)
When we compare the infrastructure – number of Sub Centers, PHCs and CHCs existing
in 2010 as compared to those reported existing in 2005 (before the National Rural Health
Mission), there is a significant increase in the number of Health care Facilities at the
national level. Also the average population covered by a Sub Centre, PHC and CHC was
5049, 31364 and 163725 respectively.61 In spite of this significant improvement, still the
substantial need to be done in providing the infrastructure to achieve the universal
coverage in the country. The following table gives the complete details of the
infrastructure and the coverage against the specified norms.
60
61
India.
2-34
Table 2.2: Number of Sub Centers, PHCs and CHCs as of 2005 and 2010
2-35
Table 2.3: Rural Health Infrastructure – Norms and Level of Achievements ( all India)
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2.4.3 Human Resources
A health human resource policy must continually balance the need for financial health
teams at primary, secondary, and tertiary levels of health care also facilitate a judicious
mix of public health practitioners and clinical practitioners and specialists. The problem
of non availability and uneven distribution of skilled health care providers is central
challenge to meeting our health goals. WHO estimates that worldwide, this factor may
lead to the failure in attaining the Millennium Development Goals within the timelines.
One international norm a minimum of about 25 skilled health workers (doctors, nurses
and midwives) per 10,000 population in order to achieve a minimum of 80% coverage
rate for deliveries by skilled birth attendants or for measles immunization as seen in cross
country analysis62,63. According to 2001 census, the density of health workers falls
approximately 8 per 10000 population, of which Allopathic physicians around 48%,
followed by nurses and midwives of 30%, pharmacists of 11%, AYUSH practitioners of
9% and rest are others. Also 60% of the health workers reside in urban areas, which
skew their distribution considerably. The density of health workers per 10000 population
in urban areas is 42 which is nearly four times that of rural areas, which is only 11.8. and
also the majority,70% of health workers are employed in private sectors. 64
Major factors related to the growth of the health sector that is responsible for the acute
shortage of health personnel are65
1. States with the greatest human resources needs also have the lowest capacity
of producing them. The distribution of medical and nursing colleges across the
country is highly skewed. The five south-western states of Andhra Pradesh,
Maharashtra, Karnataka, Kerala and Tamil Nadu (with 31% of the country‟s
population) accounts for 58% of medical colleges in India and 63% of nursing
colleges in the country. States with poor health records like Bihar, Madhya
62
Mario R Dal Poz, Estelle E quain, Mary O‟ Neil, Jim McCaffery, Gis Elzinga and Tim Martineau, Addressing the health workforce
crisis: towards a common approach, Human Resources for Health 2006, 4: 21.
63
Human Resources for Health, overcoming the crisis – Joint Learning Initiative (JLI), WHO 2006-2015.
64
Census of India, 2001, Office of the Registrar General and Census Commissioner, India.
65
Annual Report to the people on Health, Sept 2010, Ministry of Health and Family Welfare, GOI.
2-37
Pradesh, Rajasthan and Uttar Pradesh have only 9% of the nursing schools in
the country.
2. Migration of health workers depletes the available stock in the country. This
also creates the shortages of teaching staff which further hinders the
production of professionals.
3. Better economic and professional opportunities, better living and working
conditions claims urban preferences.
4. Specialization makes government employment and rural services less
attractive.
5. The failure to provide for adequate sanctioned posts in the public sector due to
decreasing public investment in health (especially earlier to NRHM period) is
another major reason for the severe shortage.
The availability of manpower is one of the important prerequisite for the efficient
functioning of the Rural Health Infrastructure. As on March 2010, the overall shortfall
(which excludes the existing surplus in some of the states) in the posts of HW (F) / ANM
was 8.8% of the total requirement as per the norm of one HW(F) / ANM per Sub Centre
and PHC. The overall shortfall is mainly due to shortfall in States namely, Arunachal
Pradesh, Bihar, Chhattisgarh, Gujarat, Himachal Pradesh, Jammu & Kashmir, Kerala,
Orissa, Tripura and Uttar Pradesh. Similarly, in case of HW (M), there was a shortfall of
64.1% of the requirement. In case of Health Assistant (Female) / LHV, the shortfall was
31.9% and that of Health Assistant (Male) was 44%. For Allopathic Doctors at PHCs,
there was a shortfall of 10.3% of the total requirement. This is again mainly due to
significant shortfall in Doctors at PHCs in the States of Bihar, Chattisgarh, Gujarat,
Himachal Pradesh, Madhya Pradesh, Orissa, Punjab, Uttarakhand and Uttar Pradesh.66
66
India.
2-38
Graph 2.4: Percentage of shortfall and Vacancy of Health Workers at SC and PHC level
Even out of the sanctioned posts, a significant percentage of posts are vacant at all the
levels.
For instance, 6.3% of the sanctioned posts of HW (Female) / ANM, 34% of the
sanctioned posts of MPW (Male)/Male Health Worker were vacant. At PHCs, 24.3% of
the sanctioned posts of Female Health Assistant/ LHV, 30.4% of Male Health Assistant
and 20.7% of the sanctioned posts of doctors were vacant.67
At the Sub Centre level the extent of existing manpower can be accessed from the fact
that 4.2% of the Sub Centres were without a Female Health Worker / ANM, 51.8% Sub
Centres were without a Male Health Worker and 2% Sub Centres were without both
Female Health Worker / ANM as well as Male Health Worker.
Graph 2.5: Percentage of Sub Centres functioning without ANMs and/ or HW (M)
67
India.
2-39
PHC is the first contact point between village community and the Medical Officer.
Manpower in PHC include a Medical Officer supported by paramedical and other staff.
As on March, 2010, 3.3% of the PHCs were without a doctor, about 36.3% were without
a Lab technician and 17.5% were without a Pharmacist.68
Graph 2.6: Percentage of PHCs without Doctor, Lab Tech,. Pharmacist
The Community Health Centres provide specialized medical care in the form of facilities
of Surgeons, Obstetricians & Gynecologists, Physicians and Pediatricians. The current
position of specialists manpower at CHCs reveal that as on March, 2010, out of the
sanctioned posts, 49.7% of Surgeons, 36.6% of Obstetricians & Gynecologists, 49.6% of
Physicians and 51.9% of Pediatricians were vacant. Overall about 42% of the sanctioned
posts of specialists at CHCs were vacant.
Moreover, as compared to requirement for existing infrastructure, there was a shortfall of

62.8% of Surgeons, 55.2% of Obstetricians & Gynecologists, 72.% of Physicians and
69.5% of Pediatricians. Overall, there was a shortfall of 68.0% specialists at the CHCs as
compared to the requirement for existing CHCs. The shortfall in Specialists is
significantly high in most of the States. However, along with the specialists, about 9971
68
India.
2-40
General Duty Medical Officers (GDMOs) are also available at CHCs as on March
2010.69
Graph 2.7: Percentage shortfall and Vacancy of Specialists at CHCs
2.4.4. Current Situation of the Human Resources compared to 2005 (Before NRHM)
The launch of the NRHM in 2005 marked a turning point in human resource for health.
The commitments of the centrally-funded scheme to provide the funds needed to close
the human resource gaps between the posts that were sanctioned by the state governments
and the posts that were required to meet the new standards, dramatically changed the
situation. This led to the appointment of almost 1,06,949 more skilled service providers
in the public health system by March 2010, of which 2,460 were specialists, 8,624 were
doctors, 7,692 were AYUSH doctors, 26,993 were nurses, 46,990 were ANMs and
14,990 were paramedical.70 This was one of the largest increments to the public health
workers in recent times. Also NRHM funds have also enabled the revitalizing of the
community health worker programme in India and the ASHAs over 7, 00,000 signifies a
massive increase in health workers in the country.
69
India.
70
India.
2-41
When we compare the manpower position of major categories in 2010 with that in 2005,
it is observed that there are significant improvement in terms of the numbers in all the
categories. For instance, the number of ANMs at Sub Centres and PHCs have increased
from 133194 in 2005 to 191457 in 2010 which amounts to an increase of about 43.7%.
Similarly, the Doctors at PHCs have increased from 20308 in 2005 to 25870 in 2010,
which is about 27% increase. Moreover, the specialist doctors at CHCs have increased
from 3550 in 2005 to 6781 in 2010, which implies an appreciable 91% increase in 5 years
71,72
of NRHM. By analyzing the state wise picture, it may be observed that the increase
in the ANMs is attributed mainly to significant increase in the states of Andhra Pradesh,
Assam, Goa, Haryana, Jammu & Kashmir, Karnataka, Madhya Pradesh, Maharastra,
Manipur, Mizoram, Nagaland, Orissa, Punjab, Rajastan, Uttarakhand, Uttar Pradesh and
West Bengal. Similarly there is a significant increase in the number of doctors at PHCs in
the states namely Andhra Pradesh, Jammu & Kashmir, Karnataka, Kerala, Madhya
Pradesh, Punjab and Rajasthan.
71
India.
72
2-42
Table 2.4: Health Worker (Female) / ANMs at Sub Centers and PHCs as of 2005 and 2010
2-43
Table 2.5 : Doctors at Primary Health Centers in 2005 and 2010
2-44
Table 2.6: Total Specialties at CHCs in 2005 and 2010
2-45
Table 2.7: Radiographers at CHCs in 2005 and 2010
2-46
Table 2.8 : Number of pharmascists at PHCs and CHCs in 2005 and 2010
2-47
Table 2.9 : Laboratory technicians at PHCs and CHCs in 2005 and 2010
2-48
Table 2.10: Nursing Staff at PHCs and CHCs in 2005 and 2010
2-49
2.4.5 Financial resources for Primary Health Care
Health financing is a significant component of Health Systems‟ architecture and deals

with sources of funding the health system. It is desirable that the health financing is so
arranged that it reduces overall Out Of Pocket expenditure on healthcare and protects
against financial catastrophe related to healthcare. The global standard related to the
“desirable” limit of Out Of Pocket to protect the people from financial catastrophe is less
than 15% of total health spending. In contrast, in India the Out Of Pocket expenditure is
almost 71% of the total health spending.
The per capita public health spending is low in India, being among the five lowest in the
world. The public health expenditure in the country over the years has been
comparatively low, and as a percentage of GDP it has declined from 1.05% in 1985-6 to
0.9% in 2000-01, increased marginally to 1.1% by 2008-09. The Eleventh Five Year
Plan (2007-12) document suggests that the necessity of building a responsive public
health system with the need for increasing the public spending on health from 0.9 per
cent of GDP to 2-3% of GDP73 and steeping up investment on primary care,
communicable disease and HIV/AIDS prevention.
The allocation under Five Year Plans is on continuous rise since 1985-90 that is Seventh
Five Year Plan
Graph 2.8 : Five Year Plan outlays for Health in India
73
Health, Family Welfare and AYUSH, Chapter 3, Eleventh Five Year Plan (2007-12) document.
2-50
The Government of India is committed to increase the allocation of funds to rise the
public spending on health to 2%. NRHM envisages an additionality of 30% over existing
annual budgetary outlays. The state governments are expected to raise their contributions
to public health budget by minimum 10% per annum to support the mission activities.74
Table 2.11 : Health Expenditure in India
Table 2.12 : Trends in Health Expenditure in India 1950-51 to 2003-04 (Latest)
74
Annual Report 2007 -08, Ministry of Health and Family Welfare, GOI.
2-51
Table 2.13 : Measured Levels of Expenditure on Health in India 2003-2007 (Latest)
Sources of Funds
As per National Health Accounts report, the total health expenditure in India, the sources
of funds are Public Funds which consists of funds from Central Government, State
Government and local bodies, Private Funds mainly constitutes House hold health
expenditure, Social Insurance Funds and funds from firms and External Flows includes
funds from NGOs others other than Public and Private funds.75
Table 2.14: Health Expenditures (%) in India from 2004-05 to 2008-09
Sources 2004 - 05 2005 – 06 2006 – 07 2007 – 08 2008 - 09
Public Funds 19.67 22.72 23.82 25.09 26.70
Private funds 78.06 75.86 74.87 73.54 71.61
External flows 2.27 1.41 1.31 1.37 1.68
Grand total 100 100 100 100 100

Source: table 15, National Health Accounts (2004-05) of MOHFW / GOI and
75
National Health Profile 2010, Central Bureau of Health Intelligence, DGHS, GOI, New Delhi.
2-52
Public Financing of Health
Public spending on health accounts for around 1% of the GDP. This ratio is among the
lowest in the world, although in recent years the share of the public spending in total
health spending has been steadily increasing. An important issue in public spending on
health relates to the distribution between the Central and State sectors. Looking at the
significance of the public health expenditure in achieving better health outcomes and
reducing their expenditure, the central and the state governments in India have been
increasing their expenditure on health, especially since 2005-06, due to the focus on
health with the launch of NRHM. With the launch of NRHM, the level of public
spending on health has risen nearly 2.6 times between 2004-05 and 2009-10. The union
health budget increased from Rs 5,255 crores in 2000-01 to Rs. 8086 crores in 2004 -05
and to Rs 21,680 crores in 2009-10 while that of states for 2009-10 was Rs 43,848
crores.76
Exhibit 2.7: Trend in expenditure in central Government Budget and State Health Govt budget
If we look at the growth rate in three time periods (i) overall 2000-05 to 2008-- 09, (ii)
pre NRHM phase 2000-01 to 2004-05 and (iii)2004-05 to 2008-09,we find that the
76
2-53
overall growth rate for all states was 12.% (compounded annually). In the pre NRHM
period as compared to the overall growth rate in the pre NRHM period.
Household spending on Health
Out-Of-Pocket (OOP) expenditure on healthcare forms a major barrier to health seeking

in India. According to the National Sample Survey Organization, the year 2004 saw 28%
of ailments in rural area go untreated due to financial reasons77 up from 15% in 1995-96.
Those who access free government health services are expected to purchase medicines
from private pharmacies, pay user fees for laboratory tests .those who use the private
services of course have to pay considerable amounts. Significantly, those who are insured
also do not get full protection. While their Out Of Pocket payments are reduced, they still
have to pay for ambulatory care and for excluded conditions. It is clear that Indians,
especially vulnerable sections do not have any form of financial protection and are forced
to make payments when they fall sick, which is of serious concern as it has both
economic as well as social consequences.
Social Health Protection
Apart from increasing public expenditure on direct provision of health care, the Central
and State governments have also initiated various innovative schemes to increase access
and choice of healthcare provider (public or private) to the people, especially in the form
of various subsidized health insurance schemes. In order to reduce OOP expenditure of
poor sections of the society, especially the unorganized sector which constitutes 93% of
the total work force, the Eleventh Plan envisages effective risk pooling arrangements at
the state level. A lot of health insurance schemes have been launched in the recent past,
Being the most important one announced in the union budget 2007-08 was Rashtriya
Swasthya Bima Yojana (RSBY).78 Launched on 1st October 2007, the RSBY provide
coverage to workers to the unorganized sector who came in the category of BPL with a
total assured sum of Rs 30,000 per family per annum. Of the estimated premium of Rs
77
country office India.
78
2-54
750 per family, the GOI contributes 75% and the remaining 25% comes from the state
governments. Until December 2009, 22 states and union territories had initiated the
scheme across 172 districts covering 2.98 crore households.
Many state governments have initiated health insurance schemes for the BPL population
and unorganized workers. Some of the notable schemes are the Arogyashri Yojana
(Andhra Pradesh), Kalainger Insurance Scheme for life-saving treatments (Tamil Nadu),
Suvarna Arogya Surakhsa Scheme (Karnataka) and Mukhya Mantri BPL Jeevan Raksha
Kosha (Rajastan). The focus of these schemes is to cover identified tertiary care diseases
which involve catastrophic expenditure and are not covered under any other pre-existing
health programmes. Further many other states have initiated various models of health
insurance schemes in 2008-09 and 2009-10 to address the financing of health
requirements of the vulnerable sections.
2.5 Current Status and Progress made in Primary Health Care in

India
2.5.1 Health Status of the country
The health of a nation is an essential component of development, vital to the nation‟s

economic growth and internal stability. Assuming the minimum level of health care to the
population is a critical constituent of the development process. Many countries in the
course of development gone through what is known as an “epidemiologic transition”,79
where the initial high burden of disease and mortality due to infectious diseases and
maternal and child mortality, declines and gives way to non-communicable diseases,
injuries and geriatric problems as the main burden of disease. India‟s Epidemiologic
Transition, however is marked by three challenges in disease control, all of which need to
be managed concurrently.
1. First, India has to complete its unfinished agenda of reducing maternal and
infant mortality as well as communicable diseases such as TB, Vector-borne
79
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disease of malaria, Kala-azar and Filaria, water borne diseases such as

cholera, diarrhoeal diseases, leptospirosis, and vaccine-preventable measles
and tetanus.
2. Second, India has to contend with the rising epidemic of non communicable
diseases including cancers, diabetes, cardiovascular diseases, chronic
obstructive pulmonary diseases and injuries.
3. Third, developing systems to cope with the new and re-emerging infectious
diseases like HIV, Avian influenza, SARS and very recent H1N1 influenza.
Since independence, India has built up a vast health infrastructure and health personnel
and considerable achievements have been made over the last six decades to improve key
health indicators such as life expectancy, child mortality and infant mortality and
maternal mortality.
India, with a population of more than 1 billion people, has many challenges in improving
the health and nutrition of its citizens. Even though there is a steady decline in fertility,
maternal, infant and child mortalities and the prevalence of severe manifestations of
nutritional deficiencies, the pace is slow and falls short of national and MDG targets. The
likely explanations include social inequities, disparities in health systems between and
within states and consequences of urbanization and demographic transition. In 2005,
India launched in a big way the National Health Mission (NRHM), an extraordinary
effort to strengthen the rural health care delivery systems. However, coverage of priority
interventions remains insufficient, and the content and the quality of existing
interventions are sub optimum.
2.5.2 India in the International Scenario in terms of key health indicators
The comparative picture with regard to key health indicators such as Life Expectancy,
Maternal Mortality Rate, Infant Mortality Rate and Total Fertility Rate points that
countries placed in almost same situations such as Indonesia, Sri Lanka and China have
performed much better than India (Refer Table 2.15 below)
2-56
Table 2.15 : Health Indicators of selected countries
Life expectancy in India has more than doubled in years the last sixty years. It increased
from around 30 years at the time of independence to over 63.5 years in 2002-2006.
India‟s life expectancy is lower than the global average of 67.5 years and the average of
most of countries that won their independence from colonial rule at about the same time
like China, Vietnam, Srilanka and so on.
India‟s Infant Mortality Rate too has shown a steady decline from 129 deaths per 1000
80,81,82
live births in 1971 t o 47 in 2010. The rate of decline has been slowing from 9
points in the 1970s to 16 points in the current decade. Currently, the urban IMR is 31 as
compared to the rural IMR of 51.82 India is not in an appreciable situation when
compared with the countries of the same region.
The problem of estimating MMR has been the fixing of a reliable denominator due to the
comparative rarity of the event, necessitating a large sample size. However, given this
80
State of the World Children 2009, Maternal and New born Health, UNICEF, UNO.
81
Sample Registration System (SRS): Maternal and Child Mortality and Total Fertility Rates, July 2011, Office of the Registrar
General, India.
82
Sample Registration System Bulletin, Office of Registrar General of India, December 2011; 46(1):1.
2-57
constraint, data suggests that India had a MMR of 400 in 1997-98 to 301 in 2001-0383,
declining to 254 deaths per 100000 live births in 2004-200684 and 212 in 2007-09.85 On
the maternal mortality front, South Asian nations except Sri Lanka do worse than India,
and South Asia as a region has poor record of maternal mortality in the world, very
significantly affecting the global effect to achieve the MDG set for 2015.
The population stabilization is indicated through TFR, which is the average number of
children that a woman would bear over her lifetime if she were to experience the current
age-specific fertility rates. Total Fertility Rate has reduced from 5.2 in 1971 to 2.6 in
2008. India‟s record compares poorly with that of Japan, China and United States which
have TFR of 1.3, 1.7 and 2.1 respectively.80 TFR varies significantly with female literacy,
mean age of women at marriage, percentage of females working in non primary sectors,
infant and child mortality, type of housing, and level of urbanization. The TFR declines
significantly with the level of education of mother, and income/wealth. Population
stabilization is also includes the maintenance of gender balance.
2.5.3 Variation of health indicators across the states
The special concern and challenge is the wide variance in health indication across the
states. Life expectancy is 74 years in Kerala whereas the life expectancy of states like
Assam, Bihar, Madhya Pradesh, Orissa, Rajasthan and Uttar Pradesh is in the range of
58-62 years, a level achieved during the period of 190-75 in Kerala. Similarly, Kerala and
Tamil Nadu reporting an MMR of 95 and 111 respectively lower than Assam (480),
Bihar/Jharkhand (312), Madhya Pradesh/ Chattisgarh (335), Orissa (303), Rajastan (388)
and Uttar Pradesh/Uttar khand (440).
83
Sample Registration System SRS) Maternal Mortality in India: 1997-2003, Trends, Causes and Risk Factors, Registrar General
India, New Delhi in collaboration with Centre for Global Health Research University of Toranto, Canada.
84
Special Bulletin on Maternal Mortality in India 2004 -06, SRS, Office of Registrar General of India, New Delhi, April 2009.
85
Special Bulletin on Maternal Mortality in India 2007 -09, SRS, Office of Registrar General of India, New Delhi, June 2011.
2-58
Table 2.16 : Health Indicators of different States
Further, TFR of Uttar Pradesh, Bihar, Jharkhand, Rajasthan, Madhya Pradesh, and
Chhattisgarh that account for over 40% of India‟ population and have a TFR in the range
of 3.0 to 3.9 – a level that Kerala and Tamil Nadu had in the early 1970s.
The nine states Assam, Bihar/ Jharkhand, Madhya Pradesh / Chhattisgarh, Orissa,
Rajasthan, Uttar Pradesh / Uttar khand account for 47% of India‟s population represent
2-59
the core of our poor performance on all four indicators that is Life expectancy, IMR,
MMR and TFR.
2.5.4 Current Scenario of Maternal and Child Health
The country has the clear vision of achieving good health status with respect to Maternal
and Child health, especially the poor and the under privileged. In order to do this, a
comprehensive approach is needed that encompasses individual health care, public
health, sanitation, clean drinking water, access to food and knowledge of hygiene and
feeding practices. To achieve this, there are time bound goals / targets that are clearly
86,87,88
specified in different National Health Policies and Programmes and also more
57
importantly in Millennium Development Goals , exhibited as below table.
Table 2.17: Goals / Targets under different Policies, Programmes and MDGs
Source: Policy statements National Population Policy, National Health Policy 2002, Eleventh Five year Plan statement, MDG 4and 5
86
87
88
2-60
Maternal Health - Antenatal Care
Maternal care involves three stages antenatal care (period of pregnancy), delivery care
and post natal care (care after the delivery of the baby) Even though every stage is
significant for the health of mother as well as child, antenatal care takes more emphasis
as it assures a safe delivery, less chances of neonatal deaths / infant deaths or maternal
deaths. Ante natal care involves timely appropriate checkups, taking Iron and Folic Acid
supplements and Tetanus toxin vaccines and delivery at hospital.89 According to NFHS-
3, less than half of the women received antenatal care during the first trimester of
pregnancy, 22% had their first visit during the fourth or fifth month of pregnancy and
51% of mothers had three or more antenatal visits. Rural women are less likely to receive
three or more visits than urban women. 65% of the mothers received IFA supplements,
but only 23% consumed them for the recommended 90 days or more. Three in Four
mothers have received the prescribe dose of TT vaccination.90
Table 2.18 : Trend in outreach of services for Maternal Health in India

Indicator NFHSI NFHS II DLHS NFHS III
(1992-93) (1998-99) (2002-04) (2005-06)
Any Antenatal 62.3 65.4 73.4 77.0
Check Up
Three or more 44.0 44.0 50.1 55.7
antenatal check ups
Total Institutional 26.0 33.6 40.5 41.0
Deliveries
Safe Deliveries 34.2 42.3 47.6 48.2
Source: National Family Health Survey (NFHS)I II III; District Level Household Survey
Delivery Care
Delivery at health facility in the presence of health professionals with the required
medical facility is recommended for safe delivery. Three out of every five delivery in
India take place at home. Only two births out of five takes place in a Health facility.
However, the percentage of birth in health facility has increased steadily since NHFS-1.
According to NHFS-3, Deliveries at home are more common in among women who
89
The World Health Report 2005: Make every Mother and Child count, WHO, Geneva, 2005.
90
2-61
received no antenatal checkups, older women, women with no education, women in the
lowest quintile and women with more than three previous births.91,92, 93
Graph 2.9 : Improvement in safe delivery practices based on NFHSs
Postnatal Care
Early postnatal care for a mother helps safeguard her health and can reduce maternal
mortality. Only 37% of mothers had a postnatal checkup within 2 days of birth, as is
recommended. Most women receive no postnatal care at all. Postnatal care is common
following births in a medical facility, however, about one in five births in medical
facilities were not followed by a postnatal checkup of the mother. Only 15% of home
deliveries were followed by a postnatal checkup.91, 94
Maternal Mortality Rate
Maternal death is an important indicator of the reach of effective clinical health services
to the poor, and is regarded as one of the composite measure to assess the country‟s
progress. Reliable estimation of levels and trends of maternal mortality is thus extremely
essential. Deaths due to pregnancy and child birth are common among women in the
reproductive age groups. Reduction of mortality of women has thus been an area of
concern and governments across the globe have set time bound targets to achieve it. The
91
International Institute for Population sciences (IIPS) and Macro International 2007, National Family Health Survey (NFHS-3),
92
International Institute of for Population sciences (IIPS) and Macro International (1992-93), National Family Health Survey (NFHS-
1), India: Mumbai: IIPS.
93
International Institute of for Population sciences (IIPS) and Macro International (1998-99), National Family Health Survey (NFHS-
2), India: Mumbai: IIPS.
94
State of the World Children 2009 , Maternal and New born Health, UNICEF, UNO.
2-62
Millennium Development Goals (MDG) have set the target of achieving 109 per lakh of
live births by 2015 95. The MMR during 2001–03 has been 301 per 100000 live births 96.
And 254 in 2006 97, 212 in 2009 98. Levels of maternal mortality vary greatly across the
regions due to variation in access to emergency obstetric care (EmOC), prenatal care, and
anemia rates among women, education level of women, and other factors. There has been
a substantial decline during the seven year period of 1997–2003. However, the pace of
decline is insufficient. At the present rate of decline, it will be difficult to achieve the goal
of 109 by 2015. The major causes of these deaths have been identified as Hemorrhage
(both ante and post partum) (37%), toxemia (hypertension during pregnancy) (5%),
obstructed labour (5%), puerperal sepsis (infections after delivery and unsafe condition)
(11%), abortions (8%), anemia and other conditions (34%).99 It is very clear that delivery
care remains an important determinant of maternal health outcomes. This reinforces that
rapid expansion of skilled birth attendance and EmOC is needed to further reduce
maternal mortality in India. The trend for undertaking an institutional delivery is on
increase as desired in India but differentials exist in different parts.
Graph 2.10: Trends and projections in Maternal Mortality Ratio
Source: SRS: Maternal and Child Mortality and Total Fertility Rates, July 2011, Office of the Registrar General, India.
95
Millennium Development Goals: Health related Indicators India, extracted from National Health Profile 2010, pp 257.
96
India, New Delhi in collaboration with Centre for Global Health Research University of Toronto, Canada.
97
Special Bulletin on Maternal Mortality in India 2004 -06, SRS, Office of Registrar General of India, New Delhi, April 2009.
98
Special Bulletin on Maternal Mortality in India 2007 -09, SRS, Office of Registrar General of India, New Delhi, June 2011.
99
India, New Delhi in collaboration with Centre for Global Health Research University of Toranto, Canada.
2-63
Infant Mortality Rate
One of the most sensitive indicators of the health status of a population is Infant
Mortality Rate. The IMR in India is steadily decreasing, which is 50 per 1000 live births.
It is 34 in urban areas far lower than 55 of the rural area during 2009.100 Further, it also
varies across states with Kerala has the lowest IMR with 12 and the highest is in Madhya
Pradesh with IMR of 67.
Graph 2.11: Infant Mortality Rate (IMR) by residence in India, 1990 -2009
Source: SRS: Maternal and Child Mortality and Total Fertility Rates, July 2011, Office of the Registrar General, India.
It is observed from the National Family Household Survey-3 and District Level
Household Survey -3 that the higher rates of antenatal, institutional deliveries and
postnatal are associated with lower IMR.101,102 Infant mortality in rural areas is 50%
higher than in the urban areas. Children whose mothers have no education are more than
twice as likely to die before their first birthday as children whose mothers have
completed at least 10 years of school. In addition, children from scheduled castes and
scheduled tribes are at greater risk of dying than other children. The risk is high in case of
mother‟s age is less than 20 or above 30. 101
100
Sample Registration System (SRS): Maternal and Child Mortality and Total Fertility Rates, July 2011, Office of the Registrar
General, India.
101
102
International Institute for Population sciences (IIPS) and Macro International (2002-04), District Level Household Survey: India:
Mumbai: IIPS.
2-64
Graph 2.12: High mortality rates in high risk births
Source: National Family Health Survey -3, IIPS, Mumbai
It is also important to note that IMR constitutes significant portion of Neo-natal

Mortality. Neo-natal Mortality in India varies between 60 to 75% in various states.103 The
causes of IMR in India comprise of Acute Respiratory Infections, Diarrhea, Sepsis,
Asphyxia, Prematurity and others.
Graph 2.13 : Causes of Neonatal Mortality in India
103
State of India’s Newborns, Report of National Neonatology Forum of India and Save the Children, New Delhi, 2004.
2-65
Source : State of India‟s Newborns, a report of National Neonatology Forum of India and Save the Children, New Delhi, 2004
In spite of much effort only 46.6 % deliveries are assisted by Trained Health Care
Personnel of which 38.7% are Institutional deliveries. 104,105 This indicates that concerted
efforts will be required under Home Based Newborn Care (HBNC) to reduce the IMR
106,107
and Neo-natal Mortality Rate (NMR) further. Also inverse relationship is observed
with higher education status of mothers and higher standard of living index.105
Exhibit 2.8: Home Based Neonatal Care (Gadchiroli study)
Home Based Neonatal Care (Gadchiroli Study)
It is based on the provision of home-based care by the woman of the community –the
VHWs, The TBAs, mother and the grandmothers. The VHWs provide health education to
the mothers during the ANC visits. They are also trained to resuscitate asphyxiated and
test sepsis / pneumonia using antibiotic, and provide are at home to preterm and LBW
infants.
The major findings of the study were: the incidence of the neonatal morbidities
(infections, breastfeeding problems, hypothermia) declined by 49% and the case fatality
in preterm LBW infants reduced by 60%.
As 83% of births in rural India are in home, this study showed a promising new avenue in
home-based care especially for the rural and tribal community.
Source: The State of the World Children 2009, : Maternal and Newborn Health, Unicef, WHO
104
105
International Institute for Population sciences (IIPS) and Macro International (2002-04), District Level Household Survey: India:
Mumbai: IIPS.
106
Abhay T. Bang, Rani A. Bang, Sanjay B. Baitule, M. Hanimi Reddy, Mahesh D. Deshmukh, Effect of home-based neonatal care
and management of sepsis on neonatal mortality: field trial in rural India, The Lancet, 1999; 354: 1955 -61.
107
Replicating the Home-Based Newborn Care in India: New evidence from 12 sites and implications for national policy, Report of
the convention, 2006, New Delhi.
2-66
2.5.5 Maternal and Child Health Programmes in India
India has a long history of Maternal and Child Health Programmes (Exhibit below) since
independence, which have undergone significant shifts in their emphasis over time.
Exhibit 2.9: Maternal and Child Health Programmes in India

1952 Family Planning Programme
1961 Dept. of Family Planning Created
1971 Medical Termination of Pregnancy (MTP) Act
1977 Renaming of Family Planning to Family Welfare
1992 Child Survival and Safe Motherhood Programme
1996 Target Free Approach
1997 Reproductive Child Health Programme Phase II
2005 Reproductive Child Health Programme Phase II
Source: Ministry of Health and Family Welfare, GOI
The 5-year phase of RCH II was launched in 2005 with a vision to bring about outcomes
as envisioned in the MDGs, the National Population Policy 2000, the National Health
Policy 2002 and The Tenth Five Year Plan, minimizing the regional variations in the
areas of RCH and population stabilization through an integrated, focused, participatory
programmes meeting the provisions of assured, equitable, responsive quality services.
The implementation of the RCH II was strengthened with its integration into the NRHM,
where improved programme implementation and health system development was seen as
mutually reinforcing processes. In the five years since the launch of the NRHM in 2005,
institutional deliveries have increased rapidly witnessing a remarkable ump in coverage
from 7.39 to 90.37 lakh beneficiaries in 2008-09. Also quality of antenatal and postnatal
care is also being strengthened, while the ASHA providing support for increasing
utilization.
2-67
Table 2.19 : Major initiatives in Maternal Health under RCH II
Source: Annual Report to the people on Health, MOHFW, GOI, Sept 2010
Major initiatives in Child Health under RCH II:
The strategy for child health care aim to reduce under 5 child mortality through
interventions at every level of service delivery and through improved child care practices
and child nutrition. One major component of the strategy was training to the AWWs and
ANMs for early diagnosis and referral to facilities. At the facility level, the focus was on
strengthening capacity to cope with essential newborn care in newborn corners in every
facility and promptly treat or refer sick newborns and sick children to more specialized
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newborn stabilization units or special newborn care units at the district hospital. 213 sick
newborn care units have been set up so far.
Table 2.20: Major initiatives in Maternal Health under RCH II
Source: Annual Report to the people on Health, MOHFW, GOI, Sept 2010
Integrated Management of Neonatal and Childhood Illness (IMNCI)
IMNCI strategy encompasses a range of interventions to prevent and manage 5 major

childhood illnesses – ARI, Diarrhea, Measles, Malaria and Malnutrition with the major
causes of neonatal mortality – prematurity and sepsis. In addition, IMNCI teaches about
nutrition including breast feeding promotion, complimentary feeding and
micronutrients.108 It focuses on preventive, promotive, a curative service i.e. it gives a
holistic outlook to the programme. Major components of the strategy are:
(a) Strengthening the skills of the health care workers

(b) Strengthening the health care infrastructure.
108
Student‟s Handbook of Integrated Management Neonatal and Childhood Illness (IMNCI), World Health Organisation.
http://megphed.gov.in/knowledge/standards/ARWSPguidelines.pdf
2-69
(c) Involvement of the community
The first two components are facility based IMNCI and the third one is community based
IMNCI. The major features of the IMNCI are
 Focus on the newborn care and young infant- since a significant proportion of
child mortality is centered in the first few months of life
 Development of protocol and algorithm for home visits by field functionaries like
ANMs and AWWs for all newborns in the first week of life.
 Ensuring harmonization between existing health interventions and programmes
like ICDS and anti Malaria programmes implemented by agencies other than the
Department of Family Welfare that impact child health.
2.5.6 Immunization Programmes in India
The expanded Programme on Immunization (EPI) was launched in 1978 in India with the
objective of reaching 80% of the children in the country with vaccinations to protect them
against six diseases namely Polio, Diphtheria, Pertussis, Tetanus, Typhoid and
Tuberculosis. The National Health policy (1983) accorded high priority to the
immunization of children and universal immunization against the six Vaccine
Preventable Disease (VPD) by 2000 was set as one of the goals. In 1985, the EPI
program was renamed as Universal Immunization Programme (UIP) aiming at universal
coverage of all children. Typhoid vaccine was withdrawn and Measles vaccine was
included in the programme as part of the primary immunization schedule to infants and in
addition, pregnant women were to receive Tetanus Toxoid Vaccination during antenatal
period. Recently Hepatitis B Vaccine and injectable Vi antigen Typhoid vaccine have
also been introduced as pilot projects.
As per the third round of the NFHS (2005-06), less than half, only 44% of children aged
between 12 -23 months are fully vaccinated against the six major childhood illness.
However, most children are atleast partially vaccinated and only 5% have received no
2-70
vaccinations at all.109 Trends in immunization coverage of different vaccines are depicted

as below figure
Graph 2.14: Children Immunization trends
Source: National Family Health Survey-3, IIPS, Mumbai
Trends in vaccination coverage over the 15 years period from NFHS-1 to NFHS-3
indicate that the percent of children not receiving any vaccination has dropped sharply
from 30% (1992-93) to 5% (2005-2006). Also between NFHS-2 (1989-99) and NFHS-
3(2005-06), full vaccination coverage increased in 19 of the 29 states and dropped in the
remaining 10 states. There was very less improvement in full vaccination coverage
between NFHS-2 (42%) and NFHS-3 (44%). The largest improvement was for polio
vaccinations (63% to 78%) undoubtedly as a result of the various rounds of Pulse Polio
Campaign. The DPT and polio vaccines are given in a series. Many children receive first
dose but not finish the series. Between the first dose and the third dose, the dropout rate
for DPT is 27% and the dropout rate for polio is 16%. 110,111,112
109
110
111
International Institute for Population sciences (IIPS) and Macro International (1992-93), National Family Health Survey (NFHS-1),
112
2-71
The overall picture masks substantial variations in trends in vaccination coverage among
the states. Several states, such as Bihar, Chattisgarh, Jharkhand, Sikkim and West Bengal
have witnessed a substantial increase in vaccination coverage, while vaccination
coverage has actually worsened substantially in other states, such as Andhra Pradesh,
Gujarat, Maharastra, Punjab and Tamil Nadu.
Polio Eradication Programme
India has achieved remarkable success in reduction of Polio cases in the country, and the
incidence of wild poliovirus has drastically declined over the years. Pulse Polio
Immunization Programme was intiated in 1994, as a pilot project in Delhi. Then in 1995
the programme is introduced in the country for children below 3 years and later on
extended up to 5 years during 1996 – 97. The programme is intensified during 1999 -
2000 with a house-to-house strategy.
As per the Ministry of Health and Family Welfare, the number of reported cases of Polio
declined from 28,757 during 1987 to 3265 cases in 1995 and this success continued in
regard to reduction in cases as depicted in following table. There were 1934 cases of
Polio in 1998 and 42 cases in 2010, where the target is complete eradication.
Table 2.21: Wild polio cases from 1998 to Nov 2011
Source: National Polio Surveillance Project, Government of India
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2.5.7 Nutrition Programmes in India
Infant feeding
Although breast feeding is nearly universal in India, only 46% of children under 6
months are exclusively breastfed, as WHO recommends. In addition, only 55% are put to
the breast within the first day of life,113 which means many infants are deprived of the
highly nutritious first milk (colostrums) and the antibodies it contains. However, mothers
in India breastfeed for an average of 25 months, which is slightly longer than the
minimum of 24 months recommended by WHO for most children.
It is recommended that nothing be given to children other than breast milk in the first
three days, however, more than half of children are given something other than breast
milk during this period.
WHO offers three recommendations for Infant and Young Child Feeding (IYCF)
practices for those 6 -23 months old. Continued breastfeeding or feeding with appropriate
calcium-rich foods if not breastfed; feeding solid and semi-solid food for a minimum
number of times per day according to age and breastfeeding status. Less than half of
children age 6 -23 months are fed the recommended minimum times per day and about
one-third are fed from the minimum number of food groups. However, only 21 % are fed
according to all three recommended practices.
Children Nutritional status
Malnutrition, defined as underweight children relative to an internationally accepted

reference population, has not declined significantly over the last decade and a half.
Almost half of the children underage five are stunted or too short for their age, which
indicates that they have been undernourished for some time. Twenty percent were wasted
or too thin for their height, which may result from inadequate recent food intake or a
recent illness. Forty three percent are underweight, which takes into account both chronic
113
2-73
and acute under nutrition. More than half of children under age five are underweight in
Madhya Pradesh, Jharkand and Bihar. It is observed that children in rural area are more
undernourished and almost two in five children are undernourished in case urban areas.
[ref NHFS -3] In 1992-93 (NFHS-1) it was 54%, in 1998-99 (NFHS -2), it was 47% and
in 2005 -06 (NFHS-3) it was 46%. 114,115,116
Table 2.22 : Trends in children’s nutritional status (Percentage of children under age three years)
Nutritional 1992-93 1998-99 2005-06
Parameter NFHS-1 NFHS-2 NFHS-3
Stunted 52.0 45.5 38.4
Wasted 17.5 15.5 19.1
Underweight 53.4 47.0 45.9
Note: Figures of NFHS-1 above are for 0-4 years. However, NFHS-1 later generated data for below 3 years children with
51.5% children being underweight
Source: NFHS Surveys, IIPS, Mumbai
Significant observation while checking the status of nutrition amongst children was the
case of Anemia. The percentage of anemic children of 6 – 35 months has increased from
74.2% in NHFS -2 to 79.2% as per NFHS-3.
Major Nutrition Programmes in India
Integrated Child Developmental Services
Integrated Child developmental Services (ICDS) scheme117 is the world‟s largest

integrated early child development programme. The supplementary nutrition component
of the scheme is the convergence point for the delivery of a range of health, nutrition
and education interventions from pregnant and lactating women and children below the
age of 6 years. A new component of nutritional supplements to adolescent girls was
added later. As on 31 March 2007, 5829 projects (Blocks) and 0.8 million AWCs have
been made operational. Currently, services under the scheme are being provided to 70
114
115
116
117
2-74
million beneficiaries, comprising of about 58 million children (0-6yrs) and about 12

million pregnant and lactating mothers. (ICDS IV Concept Note, 2007). The ICDS is
essentially seen to function as an important aspect of the primary health care
programme. Apart from the distribution of nutrition supplements, the Anganwadi Centre
is a hub for the delivery of primary health care interventions by the ANM such as
immunization, distribution of Iron Folic Acid and Vitamin A supplements, growth
monitoring and promotion, health education and counseling to mothers. The
beneficiaries and functions of ICDS are depicted in the following figure.
The programme is implemented through a network of community-based Anganwadi

Centers (AWCs) run by an AnganWadi Worker (AWW) with assistants from a helper or
sevika. At present, there are 7, 81,000 AWCs operating in all the blocks of the country,
though the scheme has yet to achieve the mandated universalization. Currently, ICDS is
under its revamping phase under which universalization of the scheme is planned.
Exhibit 2.10 : Beneficiaries of ICDS
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Mid-Day Meal Scheme (MDMS)
The national Programme of nutritional support to primary education or the Mid-Day

Meal Scheme was launched on 15th August 1995 to give a boost to universal primary
education. It was expected to increase enrolment, attendance and retention and improve
the nutritional status of children in primary classes in government, local body and
government-aided schools. The programme provides cooked meals to children through
local implementing agencies. Mid day meals to children are now being supplied to
children in drought-affected areas during summer vacations also. The scheme is
implemented in convergence with ongoing rural and urban development schemes for
adequately meeting infrastructure requirements and with the involvement of local
community, self help groups and non-governmental organizations.
Certain states have innovated the MDMS and health issues at primary education level. In
Tamil Nadu, Health Cards are issued to all children and school health day is observed
every Thursday. In Gujarat, Chhattisgarh and Madhya Pradesh, children are provided
micronutrients and deworming medicines under MDMS.118
National Nutritional Anemia Prophylaxis Programme
India was the first developing country to take up a National Nutritional Anemia
Prophylaxis Programme (NNAP) in 1972 to prevent anemia among pregnant women and
children. However, coverage under the programme needs improvement as only 22.3% of
pregnant women consumed iron and folic acid for 90 days and only 50.7% had at least
three antenatal visits for their last child birth (NHFS-3). The current strategy, included as
part of RCH, programme under NRHM, recommends that pregnant and lactating women,
6 -12 months infants, school children, 6 -10 year olds, and adolescents (11 -18 years old)
should be targeted in the NAPP as per the recommended dosage.
118
2-76
Convergence of Nutrition and NRHM
NRHM promotes integration of nutrition and health. It urges ASHA to work in strong
coordination with AWW. It promotes AWC to be the focal point for all health and
nutrition services. Village health and nutrition days are to be organized under this
coordinated effort. It aims to promote health awareness generation and nutrition
education. It also brings opportunities to link pregnant and lactating mothers, newly
married women with health system. States have developed models of this synergy
between two strongly inter-related sectors of health and nutrition.
The Navjat Shishu Suraksha Karyakram (NSSK)
A two day training programme on basic new born care and resuscitation has been
launched in September 2009. 651 Nutrition Rehabilitation Centres have been set up
across states for treatment of sick and severely malnourished children and this would be
expanded to more districts.
2.5.8 Safe water and Basic Sanitation Programmes in India
Provision of clean drinking water, sanitation and a clean environment are vital to improve
the health of population and to reduce incidence of diseases and deaths.
The status of provision of water and sanitation has improved gradually. According to
Census of India (1991), 55.54 % of the rural population had access to an improved water
sources. As on 1st April 2007, the department of drinking water supply‟s figures show
that out of a total of 15,07,349 rural habitations in the country, 74.39% are fully covered
and 14.64% are partially covered and around 91% of the urban population has got access
to water supply facilities. However, this access does not ensure adequacy and equitable
distribution and the per capita availability is not as per the norms in many areas.119
119
Census of India, 2001, Office of the Registrar General and Census Commissioner, India.
2-77
Access to Toilets: As per the latest Census data (2001), only 36.45% of the total
population has latrines within or attached to their houses. However in rural areas, it is
only 21.9% as on November 2007. Sanitation coverage in the country at about 49% - an
estimate based on the number of individual household toilets constructed under the Total
Sanitation Campaign Programme 120
Sewerage and sanitation: As on 31st March 2004, 63% of the urban population has access
to sewerage and sanitation facilities (47% from sewer and 53% from low cost sanitation).
As a consequence. Open defecation is prevalent widely in rural areas but also
significantly in urban areas too.
The Government of India‟s major intervention in water sector started in 1972-73 through
the Accelerated Rural Water Supply Programme (ARWSP) for assisting States / UTs to
accelerate the coverage of drinking water supply. In 1986, the entire programme was
given a mission approach with the launch of the Technology Mission on Drinking Water
and Related Water management. This Technology Mission was later renamed as Rajiv
Gandhi National Drinking Water Mission (RGNDWM) in 1991-92.121
In 1999, “Total Sanitation Programme” was launched by restricting the Central Rural
Sanitation Programme. A “demand driven approach‟ was adopted with increased
emphasis on awareness creation and demand generation for sanitary facilities in houses,
schools and for cleaner environment. Incentives were planned to the poorest of the poor
households for constructing individual household latrine units. Rural school Sanitation
was a major component and an early point for wider acceptance of sanitation by the rural
people. Technology improvisations to meet the customer preferences and location
specific intensive IEC campaign involving Panchayat Raj Institutions, Co-operatives,
Women Groups, Self Help Groups, NGO etc. were important components of the strategy.
The strategy addressed all sections of rural population to bring about the relevant
behavioural changes for improved sanitation and hygiene practices and meet their
sanitary hardware requirements in an affordable and accessible manner by offering a
120
Census of India, 2001, Office of the Registrar General and Census Commissioner, India. (P)
121
http://www.ddws.gov.in/
2-78
wide range of technological choices. To increase the implementation of the campaign,

Government of India has separately launched an award scheme called the „Nirmal Gram
Puraskar‟ for fully sanitized and open defection free Gram Panchayats, from a mere 40
village / block panchayats from 6 states that received the award in 2005, the number of
awardees has gone up to 4959 from 22 states in the year 2007. Maharashtra, which got 13
awards in 2005, received 1974 awards in 2007 –a significant achievement followed by
Gujarat with 576 awards.
2-79
Exhibit 2.11: Success story in achieving Nirmala Gram Puraskar (NGP)

Success story of Suravadi Panchayat in Phaltan Block in Satara District of Maharasthtra in achieving Nirmala
Gram Puraskar (NGP)
This panchayat that has a population of 2891 people has 412 households out of which 112 are BPL households. The
Panchayat has a village primary school, an anganawadi centre and a primary health center 5 km away. There was no
community toilet facility in the village. Men, women, and children used to defecate in the open. Out of 47 individual
toilets 34 were not in use (used only for the other purposes). Village was always highly stinking, no drainage, many ill
with diseases like jaundices, flu, cholera, etc. Several village meetings were held for stoppage of open defecation. It
looked like a Herculean task in the beginning, as people were not coming forward for construction of toilets.
Things began to change with Sant Gadge Baba Gram Swachhata Abhiyan started in 2000 and motivational campaign
and meetings were organized by Panchayat. The school teachers and students were involved in this campaign.
Sanitation campaign started with making a 28-seater complex and few individual units. Persons still going for open
defecation were penalized with no distribution of wheat and keronsene from Public Distribution System. It was also
decided to give Rs 500 to every family to construct its own latrine. Construction of toilets geared up slowly but taken
up in later stages by community participation.
The Gram Panchayat and youth group of the same village monitored the sanitation programme.
Recognition of community is shown by painting all houses using toilets in pink colour. Today everybody is using
toilets in the village. With the campaign, people also gained knowledge on bio-gas plants and about conservation of
sources. The scheme was also linked with and benefited through other rural development schemes like Yaswant Gram
Samruddhi Yojana.
To sustain the programme women and children get regular knowledge on cleanliness through school. Extra classes
have been organized for students on promotion of sanitation and hygiene activities in the schools. The village now has
a better school facility and the Panchayat is fully involved, as it had initiated this campaign. There is a feeling of pride
with their becoming the first village in the entire state to get the NGP award.
Present status in the village is as follows:
Number of households 412
Status of Toilets 100% using toilets
Community Complexes 200 users
Gobar Gas plants linked to toilets 10
Source: Eleventh Five Year plan (2007 – 2012), Government of India
2-80
2.5.9 Health Education
Improving access to information through a range of health education strategies has been a
significant component of all the national health programs in India. This includes
information about immunization schedules, dissemination of treatment protocols such as
for TB, Diarrohea, leprosy and communication for behavioural changes to prevent HIV/
AIDS and other life style diseases The Pulse Polio Immunisation Programme and the
Leprosy Control Programme have been cited as having successful social mobilization
components utilizing several innovative approaches for effective communication.
However, despite funding for IEC interventions in all health programs, criticism remains
that these strategies rely heavily on mass media and that the contextual needs of the
population are not addressed. National Health Policy – 2002 acknowledges the limited
accountability of existing health education programs given the difficulties in evaluating
the effectiveness of such interventions. A World Bank review (1999) of health care in
India suggests that IEC as one area of health programming remains relatively neglected
and that government IEC programs are often not well implemented. It recommends using
a client-oriented approach to formulate messages, training health workers in interpersonal
communication and training, carefully researching campaigns and monitoring the impact
of IEC interventions.
The NRHM promotes health education on a sustained basis in multiple ways. It urges
ASHA, ANM, AWW and VHSCs in coordination to organize village health and nutrition
days. Many states have organized Health Melas (Fairs) to spread health awareness to
masses.
2-81
Bibliography:
Books:
Banerji D., Health and family planning services in India: An epidemiological, socio-cultural and political analysis and
a perspective. Lok Paksh, New Delhi, 1985.
ICMR and ICSSR , Health For All: An Alternate Strategy, Published by Indian Institute of Education, 1981.
Noshir Anita, Seema Deodhar, Neges Mistry, Developing an Alternative Strategy for Achieving Health for all, The
ICSSR/ ICMR Model – The FRCH Experience, Foundation for Research in Community Health, Pune, 2004.
Peters, D., Yazbeck, A.S., Sharma R., Ramana, G.N.V., Pritchett, L,Wagstaff, A., Better Health Systems for India’s
Poor. Findings, Analysis and Options, 2002, Economic Research, World Bank, Washington DC.
Student‟s Handbook of Integrated Management Neonatal and Childhood Illness (IMNCI), World Health Organisation.
http://megphed.gov.in/knowledge/standards/ARWSPguidelines.pdf
World Health Organisation, Select Health Parameters: A comparative analysis across the National Sample Survey
Organisation (NSSO) 42nd, 52nd and 60th rounds, 2007, Ministry of Health and family Welfare, Government of India, in
collaboration with WHO, country office India.
Documents (Policy documents / Guideline documents):
Declaration of Alma-Ata International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978,
accessed from www.who.int/hpr/NPH/docs/declaration_almaata.pdf
First National Health Policy, Ministry of Health and Family Welfare, Government of India, New Delhi, 1983.
Human Resources for Health, overcoming the crisis – Joint Learning Initiative (JLI), WHO 2006-2015.
National Rural Health Mission Document, 2005- 12, Ministry of Health and Welfare, Government of India, New Delhi,
April 2005.
National Rural Health Mission, Frame work for implementation, 2005-12, Ministry of Health and Family Planning,
New Delhi, April 2005.
Journals / Periodicals / Bulletins:
Abhay T. Bang, Rani A. Bang, Sanjay B. Baitule, M. Hanimi Reddy, Mahesh D. Deshmukh, Effect of home-based
neonatal care and management of sepsis on neonatal mortality: field trial in rural India, The Lancet, 1999; 354: 1955 -
61.
Bhattacharya S.N., Community Development– An Analysis of the Programme in India, Community Development
Journal, 1971, 6(1), 51-52.
Bulletin on Rural Health Statistics in India 2010, Infrastructure division, Ministry of Health and Family Welfare,
Government of India.
2-82
Joy E Lawn, Jon Rohde, Suson Rifkin, Miriam Were, Vinod K Paul, Mickey Chopra, Alma-Ata 30 years on:
revolutionary, relevant, and time to revitalize, The Lancet 2008; 372: 917 -27.
Mario R Dal Poz, Estelle E quain, Mary O‟ Neil, Jim McCaffery, Gis Elzinga and Tim Martineau, Addressing the
health workforce crisis: towards a common approach, Human Resources for Health 2006, 4: 21.
Millennium Development Goals: Health related Indicators India, extracted from National Health Profile 2010, pp 257
Sample Registration System (SRS): Maternal and Child Mortality and Total Fertility Rates, July 2011, Office of the
Registrar General, India.
Sample Registration System Bulletin, Office of Registrar General of India, December 2011; 46(1):1.
Sample Registration System SRS) Maternal Mortality in India: 1997-2003, Trends, Causes and Risk Factors, Registrar
General India, New Delhi in collaboration with Centre for Global Health Research University of Toranto, Canada.
Special Bulletin on Maternal Mortality in India 2004 -06, SRS, Office of Registrar General of India, New Delhi, April
2009.
Special Bulletin on Maternal Mortality in India 2007 -09, SRS, Office of Registrar General of India, New Delhi, June
2011.
Reports:
D.G. Satihal, K.E.T. Rajarama, Evaluation of Village Health Guide Scheme, Belgaum District, Karnataka, Report
prepared for the Ministry of Health and Family Welfare, Government Of India, New Delhi, 2000.
International Institute for Population sciences (IIPS) and Macro International 2007, National Family Health Survey
(NFHS-3), India: Mumbai: IIPS.
International Institute for Population sciences (IIPS) and Macro International (1992-93), National Family Health
Survey (NFHS-1), India: Mumbai: IIPS.
International Institute for Population sciences (IIPS) and Macro International (1998-99), National Family Health
Survey (NFHS-2), India: Mumbai: IIPS.
International Institute for Population sciences (IIPS) and Macro International (2002-04), District Level Household
Survey: India: Mumbai: IIPS.
National Health Profile 2010, Central Bureau of Health Intelligence, DGHS, GOI, New Delhi.
National Rural Health Mission, Meeting the people’s health needs in partnership with states, the journey so far, 2005-
2010, Ministry of Health and Family Welfare, GOI, New Delhi.
Replicating the Home-Based Newborn Care in India: New evidence from 12 sites and implications for national policy,
Report of the convention, 2006, New Delhi.
Report of 66th NSSO Survey, Census of India, Office of the Registrar General and Census Commissioner, India.
Report of Census of India, 2001, Office of the Registrar General and Census Commissioner, India.
Report of Mukerji Committee on Basic Health Services, Government of India, New Delhi, 1966.
2-83
Report of National Planning Committee – Sub Committee on National Health, Government of India, 1948.
Report of the Committee of Multipurpose Workers under Health and Family Planning Programme Ministry of Health
and Family Planning, New Delhi, 1973.
Report of the committee on Integration of Health Services, Directorate General of Health Services, New Delhi, March
1967.
Report of the Expert Committee on Health Manpower Planning, Production and Management, Ministry of Health and
Family Welfare, Government of India, New Delhi, 1987.
Report of the Expert Committee on Public Health System, Ministry of Health and Family Welfare, Government of
India, New Delhi, 1996.
Report of the group on Medical Education and Support Manpower, Health Services and Medical Education –A
programme for immediate Action, Ministry of Health and Family Planning, Government of India, New Delhi, 1975.
Report of the Health Survey and Development Committee, Volume II and Volume IV, Government of India, New
Delhi, 1946.
Report of the Health Survey and Planning Committee, Ministry of Health, Government of India, New Delhi, 1961.
Report of the Medical Education Review Committee, Ministry Of Health and Family Welfare, Government of India,
1983.
Report of the National Commission on Macroeconomics and Health (Chapter 7), Ministry of Health and Family
Welfare, Government of India, 2005.
Report of the Working Group on HEALTH FOR ALL by 2000 AD, Ministry of Health and Family welfare,
Government of India, 1981.
State of India’s Newborns, Report of National Neonatology Forum of India and Save the Children, New Delhi, 2004
State of the World Children 2009, Maternal and New born Health, UNICEF, UNO.
The World Health Report 2002 – Reducing risks, Promoting Healthy life, (Chapter 5), World Health Organization,
Geneva, 2002.
The World Health Report 2005: Make every Mother and Child count, WHO, Geneva, 2005.
Websites:
http://phm-india.org/
http://www.phmovement.org/en/node/302
http://indianmedicine.nic.in/
http://www.mciindia.org/
http://www.dciindia.org/
http://www.indiannursingcouncil.org/
http://www.pci.nic.in/
http://mohfw.nic.in/
http://www.ddws.gov.in/
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CHAPTER 2

RURAL HEALTH CARE IN INDIA

1. Different committee reports / recommendations, policies and programmes to

2.1 Origin and Evolution of Primary Health Care in India

2.1.1 Bhore Committee on Health Planning and Development

 the integration of preventive and curative services at all administrative levels

2.1.2 Sokhey committee report on National Health

2.1.3 Community Development Programme

2.1.4 Mudaliar Committee on Health Survey and Planning

2.1.5 Mukherji Committee Reports on Basic Health Services

2.1.6 Jungalwalla Committee on Integration of Health Services

conditions of doctors. The committee defined “integrated health services” as “a service

2.1.7 Kartar Singh Committee on Multipurpose workers

2.1.8 Shrivastav Committee on Medical Education & Support Manpower

(a) Creation of bands of paraprofessional and semi-professional health workers from

2.1.9 Rural Health Scheme: Community Health Volunteer Scheme-Village Health

Acceptance of the recommendations of the Shrivastav Committee report led to the

Pre Alma Ata Declaration

1946 Bhore Committee Report on Health Survey and Development

1948 Sokhey Committee Report on National Health

1952 Community Development Programme

1962 Mudaliar Committee Report on Health Survey and Planning

1966 Mukheree Committee Reports on Basic Health Services

1967 Jungalwalla Committee Report on Integration of Health Services

1973 Kartar singh Committee report on Multipurpose Health Workers

1975 Shrivastav Committee Report on Medical Education and Support

1977 Rural Health Scheme: Community Health Volunteer Scheme-Village Health

Alma Ata Declaration and beyond

1978 Alma Ata Declaration – Health For All by 2000

1983 Mehta Committee on Medical Education Review

1983 First National Health Policy

1987 Bajaj Committee on Health Manpower Planning, Production and

1996 Bajaj Committee on Public Health Systems

2000 National Population Policy

2002 Second National Health Policy

2005 National Rural Health Mission (NRHM)

2.1.10 Alma Ata Declaration – Health for all by 2000

people it served. It advocated - 1) encouraging people to utilize their age-old health

2.1.12 Mehta Committee on Medical Education Review, 1983

2.1.13 First National Health Policy, 1983

played by private and voluntary organizations working in the country to support

Meanwhile, A selective approach as an “interim” measure to the long term process of

2.1.14 Bajaj Committee on Health Manpower Planning, Production and

An “Expert Committee for Health Manpower Planning, Production and Management”

1. Formulation of National Medical and Health Education Policy.

2.1.15 Bajaj committee on Public Health System, 1996

2.1.16 National Population Policy, 2000

2.1.17 Second National Health Policy, 2002

Exhibit 2.2: Major Goals of National Health Policy 2002

National Health Policy 2002

Major Goals to be achieved Year

Eradication of Polio and Yaws 2005

Eliminate Leprosy 2005

Eliminate Kala Azar 2010

Eliminate Lymphatic Filariasis 2015

Achieve zero level growth of HIV/AIDS 2007

Reduce Mortality by 50% on account of TB Malaria, other 2010

Reduce IMR to 30/100 and MMR to 100 per 1 Lakh 2010

Increase health expenditure by Govt as a %GDP from existing 0.9% to 2% 2010

Establish an integrated system of surveillance,

Further increase to 8% of the budget 2010

2.1.18 National Rural Health Mission (NRHM, 2005-2012)

NRHM is visualized as an architectural correction of the Indian Public health system to

Exhibit 2.3 : NRHM - Illustrative Structure